A client comes into the health clinic 3 years after undergoing resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching?
A. “I have been drinking plenty of fluids.”
B. “I have been gargling with warm salt water for my sore tongue.”
C. “I have 3 to 4 loose stools per day.”
D. “I take a vitamin B12 tablet every day.”
Correct Answer: D. “I take a vitamin B12 tablet every day.”
Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed.
Option A: Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Massive small bowel resection can lead to short bowel syndrome (SBS), a condition that is characterized by malnutrition and malabsorption secondary to loss of functional small bowel and more rapid intestinal transit. In addition to weight loss and protein-calorie malnutrition, patients suffer from diarrhea, steatorrhea, electrolyte abnormalities, and deficiencies in fat-soluble vitamins.
Option B: Warm salt water is used to soothe sore mucous membranes. Parenteral nutrition, therefore, is a mainstay of early SBS management to limit malnutrition. Early return to enteral feeds once ileus has resolved is advised, even if a diagnosis of SBS is expected. Enteral feeding is thought to stimulate intestinal adaptation by both directly stimulating enterocytes and by inducing endocrine and paracrine effects signaling for hypertrophy of the remaining small bowel mucosa.
Option C: Crohn’s disease and small bowel resection may cause several loose stools a day. Drugs such as loperamide, diphenoxylate and atropine, and opiates will slow gut function, increasing the potential absorptive time of enteral feeds. Reducing gastrointestinal secretion and controlling diarrhea are also important goals for maximizing absorption.
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