Post-Operative Care for Bariatric Surgery

Bariatric surgical candidates spend many months preparing for weight loss surgery. Support groups, pre-operative classes, psychological assessments, nutritional information sessions, and multiple physician visits with various tests and procedures are all part of the educational process to assist patients in making the lifestyle changes needed to be made in order to have a successful post=operative course. The greater the motivation and readiness to better understand the challenges and emotional issues that will present, the better chance of a successful journey toward a healthier lifestyle.

The education patients receive pre-operative and post -operative from their surgeons, bariatric coordinators, dietitians, and psychiatrists is extremely valuable. The more information and assistance the multidisciplinary team can give the patient during this time, the less chance issues will arise and the more comfortable the patient will be. The ultimate goal of patient education is to enable patients to be responsible for their own healthcare. Patient education is a planned experience designed to change or improve health behaviors and health status, and in evidence-based practice, is based on the best information available. Patient education is a systematic way of introducing new information, events, skills, or objects into the patient’s environment. 1Setting goals and creating catchy algorithms are some of the tools that help patients remember what will help them in their postoperative course.

One of the algorithms I have found to be helpful in the immediate postoperative time period of the bariatric patient is H-A-P-I. H-A-P-I stands for hydration, ambulation, protein,and incentive sprirometry.

We want all of our patients to be H-A-P-I. H-A-P-I patients are patients that move forward even though they may be uncomfortable initially following surgery. A H-A-P-I patient is one who knows what is expected of them and works within the restraints they are given. So, what does H-A-P-I mean?

Hydratian
H stands for HYDRATION. The goal is to sip. Sipping fluids and staying hydrated will prevent patients from developing dehydration. Dehydration can occur for multiple reasons and is very common during the first 6 months postoperatively. The first challenge is the very small surgical pouch that remains after bariatric surgery that limits the volume of liquid that can be consumed at any one time. Furthermore, fluid loss can result from “dumping” syndrome that can occur when patients try to combine fluid with solid foods or have high-sugar foods like ice cream or pastries. Vomiting is another commonly reported problem that increases the risk for dehydration. Patients must quickly learn how to chew food to a soft consistency and must drastically limit portions. Failing to comply with the diet can lead to vomiting. Maintaining proper hydration can help ward off the cycle of nausea, to vomiting episodes, to dehydration, and repeat nausea.2

Initially, many patients need to be reminded to slow down; taking in too much fluid at one time can be painful. If patients have trouble sipping, instruct them to slow down, take the cap off of the water bottle, pour the fluid into the cap and then sip from the cap. Fluids should be sipped, not gulped and frequent sips will help the patient stay hydrated. Remind the patient that initially fluid intake may be challenging. With time and patience, adequate intake will be attained.

Ambulation
A stands for AMBULATION. The benefits of mobility outlined in current nursing textbooks indicate, “Early ambulation is the most significant general nursing measure to prevent postoperative complications”. The benefits of ambulating in the early post-operative period include stimulation of circulation, prevention of deep venous thrombosis/pulmonary embolism, coordination and independence, improved gastrointestinal, genitourinary and pulmonary functions.3The goal is to stay out of bed during the day, sit up in the chair and walk frequently. All patients are prepared pre operatively and understand that they will be out of bed the day of surgery.

Protein
P stands for PROTEIN. The American Society for Metabolic and Bariatric Surgery guidelines indicate that every bariatric patient should have a pre-operative consultation with a dietitian. This consultation should educate the patient on the need for proper and adequate amounts of protein pre operatively and post operatively. Dietary consults provide a means for the patient to go over meal plans, track foods, learn about mindful eating, and discuss compulsive eating behavior, triggers and other plans of action that could aid the patient into a successful weight loss journey.

Bariatric surgery a highly successful treatment for obesity requires adherence to special dietary recommendations to insure the achievement of weight loss goals and weight maintenance. Postoperative consumption of protein is linked to satiety induction, nutritional status, and weight loss. The quality and composition of protein sources are also very important, particularly with respect to the quantity of leucine, which helps to maintain muscle mass, and thus is particularly important for this patient group.We remind patients that they need to reference their dietary materials as prescribed by their weight loss management team. They need to increase protein intake daily in order to continue the healing process, continue to lose weight and sustain energy.

Incentive Spirometer
I stands for INCENTIVE SPIROMETER. Previous studies have suggested that between 17% and 88% of people having surgery on the upper abdomen will suffer complications that affect their lungs after the operation (postoperative A pulmonary complications). The lung volume tends to fall after such surgeries. These complications can be made less likely and less severe with the careful use of treatments designed to encourage breathing in(inspiration) and thus increasing the volume of the lungs, as these volumes tend to fall after such surgeries. Incentive spirometers are mechanical devices developed to help people take long, deep, and slow breaths to increase lung inflation.5

SEE ALSO: Earn CE: Treatment of Obesity

Our patients are encouraged to cough, take deep breaths, and use their incentive spirometer every hour while awake. They are also given the apparatus to take home and use for at least the first week after surgery. We give them simple reminders to help them remember when they are home such as every time they see a commercial, take a walk or sip fluids.

When I educate the bariatric patient in the hospital and discuss H-A-P-I, they often initially chuckle. Postoperative day one is difficult; everything is a struggle. Our patients’ mouths are dry from having nothing to drink or eat since midnight before the day of surgery, they are using their pain controlled anesthesia medication and they are wondering what they have done. The most important thing we can do as part of their health care team is support them and make them feel comfortable. Giving patients the knowledge they need to prevent complications after surgery is one way to make them H-A-P-I.

References

1. How can a nurse practitioner improve patient compliance and patient education in a perioperative setting? . (2008, January). Medscape ,1-3. Retrieved from http://www.medscape.com/viewarticle/566301-5.
2. Hemphill, S., & Gorman, K. (2009). Staying hydrated after bariatric surgery. Obesity Management, 5(3), 128-129. doi:http://dx.doi.org/10.1089/obe.2009.0308.
3. Lewis S. L., Heitkemper M. M., Dirksen S. R. (Eds.). (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 401-407). St. Louis, MO: Mosby.
4. Faria, S. L., Faria, O. P., Buffington, C., de, A. C., & Ito, M. K. (2011). Dietary protein intake and bariatric surgery patients: A review. Obesity Surgery, 21(11), 1798-805. doi:http://dx.doi.org/10.1007/s11695-011-0441-y.
5. Incentive spirometry for prevention of postoperative pulmonary complications after upper abdominal surgery. (2014). Pub Med Health. Retrieved from http://www.ncbi.nlm.nhi.gov/pubmedhealth/PMH0013700/.

Roseann DeLuca is bariatric coordinator at Good Samaritan Hospital Medical Center.

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