Nursing Grand Nursing Grand RoundsRounds

Care of the Bariatric Patient

February 15, 2012

Presented and Planned Presented and Planned by: by:

Needham 3: Jessica Kaloyanides, RNJessica Kaloyanides, RN Marjorie Petit, RN, BSNMarjorie Petit, RN, BSN Kayleen Sussman, RNKayleen Sussman, RN Kelly Donahue, RN, BSNKelly Donahue, RN, BSN

Operating RoomOperating Room: : Eric Starble, RN, BSN, Eric Starble, RN, BSN,

CNORCNOR Leslie Schneiderhan, RN, Leslie Schneiderhan, RN,

BSN, MEd, CNORBSN, MEd, CNOR Al Ghilardi Orthopedic Al Ghilardi Orthopedic

Tech PhotographyTech Photography

Weight Weight Management Center: Lisa C. Luz, RN, MSN, Lisa C. Luz, RN, MSN,

CBNCBN

Nutrition: Nutrition: Dana Eiesland, RD, Dana Eiesland, RD,

LDN LDN Stacey A. Nelson, BS, Stacey A. Nelson, BS,

RD, LDNRD, LDN

ObesityObesity Obesity is defined as having an Obesity is defined as having an

excessive amount of body fat. excessive amount of body fat. Doctors often use Body Mass Index Doctors often use Body Mass Index

to determine obesityto determine obesity

BMIBMI Weight statusWeight status

Below 18.5 UnderweightBelow 18.5 Underweight

18.5 -24.9 Normal18.5 -24.9 Normal

25.0 -29.9 Overweight25.0 -29.9 Overweight

30.0 and higher Obese30.0 and higher Obese

40.0 and higher Morbid obesity40.0 and higher Morbid obesity

Obesity in the USObesity in the US

About one-third of U.S. adults About one-third of U.S. adults (33.8%) are obese. (Center for (33.8%) are obese. (Center for Disease Control and Prevention)Disease Control and Prevention)

During past 20 years there has been During past 20 years there has been a dramatic increase in obesity in the a dramatic increase in obesity in the United States United States

The Dangers of ObesityThe Dangers of Obesity

Obesity results in Obesity results in many co-many co-morbidities such as:morbidities such as:

sleep apneasleep apnea joint diseasejoint disease hypertensionhypertension strokestroke diabetesdiabetes respiratory diseasesrespiratory diseases

World health World health organization organization estimated that being estimated that being overweight and overweight and inactive accounts for inactive accounts for ¼-1/3 of all cancers of ¼-1/3 of all cancers of the breast, colon, the breast, colon, endometrium, kidney, endometrium, kidney, and esophagusand esophagus

Obesity Attitudes Obesity Attitudes in Health Carein Health Care

self-report studies show that self-report studies show that physicians, nurses, and other physicians, nurses, and other medical personnel view obese medical personnel view obese patients as:patients as:

non-compliant non-compliant lazylazy dishonestdishonest lacking in self-controllacking in self-control unsuccessfulunsuccessful sloppysloppy

Surgical Weight Surgical Weight ManagementManagementLisa C. Luz, RN, MSN, CBNLisa C. Luz, RN, MSN, CBN

Surgical Weight Surgical Weight ManagementManagement

Under the direction of expert bariatric Under the direction of expert bariatric surgeons:surgeons: Julie Kim, MD, FACSJulie Kim, MD, FACS Associates from TMC: Associates from TMC: Dr. Abeles, Dr. Shah, Dr. Tarnoff, fellowsDr. Abeles, Dr. Shah, Dr. Tarnoff, fellows

Multidisciplinary TeamMultidisciplinary Team DietitianDietitian PsychologistPsychologist Program Coordinator/NurseProgram Coordinator/Nurse Insurance SpecialistInsurance Specialist

Who is a Surgical Who is a Surgical Candidate?Candidate?

Meets National Institutes of Health Criteria: Meets National Institutes of Health Criteria: BMI BMI > > 40 40 >35 with significant obesity-related co-morbidities>35 with significant obesity-related co-morbidities

18 years or older18 years or older No endocrine cause of obesity No endocrine cause of obesity Stable psychological conditionStable psychological condition Absence of drug or alcohol problem/Absence of drug or alcohol problem/Non-SmokingNon-Smoking Understands surgery and risksUnderstands surgery and risks Acceptable operative risks (patient and procedure)Acceptable operative risks (patient and procedure) Consensus after bariatric team evaluation:Consensus after bariatric team evaluation:

psychologist, dietitian, surgeonpsychologist, dietitian, surgeon Dedicated to lifestyle change and follow-upDedicated to lifestyle change and follow-up

The Surgical ProcessThe Surgical Process Information SessionInformation Session

Preliminary ApplicationPreliminary Application Health History QuestionnaireHealth History Questionnaire

Immersion DayImmersion Day Psychologist/Behavioral AssessmentPsychologist/Behavioral Assessment Nutritional CounselingNutritional Counseling Medical Clearance from PCP or SpecialistMedical Clearance from PCP or Specialist Medical Testing: Labs, X-ray, EKGMedical Testing: Labs, X-ray, EKG Consultation with SurgeonConsultation with Surgeon Support GroupsSupport Groups Insurance ApprovalInsurance Approval

The Surgical ProcessThe Surgical Process

Mental Health Evaluation Mental Health Evaluation Preparing for new LifePreparing for new Life Identify the support needed to be successfulIdentify the support needed to be successful

Individual Nutrition AppointmentsIndividual Nutrition Appointments Minimum 2 visits (for insurance approval)Minimum 2 visits (for insurance approval) Individual Diet Planning and EducationIndividual Diet Planning and Education

Medical TestingMedical Testing Labs, Chest X-ray, EKG and any testing TBD by Labs, Chest X-ray, EKG and any testing TBD by teamteam

The Surgical ProcessThe Surgical Process Surgical ConsultationSurgical Consultation

One on One consultation to answer all questions One on One consultation to answer all questions and individual concernsand individual concerns Medical ClearanceMedical Clearance

By PCP, or specialistBy PCP, or specialist Support Groups~ Make the DifferenceSupport Groups~ Make the Difference

This process takes approximately 3-6 This process takes approximately 3-6 months!months!

Bariatric Bariatric SurgerySurgery

Eric Starble RNEric Starble RN

Review of the Digestive Review of the Digestive SystemSystem

EsophagusEsophagus StomachStomach Small IntestineSmall Intestine

(Duodenum, Jejunum, Ileum) (Duodenum, Jejunum, Ileum) Large IntestineLarge Intestine

Bariatric Surgery TodayBariatric Surgery TodayThree Types of Most Commonly Performed Three Types of Most Commonly Performed Bariatric Surgery ProceduresBariatric Surgery Procedures

Biliopancreatic Diversion with Duodenal Switch

Malabsorptive

Roux-en-Y Gastric Bypass

Combination

Adjustable Band Gastroplasty

Restrictive

Restrictive SurgeryRestrictive Surgery

Relatively easy surgical procedureRelatively easy surgical procedure Less dietary deficienciesLess dietary deficiencies Less weight lossLess weight loss More late failures due to dilationMore late failures due to dilation Less effective with sweet eatersLess effective with sweet eaters Significant dietary complianceSignificant dietary compliance

Adjustable Band Gastroplasty

Malabsorptive SurgeryMalabsorptive Surgery

Greater sustained Greater sustained weight loss with less weight loss with less dietary compliancedietary compliance

Increased risk of Increased risk of malnutrition and malnutrition and vitamin deficiencyvitamin deficiency

Constant follow–up to Constant follow–up to monitor increased monitor increased riskrisk

Intermittent diarrheaIntermittent diarrhea Biliopancreatic Diversion with Duodenal Switch

Laparoscopic Sleeve Laparoscopic Sleeve GastrectomyGastrectomy

Restrictive procedure Restrictive procedure Purpose: Suppression of hunger hormonesPurpose: Suppression of hunger hormones No intestinal connectionNo intestinal connection Considered a standard procedure by Considered a standard procedure by

national society (ASMBS)national society (ASMBS) Newer procedureNewer procedure Covered by many but not all insurance Covered by many but not all insurance

companiescompanies

Mechanics of Sleeve Mechanics of Sleeve GastrectomyGastrectomy

Permanent removal of the lateral portion of Permanent removal of the lateral portion of the stomach the stomach

Creates a long, narrow, "banana" shaped Creates a long, narrow, "banana" shaped stomach or "sleeve" stomach or "sleeve"

Reduces the capacity of the stomach by 2/3rdsReduces the capacity of the stomach by 2/3rds No foreign body or needle sticks requiredNo foreign body or needle sticks required The body's natural pyloric and The body's natural pyloric and

gastroesophageal valve act to restrict the gastroesophageal valve act to restrict the passage of food with removal of many of the passage of food with removal of many of the hunger hormoneshunger hormones

Laparoscopic Sleeve Laparoscopic Sleeve GastrectomyGastrectomy

Roux-en-Y Gastric-Roux-en-Y Gastric-BypassBypass

Long-term sustained weight lossLong-term sustained weight loss No protein-calorie malabsorptionNo protein-calorie malabsorption Little vitamin or mineral deficienciesLittle vitamin or mineral deficiencies Technically difficult procedureTechnically difficult procedure

Roux-en-Y Gastric Bypass

The Roux-en-Y Gastric The Roux-en-Y Gastric BypassBypass

1.1. A small, 15 to 20cc, A small, 15 to 20cc, pouch is created at the pouch is created at the top of the stomach.top of the stomach.

2.2. The small bowel is The small bowel is divided. The divided. The biliopancreatic limb is biliopancreatic limb is reattached to the small reattached to the small bowel.bowel.

3.3. The other end is The other end is connected to the connected to the pouch, creating the pouch, creating the Roux limb.Roux limb.

Roux-en-Y Gastric Bypass

Roux-en-Y Gastric BypassRoux-en-Y Gastric Bypass

Small pouch releases food slowly, Small pouch releases food slowly, causing a sensation of fullness with causing a sensation of fullness with very little foodvery little food

Biliopancreatic limb preserves the Biliopancreatic limb preserves the action of the digestive tractaction of the digestive tract

Open and Laparoscopic Open and Laparoscopic Technique in Bariatric Technique in Bariatric

SurgerySurgery OpenOpen Increased post op Increased post op

pain, longer pain, longer hospitalizationshospitalizations

Increased incidence Increased incidence of wound of wound complications - complications - infections, hernias, infections, hernias, seromasseromas

Return to work in Return to work in 4-8 weeks4-8 weeks

LaparoscopicLaparoscopic Less post op pain, Less post op pain,

early mobilityearly mobility Wound Wound

complications are complications are significantly reducedsignificantly reduced

2-3 day hospital stay2-3 day hospital stay Return to work in Return to work in

1-3 weeks1-3 weeks

What Happens in What Happens in the OR?the OR?

Bariatric Surgery:Bariatric Surgery:Beyond the SurgeryBeyond the Surgery

Bariatric Surgery will NOT work Bariatric Surgery will NOT work alonealone

Intricate parts of your weight loss Intricate parts of your weight loss success:success:

Commitment to:Commitment to: Diet Diet Exercise Exercise Support groupsSupport groups

Resolution of Resolution of ComorbiditiesComorbidities

Schauer, et al, Ann Surg 2000 Oct;232(4):515-29

N=104N=1041 year post-op1 year post-op

Number Prior to Surgery % Worse% Worse

% No % No ChangeChange

% % ImprovedImproved

% % ResolvedResolved

Osteoarthritis 6464 22 1010 4747 4141Hypercholesterimia 6262 00 44 3333 6363GERD 5858 00 44 2424 7272Hypertension 5757 00 1212 1818 7070Sleep Apnea 4444 22 55 1919 7474Hypertriglyceridemia 4343 00 1414 2929 5757Peripheral Edema 3131 00 44 5555 4141Stress Incontinence 1818 66 1111 3939 4444Asthma 1818 66 1212 6969 1313Diabetes 1818 00 00 1818 8282

AverageAverage 1.6%1.6% 7.8%7.8% 35.1%35.1% 55.7%55.7%90.8%90.8%

Improved or Resolved

Possible ComplicationsPossible Complications May Lead to Short or Long-term Hospitalization and/or May Lead to Short or Long-term Hospitalization and/or

Re-operationRe-operation

Infection, bleeding or leaking at suture/staple linesInfection, bleeding or leaking at suture/staple lines

Blockage of the intestines or pouchBlockage of the intestines or pouch

DehydrationDehydration

Blood clots in legs or lungsBlood clots in legs or lungs

Vitamin and mineral deficiencyVitamin and mineral deficiency

Protein malnutrition Protein malnutrition

Incisional herniaIncisional hernia

DeathDeath

Possible Side EffectsPossible Side Effects

Nausea and vomitingNausea and vomiting Gas and bloatingGas and bloating Dumping syndromeDumping syndrome Lactose intoleranceLactose intolerance Temporary hair thinningTemporary hair thinning Depression and psychological distressDepression and psychological distress Changes in bowel habits such as Changes in bowel habits such as

diarrhea, constipation, diarrhea, constipation, gas and/or foul smelling stoolgas and/or foul smelling stool

Post-Operative SummaryPost-Operative Summary

On Average, Gastric-bypass On Average, Gastric-bypass Patients…Patients…

Lose 65-80% of their excess body Lose 65-80% of their excess body weight, the majority of it in the first weight, the majority of it in the first 18 to 24 months after surgery.18 to 24 months after surgery.

May have rapid improvements in May have rapid improvements in the morbid side effects of their the morbid side effects of their obesity, such as type 2 diabetes, obesity, such as type 2 diabetes, high blood pressure, sleep apnea, high blood pressure, sleep apnea, and high cholesterol levels.and high cholesterol levels.

Dana Eiesland, RD, LDN Dana Eiesland, RD, LDN

Stacey A. Nelson, RD, LDNStacey A. Nelson, RD, LDN

Bariatric Surgery Nutrition Education

Pre-Surgery Nutrition Education :Pre-Surgery Nutrition Education : Immersion Day Immersion Day

•Post-op diet progression

•Long-term food selection guidelines

•Fluid guidelines

•Protein supplements

•Vitamin & mineral supplementation

•Reading nutrition fact labels

•Mindful eating (eating speed, environment)

•Self- monitoring (keeping daily food journal)

•Dietary changes to promote pre-op weight loss (ie. Meal planning, lean protein sources, snacks)

•Exercise Recommendations

Education Provided:

Pre-op Pre-op BariatricBariatric “To Do” List “To Do” List

___ Read the Nutritional Guidelines

___ Buy everything on shopping list

___ Follow low-calorie diet (to lose ~5% of start weight pre-op)

___ Keep daily food dairy(Measure & weigh all food & drinks)

___ Count daily protein & fluid intake

___ Begin taking vitamin/mineral supplements

___ Practice using approved protein supplements

___ Exercise: Goal = 30 minutes most days

___ Practice eating slowly (30min/meal)___ Practice drinking ONLY between meals; avoid drinking 30 minutes before & after eating

___ Avoid caffeine, soda, carbonation, juice, & sweetened beverages

___ Try Stage 4 (pureed & soft moist protein foods) for 2 full days

___ Attend support groups

Pre-Surgery Nutrition Education:Pre-Surgery Nutrition Education:Individual CounselingIndividual Counseling

••Min. 2 individual visits with Outpatient RDMin. 2 individual visits with Outpatient RD Re-enforce information provided at Re-enforce information provided at

Immersion DayImmersion Day Pre-op weight lossPre-op weight loss Practicing portion controlPracticing portion control Meal planningMeal planning Self-monitoring of eating & physical Self-monitoring of eating & physical

activityactivity Strategies to adopt more mindful eating Strategies to adopt more mindful eating

habitshabits Increasing regular physical activityIncreasing regular physical activity Increasing intake of fruits/vegetables/low-Increasing intake of fruits/vegetables/low-

fat dairy &proteins/whole grains/waterfat dairy &proteins/whole grains/water

Inpatient Bariatric DietInpatient Bariatric DietDiet stages 1-3Diet stages 1-3

Nutrition Consult ordered upon Nutrition Consult ordered upon admissionadmission Review diet progression, stages 1-3Review diet progression, stages 1-3 Discuss fluid intake journal: focused on Discuss fluid intake journal: focused on

hydration, sipping slowly, 1-4 oz/hour hydration, sipping slowly, 1-4 oz/hour between meals, no strawsbetween meals, no straws

Work with inpatient team to identify and Work with inpatient team to identify and minimize complications post-opminimize complications post-op

Confirm patient post-op RD appointmentConfirm patient post-op RD appointment

Inpatient Bariatric DietInpatient Bariatric DietDiet stages 1-3Diet stages 1-3

Stage 1: Water (provided by RN)Stage 1: Water (provided by RN) No strawsNo straws 1oz/hr1oz/hr Fluid intake journalFluid intake journal

Stage 2: Clear Liquids (standard tray)Stage 2: Clear Liquids (standard tray) Non-carbonated, caffeine-free, sugar-free:Non-carbonated, caffeine-free, sugar-free:

Water, diet cranberry juice, sugar-free jello and Water, diet cranberry juice, sugar-free jello and ice pops, broths, decaf coffee and teaice pops, broths, decaf coffee and tea

Stage 3: High Protein Full Liquids (self-order)Stage 3: High Protein Full Liquids (self-order) Low-fat, high protein food items:Low-fat, high protein food items:

Broth, low-fat milk, protein shakes (SF CIB), Broth, low-fat milk, protein shakes (SF CIB), tomato soup, low-fat yogurt, and diet custard/ tomato soup, low-fat yogurt, and diet custard/ puddingpudding

Bariatric Diet AdvancementBariatric Diet AdvancementDiet Stage 4Diet Stage 4

Stage 4: Soft & Moist ProteinStage 4: Soft & Moist Protein Start: 2 wks post-op; Duration 4-6 wksStart: 2 wks post-op; Duration 4-6 wks Examples of protein sources: Examples of protein sources:

Chicken salad made w/ low-fat mayonnaise Chicken salad made w/ low-fat mayonnaise Chili made w/ lean ground turkey/beefChili made w/ lean ground turkey/beef Moist fish/shellfishMoist fish/shellfish

Avoid fluids 30 min before & after each meal/snack. Avoid fluids 30 min before & after each meal/snack. Will begin taking chewable/liquid vitamin & mineral Will begin taking chewable/liquid vitamin & mineral

supplements.supplements. Multi-vitamin w/ iron 200% DRI, Vit D3 1000IU, Vit Multi-vitamin w/ iron 200% DRI, Vit D3 1000IU, Vit

B12 1000mcg, Calcium Citrate 1200-1500mg B12 1000mcg, Calcium Citrate 1200-1500mg Keep daily food journal. Keep daily food journal.

Bariatric Diet AdvancementBariatric Diet AdvancementDiet Stage 5Diet Stage 5

Stage 5: Low Fat, Low Sugar, High Protein Stage 5: Low Fat, Low Sugar, High Protein Start: 4-6 wks post-op; Duration: lifelong Start: 4-6 wks post-op; Duration: lifelong Balanced solid food diet. Balanced solid food diet. Continue to practice mindful eating & separate Continue to practice mindful eating & separate

fluids from your meals. fluids from your meals. Vitamin/Mineral supplementation for life. Vitamin/Mineral supplementation for life.

For More Information on Diet StagesFor More Information on Diet Stages Clinical Portal > Bariatric Center > Bariatric Clinical Portal > Bariatric Center > Bariatric

Nutrition Nutrition

Immediate (2wks- 12mo. post-op): * Diet Advancement

* Protein & Hydration Status * Vitamin & Mineral Status/ Supplementation * Lifestyle and Behavior Changes* Meal Planning & Appropriate Food Choices

Long-Term (>1yr post-op): * Prevention of Vitamin/Mineral Deficits & Deficiencies* Co-morbid Conditions (i.e. DM, HTN, Dyslipidemia)* Managing Changes to Bowel Habits* Promotion of a Balanced Diet* Weight Maintenance & Weight Loss* Exercise * Promotion of Self-Care* Lifestyle & Behavior Changes

Post-Op Nutrition & Support

Thank you!Thank you!

Dana Eiesland, RD, LDN Dana Eiesland, RD, LDN (outpatient)(outpatient)

617-499-6767617-499-6767 deieslan@mah.harvard.edudeieslan@mah.harvard.edu

Stacey A. Nelson, RD, LDN Stacey A. Nelson, RD, LDN (inpatient)(inpatient) Pager: #6052Pager: #6052 sanelson@mah.harvard.edusanelson@mah.harvard.edu

Postoperative Care Postoperative Care on N-3on N-3

Jessica Kaloyanides RNJessica Kaloyanides RN Marjorie Petit RN, BSNMarjorie Petit RN, BSN

PACU (Report from PACU PACU (Report from PACU RN- N3 RNRN- N3 RN

5 incisions total (one is JP drain)5 incisions total (one is JP drain) 100mg IV thiamine for all pts. on arrival 100mg IV thiamine for all pts. on arrival Hct within 2hrs : Drop of 4 points wait on Hct within 2hrs : Drop of 4 points wait on

transfer to floor/redraw transfer to floor/redraw If vomiting or spitting up blood CALL MDIf vomiting or spitting up blood CALL MD Wake to assess every 10 min during first hr Wake to assess every 10 min during first hr FentanylFentanyl Dilaudid Dilaudid PCA PCA Shoulder pain/left side trocar pain ( CO2 Shoulder pain/left side trocar pain ( CO2

gas in abd) gas in abd) Wean O2 to NCWean O2 to NC

Setup of the bariatric Setup of the bariatric roomroom

Bariatric bed – holds up to 750lbsBariatric bed – holds up to 750lbs Bariatric tray fits under each bariatric Bariatric tray fits under each bariatric

bedbed Telemetry monitor with continuous 02 Telemetry monitor with continuous 02

monitoringmonitoring Pneumatic Compression SleevesPneumatic Compression Sleeves Incentive spirometryIncentive spirometry Bariatric menuBariatric menu Moving IV pole: pt OOB ambulating Moving IV pole: pt OOB ambulating

same day as surgery (unless up to floor same day as surgery (unless up to floor too late)too late)

Bariatric room pic (plus say pt will have lap sites)Bariatric room pic (plus say pt will have lap sites)

Possible Complications: Possible Complications: AnastomoticAnastomotic Leak Leak

SymptomsSymptoms tachycardiatachycardia feverfever abdominal painabdominal pain purulent drain purulent drain

outputoutput nausea/vomiting nausea/vomiting shoulder painshoulder pain hypotension hypotension

TreatmentTreatment surgical vs medicalsurgical vs medical

stability of patient stability of patient size of leak size of leak

Possible Complications: Possible Complications:

Pulmonary EmbolismPulmonary Embolism Symptoms Symptoms

sudden SOB (active sudden SOB (active or @ rest)or @ rest)

chest painchest pain cough with bloody cough with bloody

sputumsputum tachycardia tachycardia leg swelling/weak leg swelling/weak

pulsepulse

Treatment Treatment CXR/CCTCXR/CCT anticoagulant anticoagulant

therapy therapy embolectomy embolectomy

Possible Complications: Possible Complications: PneumoniaPneumonia

Symptoms Symptoms classic symptomsclassic symptoms sudden onsetsudden onset fever/chillsfever/chills coughing coughing chest pain chest pain

Treatment Treatment CXRCXR antibiotics antibiotics

Possible Complications: Possible Complications: Small Bowel ObstructionSmall Bowel Obstruction

SymptomsSymptoms constipation constipation abdominal swellingabdominal swelling vomiting (green or vomiting (green or

fecal vomit)fecal vomit) passing jelly like passing jelly like

mucousmucous abdominal abdominal

cramping cramping

Treatment Treatment needs ABD CT/UGIneeds ABD CT/UGI Possible IR Possible IR

procedure (place procedure (place drain) or return to drain) or return to OROR

Possible Complications: Possible Complications: Internal Bleeding Internal Bleeding

(immediately post op)(immediately post op)

Symptoms Symptoms hypotensionhypotension tachycardiatachycardia decreased hctdecreased hct bloody drainage bloody drainage melenamelena

CausesCauses r/t internal organ r/t internal organ

damagedamage r/t stapled r/t stapled

anastomosis @ anastomosis @ sitessites

Possible Complications:Possible Complications:InfectionInfection

Symptoms:Symptoms: feverfever foul smelling odor foul smelling odor

from lap sites/drain from lap sites/drain sitessites

redness/warmth @ redness/warmth @ lap sites or drain lap sites or drain sitessites

yellow dischargeyellow discharge

TreatmentsTreatments antibioticsantibiotics

General Nursing General Nursing Guidelines:Guidelines:

ActivityActivity

Pt out of bed same day as surgery Pt out of bed same day as surgery Ambulate in hallway 3x per dayAmbulate in hallway 3x per day Out of bed to chair as much as Out of bed to chair as much as

tolerated tolerated IS 10x/hr while awake IS 10x/hr while awake

General General NursingNursing GuidelinesGuidelines

Foley DC post op day 2 Foley DC post op day 2 PCA pump/IV fluids DC post op day 2 PCA pump/IV fluids DC post op day 2

when pt tolerating liquids when pt tolerating liquids JP drain removed by MD post op day JP drain removed by MD post op day

2 2 abd incisions checked Q4abd incisions checked Q4 VS Q4VS Q4 Maintain accurate I’s/O’sMaintain accurate I’s/O’s

Bariatric DietBariatric Diet

Stage 1: Water Stage 1: Water Typically start day of surgeryTypically start day of surgery NO STRAWSNO STRAWS Nurse to administer 1oz water per hr Nurse to administer 1oz water per hr

via med cupvia med cup Sip slowly and stop if feeling fullSip slowly and stop if feeling full All meds in IV or liquid form All meds in IV or liquid form IV fluid until tolerating liquidIV fluid until tolerating liquid

Discharge InstructionsDischarge Instructions

Activity:Activity: walk inside/outsidewalk inside/outside may climb stairsmay climb stairs avoid rigorous exerciseavoid rigorous exercise

Pain: Pain: use pain meds as prescribeduse pain meds as prescribed pain should improve over time/ call MD pain should improve over time/ call MD

if pain is not under controlif pain is not under control

Discharge Instructions Discharge Instructions

Diet:Diet: stage 3 diet stage 3 diet each meal slowly over one houreach meal slowly over one hour drink at least 48 ounces of fluid per day, goal is drink at least 48 ounces of fluid per day, goal is

64 ounces per day64 ounces per day 60-80 grams protein a day60-80 grams protein a day no straws/no chewing gumno straws/no chewing gum

Incision Care:Incision Care: adhesive will fall off on its own adhesive will fall off on its own if incision reddened, thick drainage or foul odor if incision reddened, thick drainage or foul odor

- call MD - call MD

Discharge Instructions Discharge Instructions Meds:Meds:

one med at a timeone med at a time cut or crush large pillscut or crush large pills vitamins and calcium restarted @ post op visit vitamins and calcium restarted @ post op visit don’t take NSAIDS until checking with MD don’t take NSAIDS until checking with MD

Contact MD If:Contact MD If: uncontrolled nausea or vomiting uncontrolled nausea or vomiting unable to tolerate meal plan unable to tolerate meal plan redness, swelling or drainage @ incision site/ redness, swelling or drainage @ incision site/

fever of 101.4 or greaterfever of 101.4 or greater diarrhea more than 24hrs /constipation more diarrhea more than 24hrs /constipation more

than 5 daysthan 5 days

Patient TestimonialsPatient Testimonials

64 Year old female64 Year old female Surgery date: 7/20/2011Surgery date: 7/20/2011 ““My hospital experience was great. I’m My hospital experience was great. I’m

very pleased with the program. I’ve done very pleased with the program. I’ve done every diet and it’s gone nowhere. I was every diet and it’s gone nowhere. I was reluctant on surgery, but when I met the reluctant on surgery, but when I met the staff I was very impressed. I can’t say staff I was very impressed. I can’t say enough of Dr. Kim, she’s beyond great. enough of Dr. Kim, she’s beyond great. Everyone was positive and reinforcing. My Everyone was positive and reinforcing. My only regret is that I hadn’t done this only regret is that I hadn’t done this sooner!” sooner!”

Patient TestimonialsPatient Testimonials

34 Year old female34 Year old female Date of surgery: 8/1/2011Date of surgery: 8/1/2011 ““I’m feeling fantastic. The surgery I’m feeling fantastic. The surgery

has been a success. So far I’ve lost has been a success. So far I’ve lost almost 90 pounds, and it’s the almost 90 pounds, and it’s the most amazing thing I’ve ever most amazing thing I’ve ever experienced. Life changing. experienced. Life changing. Besides my kids it’s the most Besides my kids it’s the most wonderful thing I’ve ever done.”wonderful thing I’ve ever done.”

Patient TestimonialsPatient Testimonials

51 Year old female51 Year old female Date of surgery: 9/26/2011Date of surgery: 9/26/2011 ““Extremely thankful to the staff Extremely thankful to the staff

and couldn’t be happier with the and couldn’t be happier with the surgery! I’ve lost 60 pounds. I no surgery! I’ve lost 60 pounds. I no longer need insulin, and my longer need insulin, and my hypoactive thyroid is now hypoactive thyroid is now dormant.”dormant.”

Post-op Care and Follow-Post-op Care and Follow-upup

Lisa C. Luz RN, MSN, CBNLisa C. Luz RN, MSN, CBN

Follow-up:Initial Post-op visits 2 weeks, 6 weeks, 3 monthsGastric Band: adjustment visit every 3-6 weeksLabs: every three months x1 year; then every 6 monthsAnnual appointments after 2 years with Medical TeamPlastic SurgeryPregnancyLifetime Dietary, Behavior Modification, and Support Groups available to every patient!

Life long commitment

Support group

Nutrition classes

Exercise guidance

Guideline literature

Office visits

Newsletters, website, email and telephone follow-up

Weight Loss Surgery

Post-Op Care and Follow-up

Improvements in overall health

Improvements in quality of lifeLonger life expectancy

Resolution/Improvement of: Type 2 Diabetes AsthmaHigh blood pressure Skin problemsSleep apnea Bone and joint diseaseCancer InfertilityHeart disease Fatty liver diseaseHeartburn Urinary incontinence

Results of Bariatric Surgery

•Surgery is ONLY a tool

•Surgery is NOT for everyone

•Surgery HAS risks

•Surgery is NOT a cure but rather a treatment

•Surgery does NOT FAIL the patient, •the patient fails the surgery

•Long term effort and follow up •ARE ESSENTIAL for success

Some Surgery Truths

Patient SuccessesPatient Successes

“Rather than feel anger or revulsion toward this person, my first obligation, especially if I am in the helping professions is to understand him or her: to gain insight into what it is like to be him or her; to imagine and to interpret the world from his or her perspective of experience…”

Source: John Banja, PhD Obesity, Responsibility, and Empathy, The

Case Manager, Nov/Dec 2004

Thank you!Thank you!

Questions / CommentsQuestions / Comments