Interdisciplinary Team

Review the roles and members of the interdisciplinary team. Depending on the patients medical plan and condition, there may be other members involved. However, this is typical of an inpatient gastroenterology team.

• Registered Dietitian: primarily responsible for nutrition care plan, transition to oral diet, nutrition education.
• Medical Doctor (MD) or Nurse Practitioner (NP): medical update, enter orders for IV fluids, labs, imaging, medications, consults.
• Pharmacist (RPh): drug and nutrient interactions, medication dosing/ indications.
• Nurse (RN, ostomy nurse): help implement nutrition care plan, provide clinical information, manage ostomy care.
• Physiotherapist (PT): ambulation, positioning, assist with obtaining body weight.
• Occupational therapist (OT): cognitive assessment to determine if patient can provide accurate information, modified eating equipment, positioning.
• Social Worker (SW): provide counselling, disposition planning and identify sources of emotional support for patients and their families.
• Speech language pathologist (SLP): prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders.
• Gastroenterologist (GI): GI specialists primarily diagnose and treat GI diseases.
• General Surgeon: the surgeon is responsible for completing the surgical procedure, determining protocols and follow up.
• Spiritual Care: responds to the needs of the patient when faced with trauma, ill health or sadness and can include the need for meaning, for self worth, to express oneself, for faith support, prayer or sacrament, or simply for a sensitive listener.

Education

When implementing your plan with your patient you may need to provide some education to them. When educating patients, try to:

• Individualize the education as much as possible: Discuss high-risk topic first since they are the priority, connect the patient’s goals to your plan, and focus on what they want to learn.
• Find out if patient has had previous education: Ask the patient if any one else has talked to them, and adjust your education accordingly.
• Focus on a few key messages: If the patient is newly diagnosed or doesn’t know much about IBD or ostomies, try not to overwhelm them with too much information during your first couple of interactions
• Use visuals and resources to convey your message whenever possible: You can provide your patient with detailed information in resources, but emphasize the key components based on the patients needs when speaking with them.

Education for IBD

Importance of Nutrition

• Inadequate food and fluid intake: resulting from nausea, abdominal pain, and loss of appetite.
• Increased losses: inflammation during acute flares resulting in increased protein losses and losses from diarrhea and bleeding.
• Increased nutritional needs: inflammation or infection increases metabolic requirements.
• Malabsorption: if the patient has severe inflammation, resection of the small intestine, and is on certain medications (i.e. prednisone), they have an increased risk of malabsorption.

Managing IBD

Review the areas you may want to educate on depending on the patient’s knowledge of IBD. It is important to distinguish between when IBD is in remission or under control and when an individual has an acute episode of IBD.

When IBD is in remission or under control:

• When you feel well, it is important to eat healthy so you build-up your strength and remain well nourished. Regular exercise like brisk walking, biking and swimming for at least 150 minutes (2 hours) each week is also important for good health.
• High-fibre diet (as tolerated), focusing on soluble fibre or supplements (Metamucil®). Avoid foods that cause symptoms.
• Drink plenty of fluids.
• Unnecessary restrictions should be avoided to maximize nutrient intake (patients with IBD commonly restrict intake due to association with fullness, pain, diarrhea — so risk of malnutrition is high).
• Micronutrients that are insufficient or malabsorbed in IBD patients may include iron, calcium, selenium, folate, thiamin, vitamin B12, zinc, magnesium, vitamins A, D, E. Consider multivitamins or supplementation, if dietary intake is insufficient.

• An individual will typically be put on bowel rest in hospital with IV fluids. They will then progress to clear fluids and a low-residue diet, slowly adding back foods to evaluate tolerance.
• A lower fibre diet (insoluble fibre) may prevent risk of obstruction
• For patients experiencing diarrhea, emphasize:
  • eating small meals frequently
  • drinking plenty of fluids to replace fluids
  • avoiding sugary drinks, alcohol and caffeine
  • including soluble fibre
• Where possible, try to maximize caloric and protein intake to prevent weight loss and malnutrition
• For patients at risk of malnutrition or experiencing poor appetite, emphasize a high-calorie and high protein diet divided into small, frequent meals which is better tolerated and maximizes nutritional intake

Energy and Protein Intake

If patients are malnourished with IBD, it may be worthwhile to provide recommendations for increasing energy and protein intake.

General recommendations for increasing energy and protein intake include:

• Eat or drink often. Aim to have a meal or snack every two to three hours.
• Drink your fluids at the end of meals or snacks as they can fill you up.
• Have ready–to-eat, small, high energy and protein foods on hand, such as yogurt, pudding, granola, or protein bars, cheese or peanut butter and crackers, nuts and seeds, or trail mix.
• Provide your patient a list of foods that add protein or energy to meals (*consider recommended foods in the context of the patient – i.e. ostomy guidelines, tolerance):
  • Add nut butters to smoothies, puddings, yogurt
  • Add extra sources of fat to meals: oil, butter, dressing, cheese, avocado
  • Choose high protein nutrition supplements

Again, these are general and non-comprehensive key points that should be expanded on in practice. Consider your recommendations in the context of the individual and the disease. For example, do not recommend including nuts and seeds to increase calories, if it does not adhere to the ostomy guidelines. It would be beneficial to seek readings and resources that cover this topic in more detail.

Medications

It is important to remind your patient of the nutritional implications of medication use. They may have already received this from the pharmacist or another health professional, but it is appropriate to ask and make sure. This is especially important if you are recommending a supplement related to medication use (such as prednisone and calcium supplementation), in order to explain why you are doing so.

For example, a patient taking Prednisone should know the following:

• Prednisone causes decreased absorption of calcium and phosphorus from the small intestine. It also causes increased losses of calcium, zinc, potassium and vitamin C.
• With continual use of high doses of prednisone, the result may be bone loss and development of bone disease.
• Protein needs also are increased for people taking prednisone because it increases protein breakdown in the body.

Education for Ileostomy

Minimizing Bowel Obstruction Risk

Individuals with a new ileostomy are at greater risk for a stoma blockage than someone with a colostomy for several reasons. First, the stoma created from the ileum (small intestine) is smaller in diameter than one created from the colon. In addition, post surgical inflammation of the bowel is normal but results in a smaller exit site in the first 6 – 8 weeks and large particles of food don’t break down easily. These particles can get stuck where the stoma is, creating a blockage.

When providing education to patients, address the following topics.

• Know the signs of a stoma food blockage:
  • Abdominal cramps, pain or distension
  • Watery stools with bad odor
  • Stool released in spurts
  • Absence of stool output, or pressure at the stoma but little stool output
• Avoid or minimize certain foods for the first 6 – 8 weeks:
  • High-fibre/ high residue foods, as foods with large fibres do not digest in the upper small intestine
  • Vegetables and fruits with skins
  • Raw fruits and vegetables – cook them well
  • Nuts and seeds
  • Popcorn
  • Meats/ casings
• Focus on the 3 C’s:
  • Cook tender
  • Cut small
  • Chew well
• Stay hydrated:
  • Prevent dehydration by drinking 8-10 cups of fluid a day (2 – 2.5 L). This can include different types of liquid besides water, but half the amount should be water.
  • Keep in mind that caffeinated drinks can add to dehydration
  • Sip liquids slowly and consistently throughout the day
  • Drink fluids with electrolytes such as sodium and potassium that are low in sugar (or an oral electrolyte solution)

Electrolytes

Educate clients with the following information to incorporate electrolytes in their diet.

•  High potassium foods: Kiwi, avocado, mango, cantaloupe and honeydew melon, banana, orange juice, dried fruit (apricots, dates, figs, raisins), potatoes, potato chips, spinach, swiss chard, rapini, tomatoes, squash, brussels sprouts, beets, parsnip, legumes and beans, peas, lentils, nuts, seeds, coconut, chocolate.
• High sodium foods: All canned vegetables and vegetable juices, processed cheese and meat slices, canned, pickled or smoked fish, salted crackers, pretzels, canned products and soups, Ovaltine, soda water, artificial fruit-flavoured crystals, or add salt to food.
• Products with electrolytes: Gastrolyte, Pedialyte, ORS rehydration salts, G2 (low sugar Gatorade), vegetable juices.

High Ostomy Outputs

• Include soluble fibre: applesauce, peeled peaches, apricots, banana, melons, potatoes, squash, lentils, beans, barley, oatmeal, psyllium.
• Avoid insoluble fibre: fruits and vegetable skins and seeds, wheat bran, whole grains, nuts and seeds.
• Include an oral electrolyte replacement: Gastrolyte or Gatorade (diluted); add salt.
• May be helpful to separate liquids and solids by up to 1 hour.
• Avoid consuming certain foods and drinks: lactose (may still be able to tolerate yogurt/cheese), fatty or greasy foods, foods that are natural laxatives (prunes, figs, licorice), caffeine (e.g. coffee, chocolate, soft drinks), alcohol, simple sugars (juices, etc)

Patients should be made aware of the following foods:

• Foods that may cause or worsen diarrhea: Sweetened milk and milk products, fruit juices and punches, sweet breads/ rolls/cakes/cookies, sweet cooking sauces, sugars (including honey, syrup, jams), alcohol, spicy foods, caffeine, very high fat or greasy foods.
• Foods that may thicken stool: Bananas, rice, tapioca, barley, oatmeal, applesauce, cheese, smooth peanut butter, and potato chips. Metamucil® or Benefibre® supplements also contain soluble fibre to thicken stools.

Controlling Gas and Odour

• Make sure you are not lactose intolerant
• Avoid high fat foods and carbonated drinks
• Maintain a regular eating pattern (i.e. meal and snack times, do not skip meals)
• Exercise regularly
• Eat slowly
• Avoid swallowing air (e.g. gulping, chewing gum, use of straws, eating quickly)

Patients should be made aware of the following foods:

• Foods that cause gas and odour: Asparagus, apples, banana, beer, broccoli, brussels sprouts, cabbage, carbonated drinks, cauliflower, corn, cucumber, dairy products, dried beans, eggs, fatty foods, grapes, melons, onions, prunes, turnips.
• Foods that may help relieve gas and odour: Yogurt with active cultures, buttermilk, cranberry juice.

General Eating Guidelines

It is important that individuals with permanent ostomies follow guidelines to prevent concerns, but also transition to a less restrictive diet for quality of life. Here are some important guidelines for a patient who is no longer in the post-operation period (6 – 8 weeks, based on tolerance and the individual):

• Eat 3 well balanced meals daily or 5 – 6 small meals
• Avoid skipping meals or long gaps between meals, which can contribute to gas production
• Avoid drinking out of straws, as they allow air to be swallowed and can contribute to gas production
• Eat slowly to avoid swallowing air, and always chew your food well
• Drink adequate amounts of fluids (8–10 glasses a day)
• Add new foods gradually to learn which foods might give you side effects, such as excess gas, odour, constipation, or loose stool
• Work with a dietitian if symptoms are not being managed

Summary of Education

Simulation Activity: Sam