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Nursing Grand Rounds

Nursing Grand Rounds. Care of the Bariatric Patient February 15, 2012. Needham 3: Jessica Kaloyanides, RN Marjorie Petit, RN, BSN Kayleen Sussman, RN Kelly Donahue, RN, BSN Operating Room : Eric Starble, RN, BSN, CNOR Leslie Schneiderhan, RN, BSN, MEd, CNOR

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Nursing Grand Rounds

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  1. Nursing Grand Rounds Care of the Bariatric Patient February 15, 2012

  2. Needham 3: Jessica Kaloyanides, RN Marjorie Petit, RN, BSN Kayleen Sussman, RN Kelly Donahue, RN, BSN Operating Room: Eric Starble, RN, BSN, CNOR Leslie Schneiderhan, RN, BSN, MEd, CNOR Al Ghilardi Orthopedic Tech Photography Weight Management Center: Lisa C. Luz, RN, MSN, CBN Nutrition: Dana Eiesland, RD, LDN Stacey A. Nelson, BS, RD, LDN Presented and Planned by:

  3. Obesity • Obesity is defined as having an excessive amount of body fat. • Doctors often use Body Mass Index to determine obesity BMI Weight status Below 18.5 Underweight 18.5 -24.9 Normal 25.0 -29.9 Overweight 30.0 and higher Obese 40.0 and higher Morbid obesity

  4. Obesity in the US • About one-third of U.S. adults (33.8%) are obese. (Center for Disease Control and Prevention) • During past 20 years there has been a dramatic increase in obesity in the United States

  5. Obesity results in many co-morbidities such as: sleep apnea joint disease hypertension stroke diabetes respiratory diseases World health organization estimated that being overweight and inactive accounts for ¼-1/3 of all cancers of the breast, colon, endometrium, kidney, and esophagus The Dangers of Obesity

  6. Obesity Attitudes in Health Care • self-report studies show that physicians, nurses, and other medical personnel view obese patients as: • non-compliant • lazy • dishonest • lacking in self-control • unsuccessful • sloppy

  7. Surgical Weight Management Lisa C. Luz, RN, MSN, CBN

  8. Surgical Weight Management • Under the direction of expert bariatric surgeons: • Julie Kim, MD, FACS • Associates from TMC: • Dr. Abeles, Dr. Shah, Dr. Tarnoff, fellows • Multidisciplinary Team • Dietitian • Psychologist • Program Coordinator/Nurse • Insurance Specialist

  9. Who is a Surgical Candidate? • Meets National Institutes of Health Criteria: • BMI > 40 • >35 with significant obesity-related co-morbidities • 18 years or older • No endocrine cause of obesity • Stable psychological condition • Absence of drug or alcohol problem/Non-Smoking • Understands surgery and risks • Acceptable operative risks (patient and procedure) • Consensus after bariatric team evaluation: • psychologist, dietitian, surgeon • Dedicated to lifestyle change and follow-up

  10. The Surgical Process • Information Session • Preliminary Application • Health History Questionnaire • Immersion Day • Psychologist/Behavioral Assessment • Nutritional Counseling • Medical Clearance from PCP or Specialist • Medical Testing: Labs, X-ray, EKG • Consultation with Surgeon • Support Groups • Insurance Approval

  11. The Surgical Process • Mental Health Evaluation • Preparing for new Life • Identify the support needed to be successful • Individual Nutrition Appointments • Minimum 2 visits (for insurance approval) • Individual Diet Planning and Education • Medical Testing • Labs, Chest X-ray, EKG and any testing TBD by team

  12. The Surgical Process • Surgical Consultation • One on One consultation to answer all questions and individual concerns • Medical Clearance • By PCP, or specialist • Support Groups~ Make the Difference • This process takes approximately 3-6 months!

  13. Bariatric SurgeryEric Starble RN

  14. Review of the Digestive System • Esophagus • Stomach • Small Intestine(Duodenum, Jejunum, Ileum) • Large Intestine

  15. Bariatric Surgery Today Three Types of Most Commonly Performed Bariatric Surgery Procedures Malabsorptive Restrictive Combination Biliopancreatic Diversion with Duodenal Switch Adjustable Band Gastroplasty Roux-en-Y Gastric Bypass

  16. Restrictive Surgery • Relatively easy surgical procedure • Less dietary deficiencies • Less weight loss • More late failures due to dilation • Less effective with sweet eaters • Significant dietary compliance Adjustable Band Gastroplasty

  17. Malabsorptive Surgery • Greater sustained weight loss with less dietary compliance • Increased risk of malnutrition and vitamin deficiency • Constant follow–up to monitor increased risk • Intermittent diarrhea Biliopancreatic Diversion with Duodenal Switch

  18. Laparoscopic Sleeve Gastrectomy • Restrictive procedure • Purpose: Suppression of hunger hormones • No intestinal connection • Considered a standard procedure by national society (ASMBS) • Newer procedure • Covered by many but not all insurance companies

  19. Mechanics of Sleeve Gastrectomy • Permanent removal of the lateral portion of the stomach • Creates a long, narrow, "banana" shaped stomach or "sleeve" • Reduces the capacity of the stomach by 2/3rds • No foreign body or needle sticks required • The body's natural pyloric and gastroesophageal valve act to restrict the passage of food with removal of many of the hunger hormones

  20. Laparoscopic Sleeve Gastrectomy

  21. Roux-en-Y Gastric-Bypass • Long-term sustained weight loss • No protein-calorie malabsorption • Little vitamin or mineral deficiencies • Technically difficult procedure Roux-en-Y Gastric Bypass

  22. The Roux-en-Y Gastric Bypass • A small, 15 to 20cc, pouch is created at the top of the stomach. • The small bowel is divided. The biliopancreatic limb is reattached to the small bowel. • The other end is connected to the pouch, creating the Roux limb. Roux-en-Y Gastric Bypass

  23. Roux-en-Y Gastric Bypass • Small pouch releases food slowly, causing a sensation of fullness with very little food • Biliopancreatic limb preserves the action of the digestive tract

  24. Open Increased post op pain, longer hospitalizations Increased incidence of wound complications - infections, hernias, seromas Return to work in 4-8 weeks Laparoscopic Less post op pain, early mobility Wound complications are significantly reduced 2-3 day hospital stay Return to work in 1-3 weeks Open and Laparoscopic Technique in Bariatric Surgery

  25. What Happens in the OR?

  26. Bariatric Surgery:Beyond the Surgery • Bariatric Surgery will NOT work alone • Intricate parts of your weight loss success: Commitment to: • Diet • Exercise • Support groups

  27. Resolution of Comorbidities Schauer, et al, Ann Surg 2000 Oct;232(4):515-29

  28. Possible Complications • May Lead to Short or Long-term Hospitalization and/or Re-operation • Infection, bleeding or leaking at suture/staple lines • Blockage of the intestines or pouch • Dehydration • Blood clots in legs or lungs • Vitamin and mineral deficiency • Protein malnutrition • Incisional hernia • Death

  29. Possible Side Effects • Nausea and vomiting • Gas and bloating • Dumping syndrome • Lactose intolerance • Temporary hair thinning • Depression and psychological distress • Changes in bowel habits such as diarrhea, constipation, gas and/or foul smelling stool

  30. Post-Operative Summary On Average, Gastric-bypass Patients… • Lose 65-80% of their excess body weight, the majority of it in the first 18 to 24 months after surgery. • May have rapid improvements in the morbid side effects of their obesity, such as type 2 diabetes, high blood pressure, sleep apnea, and high cholesterol levels.

  31. Dana Eiesland, RD, LDN Stacey A. Nelson, RD, LDN Bariatric Surgery Nutrition Education

  32. Pre-Surgery Nutrition Education : Immersion Day Education Provided: • 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 • Post-op diet progression • Long-term food selection guidelines • Fluid guidelines • Protein supplements • Vitamin & mineral supplementation • Reading nutrition fact labels

  33. Pre-op Bariatric “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

  34. Pre-Surgery Nutrition Education:Individual Counseling •Min. 2 individual visits with Outpatient RD • Re-enforce information provided at Immersion Day • Pre-op weight loss • Practicing portion control • Meal planning • Self-monitoring of eating & physical activity • Strategies to adopt more mindful eating habits • Increasing regular physical activity • Increasing intake of fruits/vegetables/low-fat dairy &proteins/whole grains/water

  35. Inpatient Bariatric DietDiet stages 1-3 • Nutrition Consult ordered upon admission • Review diet progression, stages 1-3 • Discuss fluid intake journal: focused on hydration, sipping slowly, 1-4 oz/hour between meals, no straws • Work with inpatient team to identify and minimize complications post-op • Confirm patient post-op RD appointment

  36. Inpatient Bariatric DietDiet stages 1-3 • Stage 1: Water (provided by RN) • No straws • 1oz/hr • Fluid intake journal • Stage 2: Clear Liquids (standard tray) • Non-carbonated, caffeine-free, sugar-free: • Water, diet cranberry juice, sugar-free jello and ice pops, broths, decaf coffee and tea • Stage 3: High Protein Full Liquids (self-order) • Low-fat, high protein food items: • Broth, low-fat milk, protein shakes (SF CIB), tomato soup, low-fat yogurt, and diet custard/ pudding

  37. Bariatric Diet AdvancementDiet Stage 4 • Stage 4: Soft & Moist Protein • Start: 2 wks post-op; Duration 4-6 wks • Examples of protein sources: • Chicken salad made w/ low-fat mayonnaise • Chili made w/ lean ground turkey/beef • Moist fish/shellfish • Avoid fluids 30 min before & after each meal/snack. • Will begin taking chewable/liquid vitamin & mineral supplements. • Multi-vitamin w/ iron 200% DRI, Vit D3 1000IU, Vit B12 1000mcg, Calcium Citrate 1200-1500mg • Keep daily food journal.

  38. Bariatric Diet AdvancementDiet Stage 5 • Stage 5: Low Fat, Low Sugar, High Protein • Start: 4-6 wks post-op; Duration: lifelong • Balanced solid food diet. • Continue to practice mindful eating & separate fluids from your meals. • Vitamin/Mineral supplementation for life. • For More Information on Diet Stages • Clinical Portal > Bariatric Center > Bariatric Nutrition

  39. Post-Op Nutrition & Support • 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

  40. Thank you! • Dana Eiesland, RD, LDN (outpatient) • 617-499-6767 • deieslan@mah.harvard.edu • Stacey A. Nelson, RD, LDN (inpatient) • Pager: #6052 • sanelson@mah.harvard.edu

  41. Postoperative Care on N-3 • Jessica Kaloyanides RN • Marjorie Petit RN, BSN

  42. PACU (Report from PACU RN- N3 RN • 5 incisions total (one is JP drain) • 100mg IV thiamine for all pts. on arrival • Hct within 2hrs : Drop of 4 points wait on transfer to floor/redraw • If vomiting or spitting up blood CALL MD • Wake to assess every 10 min during first hr • Fentanyl Dilaudid PCA • Shoulder pain/left side trocar pain ( CO2 gas in abd) • Wean O2 to NC

  43. Setup of the bariatric room • Bariatric bed – holds up to 750lbs • Bariatric tray fits under each bariatric bed • Telemetry monitor with continuous 02 monitoring • Pneumatic Compression Sleeves • Incentive spirometry • Bariatric menu • Moving IV pole: pt OOB ambulating same day as surgery (unless up to floor too late)

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

  45. Symptoms tachycardia fever abdominal pain purulent drain output nausea/vomiting shoulder pain hypotension Treatment surgical vs medical stability of patient size of leak Possible Complications: Anastomotic Leak

  46. Symptoms sudden SOB (active or @ rest) chest pain cough with bloody sputum tachycardia leg swelling/weak pulse Treatment CXR/CCT anticoagulant therapy embolectomy Possible Complications: Pulmonary Embolism

  47. Symptoms classic symptoms sudden onset fever/chills coughing chest pain Treatment CXR antibiotics Possible Complications: Pneumonia

  48. Symptoms constipation abdominal swelling vomiting (green or fecal vomit) passing jelly like mucous abdominal cramping Treatment needs ABD CT/UGI Possible IR procedure (place drain) or return to OR Possible Complications: Small Bowel Obstruction

  49. Symptoms hypotension tachycardia decreased hct bloody drainage melena Causes r/t internal organ damage r/t stapled anastomosis @ sites Possible Complications: Internal Bleeding (immediately post op)

  50. Symptoms: fever foul smelling odor from lap sites/drain sites redness/warmth @ lap sites or drain sites yellow discharge Treatments antibiotics Possible Complications:Infection

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