Obesity affects more than one-third of U.S. adults (Centers for Disease Control and Prevention). Obesity is defined by World Health Organization as an individual that has a BMI greater than 30. Obesity alone can hinder a person’s daily living lifestyle. However along with obesity come several co-morbidities that can affect a person’s health and lifestyle in a negative way. Obesity related conditions include heart disease, stroke, type two diabetes, hypertension, sleep apnea, and asthma. One alternative solution for obese patients’ to improve their quality of life is bariatric surgery. Bariatric surgery is the only weight loss method proven to achieve lasting, long term results (Kaser & Kukla., 2009, p. 3).
Bariatric surgery works on two principals: restriction and malabsorption (Kaser & Kukla. 2009 p. 3). Per Kaser & Kukla on page 3 of the Online Journal of Issues in Nursing there are 3 types of bariatric surgery available; One is the least invasive, uses an adjustable gastric band to adjust the size of the stomach and is reversible. The second one uses a sleeve that reduces the stomach and also eliminates some of the ghrelin hormone that is used to stimulate appetite. The last procedure divides the stomach to create 15-30 ml pouch and is connected directly to the small intestine. This procedure is the most common weight lost surgery performed in the US and makes up 80% of all bariatric procedures (Kaser & Kukla. 2009 p. 3). This paper will discuss the nurse’s role during the pre-op, intra-op, and post-op phases of bariatric surgery, including some of the complications that may arise, proper nursing interventions, and relevant nursing diagnoses with every phase of the patient’s procedure. Nurses play a large role in caring for patients who have bariatric surgery.
The nurses’ role starts in the evaluation phase during office visits and all the way through to post-operative care including follow up visits. During the preoperative phase the nurse works with the health care team of “…surgeons, dietitians, psychologist, bariatricians…during patient evaluation to help reinforce key points for successful surgical weight loss…” (Kaser & Kukla, 2009, p. 2) and provide on-going education regarding the patient’s current diet and future diet, activity, and the available surgical procedure options. The nurse ensures that the surgery is appropriate by ensuring the person has “….a BMI >40 or BMI >35 along with comorbid conditions, such as cardiovascular disease, sleep apnea, uncontrolled type two diabetes, and/or physical problems interfering with performance of daily activities” (Kaser & Kukla, 2009, p.2).
In the obese patient, “minimizing risk factors is directly connected with patients’ assessment in the preoperative period. Important physiopathologic changes occur in the cardiovascular, respiratory and gastrointestinal systems” (Tanaka, D., & Peniche, A. 2009 p.619). Nursing diagnoses that should be considered for preoperative bariatric surgery would be knowledge deficit, anxiety, nutritional imbalance (more than the body requirements), risk for impaired skin integrity, and ineffective breathing pattern related to morbid obesity and/or comorbidities (Drake, McAuliffe. 2012 p.6). “The key to an effective and safe bariatric patient handling program is to be prepared prior to the admission” (Muir & Archer-Heese, 2009, pg.2). “Studies have demonstrated that over 50% of bariatric-surgery patients have a concurrent diagnosis of anxiety, depression, or a psychological disorder” (Kaser & Kukla, 2009, p.6).
“Ensure the patient understands the lifestyle changes that are required for a safe, successful, postoperative course including a lifelong commitment to revised eating patterns, vitamin supplementation, and regular monitoring by their healthcare provider” (Kaser & Kukla, 2009, p. 2). The nurse can provide care during the intraoperative phase by making sure the operating room is sufficient in size, the equipment can accommodate obese patient size by having stretchers with a 1,000 pound capacity and extra width, bariatric bed with expandable deck with power assisted for moving, and a built-in scale (Muir & Kukla 2009 p. 4). Some of the most frequently practiced nursing diagnoses for the patient during bariatric surgery would be risk for ineffective airway, and risk for hypothermia. Bariatric surgery patients are especially susceptible to an ineffective airway during surgery because these patients “…tend to have decreased lung expansion due to an elevated diaphragm as well as less compliant lungs and chest walls…layers of fat on the chest wall and abdomen along with an elevated diaphragm increase the work of breathing” (Drake, D. J., & Lopez, C. C., 2005, p.5). It is the nurse’s job to closely monitor the patient’s work of breathing during surgery to ensure no complications arise.
Along with the post-op phase of bariatric surgery come an array of nursing interventions and much needed education for the patient. While the patient is fully aware of the lifestyle changes they must make before surgery is even performed, it now comes to a point where they must act on those changes with full confidence and tenacity if the procedure is to be a life-long success. Some common nursing diagnoses for post-op bariatric surgery include risk for nutritional imbalance (less than body requirements), risk for infection, risk for unstable blood glucose level, risk for impaired tissue integrity, mainly the tissue lining the stomach, and readiness for enhanced self-health management. Diet must be completely altered following surgery. Bariatric surgery patients are given a “strict diet post-operatively that regulates the consistency, volume, nutritional and chemical makeup of foods…nurses must understand diet recommendations for the immediate postoperative period and assist the patient in understanding the importance of adherence” (Drake, D. J., & Lopez, C. C., 2005, p.6).
Diet compliance is of great importance, but there are other very important interventions to take into account after bariatric surgery. Three important aspects of nursing care include pain management, wound and skin care, and venous thromboembolism prophylaxis. “Pulmonary embolism is the second most common cause of mortality in bariatric-surgery patients” (Kaser & Kukla, 2009, p.4). DVT’s and VTE’s can be easily avoided when the proper nursing interventions are practiced. “…turning, coughing, and deep breathing (incentive spirometry) are the tried and true nursing interventions for pulmonary care in the postoperative surgical patient” (Kaser & Kukla, 2009, p.5). As with wound care, patients should be careful with coughing or possible nausea leading to vomiting due to chances of dehiscence of the surgical incision sites.
Proper nursing care for wounds should be practiced, including “observing for signs of infection, and keeping the dressings clean and dry…treatment of nausea and prevention of vomiting are important during the postoperative phase” (Kaser & Kukla, 2009, p.4). In conclusion the nurses’ role goes beyond providing direct nursing care in the preoperative, intraoperative, and postoperative phases. For nurses’ to be successful in caring for bariatric patients they need to look at their own personal attitudes and biases. Make sure they are treating the individual, not making assumption on the person’s character, intelligence, or health status based off their weight, be respectful and do not blame. Nurses need to treat the psychosocial aspect of the specific needs of the bariatric patient by giving them appropriate feedback and encourage healthful behaviors. All of these will make for a successful outcome for the patient. Bariatric surgery is a health promoting and life-sustaining intervention (Drake, D. J., & Lopez, C. C., 2005, p.7).
Centers for Disease Control and Prevention. Overweight and Obesity; Retrieved from: http://www.cdc.gov/obesity/data/adult.html Drake, D. J., & Lopez, C. C. (2005). Postoperative nursing care of patients after bariatric surgery. Perspectives, 6, 1-5. Grindel, M., & Grindel, C. (2006). Nursing care of the person having bariatric surgery. MEDSURG Nursing, 15(3), 129-146. Kaser, N., Kukla, A., (January 31, 2009). “Weight-Loss Surgery”. OJIN: The Online Journal of Issues in Nursing Vol. 14, No. 1, Manuscript 4. Retrieved from: http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No1Jan09/Weight-Loss-Surgery.html Tanaka, D., & Peniche, A. (2009). Perioperative care for morbid obese patient undergoing bariatric surgery: challenges for nurses [Portuguese]. Acta Paulista De Enfermagem, 22(5), 618-623.