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Perioperative Nursing Care of the Bariatric Surgical Patient

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Title: Perioperative Nursing Care of the Bariatric Surgical Patient


1
Perioperative Nursing Care of the Bariatric
Surgical Patient
  • Patricia Ide, RN, MS, CNOR
  • Elliott Farber, MD
  • David Lautz, MD

2
Background
  • 60 of the US population is overweight
  • 30.5 of the population is obese
  • 300,000 deaths per year
  • Prevalence is steadily increasing in
  • Both genders
  • All ages
  • All ethnic and racial groups
  • And all geographical locations across the US

3
Bariatric Surgery
  • Currently the most effective means of losing
    substantial weight and maintaining the weight
    loss is Bariatric Surgery
  • From the Greek words
  • Baros, that is weight and
  • -iatreia, that is medical treatment

4
Knowledge Deficits of Caregivers
  • 16 Patients died in Massachusetts between March
    1, 2003 and October 31, 2004
  • Sepsis and pulmonary emboli were contributing
    factors or the cause of death in 10 of the 16
    cases
  • Number one trend noted in the review of all 16
    mortalities was knowledge deficit

5
Defining Overweight and Obesity
  • Body Mass Index (BMI) has become the medical
    standard to measure overweight and obesity
  • Calculation to determine BMI
  • Weight in kilograms divided by the square of the
    patients height in meters
  • Many BMI tables are also available

6
Weight Categories by Body Mass Index
  • Underweight lt18.5
  • Normal 18.5-24.99
  • Overweight 25-26.99
  • Mild Obesity 27-30
  • Moderate Obesity gt30
  • Severe Obesity gt35
  • Morbid Obesity gt40
  • Super Obesity gt50

7
Patient Selection
  • gt 18 years old
  • Fully understand the surgery, required life style
    changes and lifetime medical care
  • Have made numerous attempts at medical weight
    loss
  • Severely obese
  • BMIgt35 with at least one co morbidity
  • BMIgt40

8
Most Common Bariatric Procedures
  • Roux-en-Y Gastric Bypass
  • Laparoscopic Adjustable Gastric Banding

9
Roux-en-Y Gastric Bypass
10
Laparoscopic Adjustable Gastric Banding
11
RYGBP Benefits/Disadvantages
  • Initial rapid weight loss
  • Higher total weight loss is reported
  • 2/3 of patients will lose 2/3 of their excess
    weight
  • 1/3 of patients will achieve ideal weight
  • Dumping syndrome
  • Cannot evaluate
  • Nutritional Deficiencies
  • Extremely difficult to reverse
  • Mild weight gain gt2yr
  • Higher mortality
  • Other complications

12
LAGB Advantages/Disadvantages
  • Lowest mortality and complication rates
  • Least invasive
  • Reversible/adjustable
  • Less malnutrition
  • Less hospitalization and faster recovery
  • Initial weight loss is slower and variable
  • Requires implant of a surgical device and its
    management
  • Band slippage and erosion
  • Band intolerance
  • Inadequate weight loss

13
The Obese Patient High Risk
  • Preoperative evaluation includes an evaluation of
    the medical consequences of the patients morbid
    obesity, in particular the cardiovascular and
    respiratory systems

14
Cardiovascular Concerns
  • Increased cardiac afterload, decreased oxygen
    supply, increased risk of CAD, all lead to left
    ventricular hypertrophy
  • Right ventricular failure can be caused by
    chronic hypoxemia, hypercarbia, polycythemia, and
    pulmonary hypertension
  • The patients body is forced to do more with less

15
Cardiac Concerns
  • Prone to heart disease
  • Weight of abdominal wall on aorta and vena cava
    may impede circulation of oxygenated blood
  • Heart rate can be increased/decreased
  • Slowed conduction
  • Ischemia
  • Past MI

16
Cardiac Concerns
  • Assure proper defibrillator is available
  • Be aware of patients HX, normal heart rhythm, HCT

17
Respiratory Concerns
  • Little respiratory reserves and O2 desaturates
    quickly
  • Increased oxygen consumption and increased CO2
    production require increased ventilation
  • SOB due to increased metabolic needs
  • Often have sleep apnea or asthma
  • Should bring CPAP to hospital

18
Respiratory Concerns
  • Assess patients ability to lie flat and optimal
    position
  • May experience asphyxiation or gastric reflux
  • Cricoid pressure may be necessary to assist with
    view and prevent aspiration

19
Respiratory Concerns
  • Failed intubation is one of gravest risks
  • Sleep apnea usually indicates a low chance of
    successful masking of patient
  • Pre-induction includes prolonged pre-oxygenation
    to maximize O2 reserves
  • Vocal cord visualization is difficult
  • Lack cervical neck mobility
  • May require awake intubation

20
Respiratory Concerns
  • Contingency planning is costly
  • Assure entire team is present and aware of plan
  • Difficult airway cart available
  • Patients inhalers
  • Laryngeal intubating mask/bronchoscopes
  • Trach kit and tubes available

21
Vascular Concerns
  • Increased risk for DVT/PE
  • IV access is difficult
  • Apply compression boots
  • Assure no tourniquet effects
  • Administer preop SQ Heparin
  • Ambulate patient DOS

22
Musculoskeletal and Nervous System Concerns
  • Strain of the weight impacts positioning
  • Risk for nerve injury--lt85 degree abduction of
    arms
  • Risk of injury due to steep reverse
    trendelenburg, need foot props
  • Assure OR bed meets manufacturers
    recommendations
  • Risk of dislocation of knees and ankles

23
Musculoskeletal and Nervous System Concerns
  • Arrange for postop bariatric bed if greater than
    350 lbs, if patient cannot move well, or needs
    additional space to turn side to side
  • Fat tissue delays medication absorption and is
    later stored in the fat
  • May require more meds
  • Avoid IM injectionsmay not be muscle

24
Musculoskeletal and Nervous System Concerns
  • Highly varied rate of medication absorption
  • May contribute to unpredictable emergence and
    re-emergence from anesthesia

25
Skin Injuries
  • Patients are obese but may be malnourished
  • Assure mattresses are in good condition
  • No sliding on the bedcreates shearing
  • Keep skin crevices clean and dry
  • Feet snug against foot supports
  • Pad pressure points

26
Fluid Management Concerns
  • Pneumoperitoneum may be responsible for transient
    oliguria during surgeryby placing pressure on
    the renal cortex and inferior vena cava
  • Therefore fluid management can be difficult

27
Psychosocial Concerns
  • Preop medication is minimized
  • Anxiety is increased
  • Stay with patient and have knowledge of bariatric
    surgery
  • Be prepared
  • Provide warmth and comfort

28
Sensitivity Training
  • It is said that obesity is the last social
    acceptable form of prejudice
  • Society values slenderness and equates it to
    youth, success, happiness and social
    acceptability

29
Nursing Survey Related to Obesity
  • Nurses self reported agreement with the following
    beliefs
  • Obese are not successful (24)
  • Obese are overindulgent (43)
  • Obese are lazy (22)
  • Obese experience unresolved anger (33)

30
Other Nursing Beliefs
  • Obesity can be prevented with self-control (63)
  • Felt uncomfortable caring for an obese patient
    (48)
  • Would prefer not to care for obese patients (31)
  • Hospital nurses do not experience with the
    patient their recovery, weight loss and
    improvement of health and quality of life

31
Strategies for Obesity Bias
  • Recognize complex etiology of obesity and its
    multiple contributors
  • Acknowledge the difficulty of achieving and
    sustaining weight loss
  • Recognize many patients have had many attempts to
    lose weight
  • Recognize that patients have had negative
    experiences with healthcare providers

32
Strategies
  • Explore all causes of patients presenting health
    problems and do not attribute all problems to the
    patients weight
  • Emphasize importance of behavioral changes and
    not just weight loss
  • Recognize that small weight losses can result in
    meaningful health results
  • Patients deserve to receive non-discriminatory,
    appropriate treatment and care

33
Modest Goals Help
  • 5-10 weight loss decreases HTN
  • 5-7 weight loss can prevent Type II Diabetes for
    people at high risk

34
Outlook
  • View patient as suffering from a chronic disease
    with bariatric surgery seen as a treatment option
    for that chronic disease

35
OR Complications
  • Hypothermia
  • Intra-abdominal injury
  • Anastomotic leaks
  • Retained foreign bodies
  • Postop Infections
  • Anesthesia complications

36
Postoperative Complications
  • Worsening abdominal pain
  • Chest pain
  • Shortness of breath
  • Leg pain
  • Swelling/redness of incisions
  • Fever
  • Persistent tachycardia

37
Postoperative Complications
  • Nausea and vomiting
  • Inability to swallow
  • Something wrong, patient not acting like self

38
Post Anesthesia Care
  • Standard handoff report
  • BMI
  • Optimal positioning
  • Management of risky airway
  • IV narcotics and PCA for pain control

39
Long Term Care is for Life
  • Management of complications
  • Prevention of nutritional deficiencies
  • Assistance with psychological adjustments
  • Management of co morbid conditions
  • Medication management
  • Prevention and management of long term weight loss

40
Conclusions
  • Many surgeons report that bariatric patients are
    among the happiest and most appreciative
  • Patients return to the hospital usually for life
  • Some patients do have buyers remorse
  • Patients experience marked improvement in health
    and often can stop medications

41
Conclusions
  • Study (Hager) measured quality of life and found
    improvement in
  • Physical functioning
  • Self esteem
  • Sexual life
  • Work

42
Further Research
  • Bariatric surgery has endless opportunities for
    research
  • New field
  • Further study is needed to support, guide or
    change current standards of care for the
    bariatric patient

43
For More Information
  • Weight Control Information Network, US Dept of
    Health and Human Services, http//win.niddk.nih.go
    v/publications
  • Commonwealth of Massachusetts Betsy Lehman Center
    for Public Safety and Medical Error Reduction
    Expert Panel on Weight Loss Surgery Executive
    Report Obes Res. 200513(2)205-305

44
For More Information
  • AORN bariatric surgery and guideline. In
    Perioperative Standards and Recommended
    Practices, AORN, 200867-85
  • Gregory Crum BS. Practicing safe care of the
    bariatric population. Perioperative Nursing
    Clinics. 20061(1)67-71.
  • Ide, Farber, Lautz. Perioperative Nursing Care of
    the Bariatric Surgical Patient. AORN 2008
    88(1)30-58
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