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CONTINUING EDUCATION
The Bariatric Patient: An
Overview of Perioperative Care
2.1
www.aorn.org/CE
JENNIFER L. FENCL, DNP, RN, CNS-BC, CNOR;
ANGELA WALSH, MA, BSN, RN, CNOR; DAWN VOCKE, MSN, MBA, RN, CNOR
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Purpose/Goal
To provide the learner with knowledge specific to obesity and
how to provide care for patients undergoing bariatric surgery.
Objectives
1.
2.
3.
4.
Discuss obesity trends in the United States.
Identify the classifications for obesity.
Describe comorbidities that accompany obesity.
Discuss the social ramifications of being obese.
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AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s
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AORN is provider-approved by the California Board of
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Conflict-of-Interest Disclosures
The behavioral objectives for this program were created by
Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms
Bakewell have no declared affiliations that could be perceived
as posing potential conflicts of interest in the publication of
this article.
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No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as CE for RNs. This
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mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.05.007
ª AORN, Inc, 2015
116 j AORN Journal
www.aornjournal.org
The Bariatric Patient: An
Overview of Perioperative Care
2.1
www.aorn.org/CE
JENNIFER L. FENCL, DNP, RN, CNS-BC, CNOR;
ANGELA WALSH, MA, BSN, RN, CNOR; DAWN VOCKE, MSN, MBA, RN, CNOR
ABSTRACT
Obesity (ie, a body mass index of 30 kg/m2) is increasing in the United States. As a result, more
overweight individuals are being surgically treated for weight loss, thus making it imperative for
perioperative RNs to understand obesity’s effects on patients’ health, its contribution to significant
comorbidities (eg, diabetes, cardiovascular disease, hypertension, sleep apnea, musculoskeletal issues, stroke), the perioperative care requirements (eg, specialized instruments and equipment, positioning and lifting aids), and unique needs of these patients (eg, diet, counseling). It is vital that the
perioperative nurse accurately assesses the patient undergoing bariatric surgery to provide safe and
appropriate nursing interventions during the perioperative continuum of care. AORN J 102 (August
2015) 117-128. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.05.007
Key words: obesity, bariatric surgery, bariatric surgical patient, perioperative care.
I
n the United States, obesity is the second-leading cause
of preventable death1,2 behind cigarette smoking.2 Sixty
percent of the US population is considered overweight
(ie, a body mass index [BMI] of 25 kg/m2 to 29.9 kg/
m2),2,3 which notably affects the health of patients. In
addition, approximately 30% of the US population is
considered obese (ie, a BMI of 30 kg/m2 or greater),1-3 with
more than 15 million Americans considered morbidly obese
(ie, defined as having a BMI of 40 kg/m2 or greater).4
Obesity must be viewed as a major public health concern
because of its contribution to serious comorbidities,5 and
perioperative RNs must understand the unique challenges
this patient population presents to provide safe care.
OVERVIEW
The United States has seen a steady increase in the number of
persons defined as obese in the past three decades.6 Obesity can
affect anyone regardless of sex, age, educational level, racial or
ethnic background, or geographic location.2,3,6 As the
incidence of Americans with obesity has steadily increased,
billions of dollars are being spent to address both the direct
and indirect costs of obesity.2 Direct costs include items such
as diagnostic tests, physician visits, medication, hospital costs,
nursing care, and any treatment required to manage
comorbidities.2,3 Indirect costs include lost wages related to
the inability to work and the effects of obesity on mobility,
quality of life, and lost future earnings from premature death.2,3
Obesity has serious effects on a patient’s health, contributing
to significant comorbidities, such as diabetes, cardiovascular
disease, hypertension, sleep apnea, musculoskeletal issues,
stroke, and quality of life.1,3 Because of the significant
contribution to comorbidities, obesity can be viewed not only
as a chronic medical condition, but also as a disease state. It is
important for nurses to recognize that a loss of 5% to 10% of a
person’s body weight can significantly improve his or her
http://dx.doi.org/10.1016/j.aorn.2015.05.007
ª AORN, Inc, 2015
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Table 1. Commonly Used Bariatric Terms
Body mass index (BMI): a mathematical calculation used by health care providers to measure body fat and determine a
patient’s weight category. The mathematical formula calculates a person’s weight in kilograms and divides this by the person’s
height in meters squared.1,2
Normal weight: a person with a BMI that ranges from 18.5 kg/m2 to 24.99 kg/m2 is considered normal weight.1-3
Obese: a person with a BMI of 30 kg/m2 or greater is considered obese.2-5
Severely obese: a person with a BMI that ranges from 35 kg/m2 to 39.9 kg/m2 is considered severely obese.2-6
Morbidly obese: a person with a BMI of 40 kg/m2 or greater is considered morbidly obese.2-5
Bariatric: describes health care that focuses on the treatment of obesity.1,5
References
1. Ide P, Farber E, Lautz D. Perioperative nursing care of the bariatric surgical patient. AORN J. 2008;88(1):1-54.
2. Calculate your body mass index. National Institutes of Health. http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.
Accessed March 30, 2015.
3. Adult obesity. The Harvard School of Public Health. http://www.hsph.harvard.edu/obesity-prevention-source/obesity-trends/obesity-rates
-worldwide/. Accessed March 18, 2015.
4. Bariatric. Merriam Webster Dictionary. http://www.merriam-webster.com/dictionary/bariatric. Accessed March 30, 2015.
5. Walsh A, Albano H, Jones D. A perioperative team approach to treating patients undergoing laparoscopic bariatric surgery. AORN J.
2008;88(1):59-64.
6. Neil J. Perioperative nursing care of the patient undergoing bariatric revision surgery. AORN J. 2013;97(2):211-226.
cardiometabolic benefits.2 This weight loss can result in lower
blood pressure and cholesterol levels and prevent the
development of diabetes or improve the condition.2,3,6 If
individuals who are overweight can achieve weight loss, the
overall positive health effects would be significant.
TERMINOLOGY
There are commonly used terms for discussing obesity (Table 1).
Although all may be used in relation to overweight patients, the
terms defining overweight categories are not interchangeable
and each has specific criteria. It is important for the
perioperative nurse to understand the terms used to diagnose
and describe this patient population and to adequately assess
and determine appropriate surgical interventions.
SOCIAL RAMIFICATIONS OF OBESITY
It is not uncommon for overweight individuals to experience
excessive stress from weight discrimination, and the typical patient
undergoing bariatric surgery can relate a lifetime of social typecasting as a result of being overweight.7 Empathy and sensitivity to
the psychological and emotional effects of being overweight are
essential when providing care to this patient population.8
The decision to undergo bariatric surgery is highly personal,
and it is not an easy way out (ie, without the rigors of dieting
and exercise), as it is sometimes characterized by the public.
Overweight individuals spend thousands of dollars on diets
and weight-reduction products and countless hours attending
weight-loss programs, all in an effort to lose weight, sustain
that weight loss, and achieve a healthier weight, in addition to
118 j AORN Journal
attaining a more socially acceptable size. Weight-loss programs
are not always successful. A literature search revealed nearly
three million evidence-based articles related to patient outcomes after weight-loss surgery; however, the search results for
articles about the patient’s real-life experience with weight-loss
surgery yielded a limited number of articles,9 most of which
were not based on research. Instead, literature related to the
experience of patients receiving bariatric care was generally
published as adjunct articles based on patient interviews.
Knowledge about the experience of undergoing bariatric
surgery, including the challenges it represents as seen from
the patient’s view, is essential to preparing for surgery and
providing optimal care, as well as to providing the best
possible support for patients after discharge.9
In addition, many caregivers are unaware of how the combination of genetics, lifestyle, and hormonal factors can negatively affect an individual’s health and quality of life. Nicotine
addiction (eg, smoking) and alcoholism are seen as disease
states and the same should apply to patients with obesity.
Currently, both the Centers for Medicare & Medicaid Services
(CMS) and the American Medical Association (AMA) recognize obesity as a disease, which allows for financial support
opportunities for interventions and treatment for this disease.2,10 One component of initial patient success begins with
the perioperative staff. In an effort to provide safe patient care,
perioperative personnel must reflect on their personal opinions
regarding the obese patient and his or her decision to pursue a
weight-loss procedure and should be professional, sensitive,
and receptive to the patient’s physical and psychological needs
while caring for this patient population. All perioperative
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personnel should be aware of peripheral conversations that
may be interpreted as derogatory and that could be overheard
by the patient and family members. Caregivers should refrain
from having food or beverages in the patient care areas. The
social skills of physicians and members of the multidisciplinary
team are important. Patients receiving bariatric care who are
treated with dignity and respect are able to establish a close
relationship with the team. Patients with obesity who feel safe
and involved in their own care are able to be more compliant
and successful when receiving bariatric care.
BARIATRIC SURGERY
The term bariatric originates from the Greek words baros
(weight) and iatreia (medical treatment).2,11 For obese patients,
bariatric surgery is the most effective way to lose weight, maintain
the weight loss over time,1,3-6 and reverse many of the comorbidities associated with obesity.3 Bariatric surgery is a viable
option for weight loss, as suggested by the 20% increase in the
rate of procedures performed annually since 2004.1-3 For
example, in 1998, 12,775 bariatric surgeries were reportedly
performed annually,1 whereas according to 2013 data, more
than 225,000 bariatric procedures are performed every year.3
Patients have several bariatric surgery options, and all of them
create some means to restrict the quantity of food a person can
ingest.1 Bariatric surgery can be categorized into two types:
restrictive (eg, gastric band, gastric sleeve) and restrictive
with malabsorptive properties (eg, Roux-en-Y, biliopancreatic
diversion).1 Each procedure is different in its approach and
degree of aggressiveness, has specific risks and benefits to the
patient, and requires different postoperative care and
maintenance after discharge.1,2 The article by McGraw and
Wool12 in this issue reviews bariatric procedures in detail.
The patient and his or her support system are responsible for
attending new patient information sessions and completing
the bariatric program preprocedure requirements, such as
psychological and medical evaluation, laboratory work, and
assessment of gallbladder, cardiac, respiratory, and liver function testing. Body mass index, comorbidities, and patient
initiative are key factors that are taken into consideration when
identifying suitable surgical candidates for bariatric procedures. The prospective candidate for weight-loss surgery
spends many months of preparation before surgical approval
by the bariatric team. One critical element is still missing from
the presurgery checklist: the required wait for insurance
approval. When approval is granted from the patient’s insurance provider, the patient receives a date for the bariatric
procedure, a weight-loss treatment plan that will provide a
significant change to his or her condition and lifestyle.
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Perioperative Care of the Bariatric Patient
The bariatric surgical patient must be motivated throughout
his or her perioperative journey. Regardless of the type of
bariatric procedure planned, the preoperative and first eight
postoperative weeks are very similar for all patients receiving
bariatric care. Suggestions to achieve optimal success for patients during the perioperative continuum of care include
the following:
Set personal goals: every patient has a specific reason for
embarking on the journey to lose weight. Preoperatively,
each patient is asked to identify three short, three medium,
and three long-term goals to provide personal motivation
and increase compliance. Reevaluation and/or revision of
these goals is made by patients.
Learn to judge size appropriately: decorative “shot glasses”
can be purchased preoperatively and are a helpful way to
acquaint patients with the hourly fluid volume requirements (ie, 3 oz to 4 oz) during the first postoperative
week and to keep track of fluid intake and prevent
dehydration.
Be creative: liquids consumed during the early postoperative
stage do not have to be boring. Almost any food can be
blended with additional liquid to produce a little variety.
Create a buddy system: in addition to the postoperative
support group, a bariatric surgery buddy, who underwent
weight-loss surgery at least six months earlier, provides
personal support for new patients.
Celebrate accomplishments: patients should celebrate each
milestone and are encouraged to remain motivated by sharing
positive affirmations at home or work or displaying pictures of
personal rewards achieved during their journey, such as
purchasing a new pair of shoes or smaller-sized clothes,
attending a movie, or taking a trip with family or friends.
BARIATRIC SURGERY FOR PEDIATRIC
PATIENTS
As the adult obesity epidemic continues to receive public
attention, childhood obesity also has become an increasing
health issue and an area of focus for schools, government, and
health care agencies. Statistics obtained in the past five years
reveal that overweight pediatric patients are affected by health
issues and comorbidities similar to those experienced by overweight adults.13 In 2012, more than one-third of children and
adolescents were reported to be overweight or obese.13
Overweight or obese children may be the target of relentless
ridicule or harassment, experience decreased self-esteem, and
develop maladaptive behaviors and depression.13,14 These
children and their parents also may have different perceptions
of the meaning of obesity and its physical effects during
growth and development. It is important for caregivers to
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assess the cognitive, emotional, and social maturity of the
pediatric patient considering weight-loss surgery, as well as
their parents and other support persons.14
Bariatric surgery has been performed on adolescents since the
1970s.14 Clinicians determine a child’s weight status using an
age- and sex-specific percentile calculation to obtain BMI,
rather than the BMI calculation used for adult weight
categories, because children’s body composition varies as
they age and varies between boys and girls.15 For children,
obesity is a BMI at or above the 95th percentile of the same
age and sex, and
extreme obesity is a BMI at or above 120% of the 95th
percentile of the same age and sex.15
Bariatric surgery has gained increasing acceptance as a treatment
modality for adolescents with extreme obesity and significant
comorbidities for whom conventional dietary and behavioral interventions have failed.16 Currently, the two main surgical options
“
demonstrates that an interprofessional team approach works best
to provide continuity of care for this patient population.3-5,11 In
addition to the surgical team, the patient’s bariatric team should
include psychologists, dieticians/nutritionists, and physical
therapy and exercise specialists who work with this patient
population to modify the habits and behaviors that contribute
to obesity.11
When patients begin to seek information about bariatric surgery, there are informative preoperative classes provided at
facilities where bariatric surgery is performed for the patient to
learn, discuss, and evaluate the different surgical options.
Additional information included in these informative classes
are in-depth discussions of the risk and benefits of bariatric
surgery, appropriate goal setting, and alternatives to surgery.
With the assistance of a trained bariatric team, the patient can
become well informed and knowledgeable regarding each
phase of the bariatric surgical process and, as a result, better
prepared to make surgical decisions.
With the assistance of a trained bariatric team,
the patient can become knowledgeable about
each phase of the surgical process and be
better prepared to make surgical decisions.
for adolescents are the Roux-en-Y gastric bypass and adjustable
gastric banding.14 Because of the unique psychosocial, physical,
behavioral, and emotional needs, surgery should take place in a
pediatric multidisciplinary center.16
INITIAL PREOPERATIVE CARE
Whether the patient is undergoing bariatric surgery or the
patient is obese and undergoing a nonbariatric procedure, it is
vital that the perioperative nurse accurately assesses the patient
to provide safe and appropriate nursing interventions during
the perioperative continuum of care. The following are care
considerations as they relate to each phase of perioperative care.
Surgical preparation for the obese patient is individualized, as
when caring for any patient; however, bariatric surgery requires
specialized preoperative preparation. There are numerous assessments and interventions that must be completed before the
bariatric patient arrives in the preoperative area. The literature
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”
Six months to a year before the intended surgical procedure,
the bariatric team provides in-depth information about lifestyle modifications and assistance to the patient to help
incorporate healthy choices into daily life. Exercise specialists
work with the patient from the very beginning of this journey
to facilitate exercises that he or she can perform and immediately incorporate into a daily routine which, it is hoped,
becomes a realistic program for life. A nutritionist works
closely with the patient regarding food modification and dietary supplements. Some programs employ mandatory
smoking cessation prior to surgery because of associated
health-related risks and potential for poor wound healing,
while other programs may strongly emphasize cessation prior
to surgery and make available helpful resources and programs.5
IMMEDIATE PREOPERATIVE CARE
Surgical and anesthetic advances, combined with changes in
the demographics and obesity levels of patients, have highlighted the importance of appropriate perioperative nursing
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care specific to patients undergoing bariatric procedures.17 The
AORN bariatric surgery task force presented recommended
perioperative patient safety guidelines at the 2004 AORN
Congress House of Delegates, followed by publication of the
guidelines in the AORN Journal in 2004.18 That same year,
an expert panel of clinicians assembled in Boston and
generated the Betsey Lehman report,19 evidence-based
guidelines for all health care professionals that established a
framework to care for this specific population, including
information regarding
patient selection,
multidisciplinary evaluation and treatment,
patient education,
informed consent,
anesthesia management,
pediatric and adolescent care, and
nursing care.19
Obese patients often have comorbid conditions, such as diabetes, hypertension, venous thromboembolism, coronary artery
disease, and obstructive sleep apnea. Therefore, it is imperative
that the surgical team conduct a thorough preoperative physical
assessment to identify and treat preexisting conditions. The
preoperative physical assessment should include
an electrocardiogram and chest x-ray to assess cardiopulmonary risk;
laboratory testing to assess for metabolic conditions,
including
o glucose/hemoglobin A1c,
o complete blood cell count,
o comprehensive metabolic panel,
o liver function test,
o protime/partial thromboplastin time, and
o lipid profile; and
assessment of any circulatory or skin integrity problems.11
Preoperative Nursing Assessment
A thorough preoperative assessment is an essential element to
safely care for patients undergoing bariatric surgery. Elements
of the preoperative nursing assessment should include
reviewing the medical history and physical examination report;
identifying comorbidities;
assessing current circulatory, respiratory, and skin integrity
status;
verifying current weight and BMI;
validating current medications; and
assessing for a history of gastroesophageal reflux, gallbladder
disease, and diabetes.1,2
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Perioperative Care of the Bariatric Patient
In addition, the perioperative nurse should assess for any
preexisting conditions that may affect positioning or other
aspects of perioperative care (eg, ability to lie flat for intubation) and assess whether the patient has used a continuous
positive airway pressure machine for sleep apnea.2 Laboratory
tests the preoperative nurse may need to verify include
pulmonary function,
arterial blood gas,
liver function,
preoperative blood glucose, and
urine pregnancy tests.1,2
Any concerns should be shared with the surgeon, anesthesia
care professional, and preoperative team before transporting
the patient to the OR.1,2 Bariatric surgery may be cancelled if
the patient demonstrates that he or she does not understand
the procedural risk, has severe liver disease with accompanying
portal hypertension, is considered to have uncontrolled severe
obstructive sleep apnea with pulmonary hypertension, is
diagnosed with a terminal illness, has not discontinued taking
appetite suppressants, or significant changes are found on the
electrocardiogram.11
INTRAOPERATIVE CARE
Anesthesia management of the bariatric surgical patient presents many challenges. These include intraoperative management of existing comorbid conditions, the patient’s airway and
oxygenation, fluid requirements, medication administration,
and pain management.11 Specific intraoperative risks regarding
cardiopulmonary functions that both the anesthesia
professional and the RN circulator must manage include the
potential for
difficult intubation and a compromised airway because of
the patient’s weight,
hypoxia or aspiration during intubation as a result of potential increased gastric and abdominal pressure,1
increased cardiac output related to the stress obesity places
on the cardiopulmonary system (eg, increased cardiac
afterload, increased coronary artery disease associated with
obesity),1
increased pulmonary artery pressure because of the elevation
in oxygen consumption and carbon dioxide production as a
result of obesity and the excess abdominal weight that affects
the ability of the anesthesia professional to ventilate the
patient well,1 and
inferior vena cava compression as a result of excess weight
putting pressure on the vena cava.1,20
The perioperative RN must be aware of and understand the
effect obesity has on the patient’s cardiopulmonary function to
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Fencl et al
accurately assess and implement interventions during the
surgical procedure. Appropriate interventions to assist the
anesthesia professional during the surgical procedure for an
obese patient may include
obtaining a difficult airway cart to be prepared for a respiratory emergency,
being present at the head of the bed to assist with
intubation,
elevating the head of the bed or placing a wedge under the
head before intubation to assist the patient’s breathing,
avoiding the Trendelenburg position until after intubation,
and
providing cricoid pressure to help prevent gastric reflux and
aspiration during intubation.1
Positioning
Intraoperative injuries such as pressure sores and nerve injuries
are more common in morbidly obese patients and obese patients with diabetes. Positioning obese patients also increases
the risk of injury to caregivers attempting to lift, move, or
position the patient. The perioperative nurse must be able to
safely position the patient without harm to the patient or
caregivers and pad pressure points appropriately before surgery
begins. Throughout the surgical procedure, the RN circulator
must be alert for potential changes in the OR bed, patient
position, or surgical manipulation that may cause body
shifts.20 Specific positioning considerations for the patient
undergoing bariatric surgery include helping to ensure that
the OR bed is able to support the patient’s weight and safely
articulate with the patient in place, which may require
special bariatric-rated beds and attachments;
the OR bed mattress pads provide adequate support;
additional extra-wide, extra-long safety straps are available;
and
the team
o places a roll or wedge under the patient’s right flank to
alleviate compression of the vena cava in the supine
position;
o repositions the patient to a sitting and/or lateral position if
the patient cannot tolerate the supine position because of
respiratory or circulatory compromise;
o sufficiently supports the patient’s upper chest and pelvis
when in the prone position in a way that frees the
abdominal viscera from pressure and reduces pressure on
the diaphragm and inferior vena cava;
o uses caution when positioning the patient in Trendelenburg because added weight against the diaphragm can
cause respiratory compromise and vascular congestion;
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o
o
o
uses a well-padded footboard to ensure proper foot
alignment and that the feet are positioned flat against the
board when the patient is in reverse Trendelenburg;
uses caution when positioning the patient in lithotomy to
avoid added intra-abdominal pressure that increases the
risk for circulatory, respiratory, and neurological complications; and
assesses the patient for fall risk or other injury secondary
to changes in the patient’s lateral position during a
procedure.1,20
Best Practice Care Bundles
Intraoperative care for surgical patients should encompass the best
practice bundles of the Surgical Care Improvement Project
(SCIP).21 These include appropriate hair removal, antibiotic
selection, and use of b-blockers, forced-air warming, and
mechanical venous thromboembolism prophylaxis (eg,
sequential compression devices). In addition, the nurse should
include a thorough intraoperative skin assessment by carefully
examining the patient’s skin for areas of irritation, infection,
and existing skin breakdown (eg, ulcerations).1 If there are skin
folds present because of weight loss, the nurse must also include
assessment of the skin under the folds, remembering that
hygiene may have been difficult for the patient.1
Prepping
Selecting a surgical skin prep includes determining the
appropriate skin antiseptic agent based on the surgical site,
contraindications, surgeon preference, patient allergies, skin
assessment, presence of large/open wounds, presence of
organic material (eg, blood, pus), and the manufacturer’s
recommendations.22 The prepped area should be larger than
the anticipated skin incision to accommodate for any
possible extension of the surgery or placement of drains.11
Based on the prepping product used, it is important to
note that additional applicators may be necessary for
adequate skin antisepsis coverage. The RN circulator must
be familiar with the manufacturer’s instructions for use,
which often indicate the surface area that can be
adequately prepped per each applicator to ensure adequate
skin antisepsis has occurred.
Physical Environment
To successfully and safely care for the patient undergoing
bariatric surgery, there must be an adequate physical environment in the facility with appropriate equipment. Following
is a list of additional considerations that are helpful in accommodating this patient population and their families, some
of whom also may be obese.23
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Emergency carts may need additional bariatric-specific
equipment, such as a video laryngoscope, to assist with
difficult intubations.
Patient care areas need transfer devices to move obese patients safely.
All care areas need appropriately sized
o chairs in patient and family member waiting areas;
o beds, wheelchairs, and walkers;
o floor-mounted toilets to provide additional support;
o enlarged doorways and shower rooms;
o medical imaging equipment large enough to provide
diagnostic studies;
o intensive care unit equipment;
o bar/extenders to widen the surgical procedure bed; and
o surgical instruments (extra-long instruments, endomechanical devices/staplers and retractors), blood pressure
cuffs, sequential compression devices, weight scales, and
gowns.
“
Perioperative Care of the Bariatric Patient
early ambulation,
urinary catheters discontinued within 48 hours, and
postoperative antibiotics for up to 24 hours.
Complications
Regardless of whether the surgical approach was open or
laparoscopic, initial postoperative complications can include
hemorrhage, surgical site infection, and pulmonary embolism.
One of the most serious complications following Roux-en-Y
gastric bypass and vertical sleeve gastrectomy is an anastomotic or staple-line leak, which can be life-threatening.
Although symptoms may not be readily apparent, any
change in patient condition (eg, tachycardia, fever, tachypnea,
oliguria, increasing oxygen requirement) warrants a call to the
surgeon, who is likely to order a gastrografin swallow x-ray and
computed tomography with contrast and may take the patient
back to the OR for a revision.7 An anastomotic leak, if not
diagnosed and repaired in the first four hours after surgery,
Preliminary exercise reinforcement begins with
early ambulation to reinforce the idea that exercise
is necessary to help prevent complications from
surgery and prolonged immobility.
POSTOPERATIVE NURSING
CONSIDERATIONS
The perioperative nurse may be unfamiliar with more than the
immediate postoperative course of the bariatric patient. The
nursing considerations, needs, and challenges of this patient
population can be divided into three postoperative components: the initial postoperative phase, phase one, and phase two.
Initial Postoperative Phase
This phase encompasses admission to the postanesthesia care
unit through hospital discharge. Customary postoperative
assessment and nursing care include assessments and interventions to address
pain control,
wound care,
deep vein thromboembolism prophylaxis,
fluid management,
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carries a 10% mortality risk24 and illustrates the importance
of early identification.
Although the patient undergoing bariatric surgery has received
a wealth of knowledge before his or her surgical experience, it
is imperative that the patient is prepared to begin his or her
new lifestyle. Preliminary exercise reinforcement begins with
early ambulation to reinforce the idea that exercise is necessary
to help prevent complications from surgery and prolonged
immobility. Postoperatively, the patient’s hydration progresses
from NPO status to sips of clear liquids. Because intake capacity has been drastically reduced to as little as 15 mL to 30
mL, the nurse should explain the importance of taking small
sips to reduce nausea and vomiting during this postoperative
phase of care.16 Typical dietary progression is detailed in
Table 2. A radiologist may perform a gastrografin “swallow
test” on postoperative day one to determine patency of the
gastric pouch.
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Stage 1
Day 0 Through Day 3
Clear Liquid Diet
Stage 2
Day 4 Through Day 14
Full Liquid Diet
Day 1
Start diet at 15 mL (0.5 oz)
of liquids every 30 minutes
for the first 2 hours, then
increase to 15 mL (0.5 oz) of
liquids every 15 minutes
Slowly add fluids, 3 oz to 4 oz
each hour
Remember to sip liquids slowly,
no straws!
Blend, strain, and add liquid to
food for a milk-like consistency
Gradually increase protein
intake to 60 g per day
Include at least 1 L (4 cups) of
water a day
Protein intake
o Shakes
o Fat-free milk
o Sugar-free nonfat yogurt
Calorie-free beverages
(eg, diet soda)
Broth, miso soup
Vegetable juice
Low-fat strained soup
Diluted juice (½ juice and
½ water)
Sugar-free ice pops
Runny hot cereal
Sugar-free pudding
Pureed fruit or vegetables
Stage 3
Day 15 through day 35
Pureed Diet (low-calorie,
high-protein [60 g/d] supplements)
Start using pureed foods
Take 20 to 30 minutes to eat each meal
Each meal should be no more than 3/4 cup
(6 oz) total and snacks should be ¼ to ½
cup (2 oz to 4 oz)
Slowly eat 1 oz to 2 oz of soft/pureed
protein foods with 1 oz soft/pureed
vegetables
Eat 5 to 6 small meals daily until able to
consume ½ cup of food at one time, then
eat 3 small meals and 2 snacks
Listen to your body: stop when satisfied,
NOT when full
Buy small knives, forks, spoons, and plates
to help eat the correct amounts of food
No liquids 15 minutes before meals and
30 min afterward
Continue to eat slowly and chew food well
to prevent blockage
Continue to get 40 g to 60 g of protein
from protein beverages
Pureed meats
Fruit/vegetables
Unsweetened applesauce
Canned fruit in water
Soft banana/pureed fruit/well-cooked
nonfibrous vegetables
Creamy strained soups
Stage 4 to Stage 5
Week 6 and beyond
Regular Diet (low-fat food, protein-rich)
(continued)
August 2015, Vol. 102, No. 2
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Stage 4
Introduce new foods one at a time to identify
problem foods
Avoid liquids 15 minutes before a meal and
30 min after
Spend 20 to 30 minutes to eat each meal
Continue to consume at least 60 g of protein
daily
Include at least 5 servings of fruits and
vegetables
Protein/dairy (hors d’oeuvres)
o Scrambled egg whites or egg substitutes
o Fat-free cottage cheese
o Sugar-free and nonfat yogurt
o Pureed meats
o Soft fish (eg, tuna), soft tofu
o Egg/chicken/tuna salad with low-fat
mayonnaise
o low-fat and nonfat refried beans
Stage 5
Full diet: Eat 5 to 6 small meals daily versus
3 large meals
Avoid fried foods or food with high fat and
sugar content
Continue to eat slowly and chew food well to
avoid blockage
Avoid liquids 15 minutes before a meal and
30 minutes after
Protein/dairy
Lean meats, including poultry and fish
low-fat and nonfat dairy foods (eg, fat-free
milk, low sugar fat-free yogurt, low fat cheese)
Cooked fruits and vegetables
Raw fruits and vegetables
Fencl et al
124 j AORN Journal
Table 2. Typical Diet Progression After Bariatric Surgery
Stage 1
Day 0 Through Day 3
Clear Liquid Diet
Stage 2
Day 4 Through Day 14
Full Liquid Diet
Stage 3
Day 15 through day 35
Pureed Diet (low-calorie,
high-protein [60 g/d] supplements)
Stage 4 to Stage 5
Week 6 and beyond
Regular Diet (low-fat food, protein-rich)
Days 2 to 3
Advance diet to 30 mL
(1 oz) of liquids every
15 minutes
Water
Flavored water
Diluted unsweetened juice
(½ juice and ½ water)
Diluted electrolyte drinks
Sugar-free gelatin
Broth
Remember to sip your
liquids slowly, no straws!
August 2015, Vol. 102, No. 2
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Table 2. (continued )
Exercise
Begin walking day of
surgery or as
recommended by your
physician
When cleared by your
physician, start your regular
activities again
Regular exercise and protein
will help keep you healthy
when losing weight
Continue to exercise as tolerated and
recommended by your physician
Continue to exercise as tolerated and
recommended by your physician
Perioperative Care of the Bariatric Patient
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August 2015, Vol. 102, No. 2
Phase One
Phase Two
This phase includes the time from discharge to the patient’s
first postoperative visit at three weeks. For the patient to
qualify for discharge, certain criteria must be met.2 Specific
discharge criteria include the ability to
Phase two includes postoperative weeks three to eight. In the
early postoperative period, the main goals of office visits are to
assess nutrition status, identify maladaptive eating disorders,
evaluate potential complications (eg, internal hernia), monitor
status of comorbidities, encourage regular exercise, discuss
weight-loss progress, and check laboratory values (eg, vitamin B1,
vitamin B12, magnesium, phosphorus, blood cell counts, albumin, a metabolic profile).20 Following the initial postoperative
visit, the patient graduates to the next stage of the diet, which
includes minimeals or smaller-sized portions of soft foods (eg,
tuna or scrambled eggs) for five weeks. Many patients have
difficulty with the extreme and instant lifestyle changes. If
patients were previous stress eaters and become stressed after
surgery, they no longer have the ability to eat for stress relief.20
It is therefore important for the bariatric team to help the
patient identify triggers that may initiate maladaptive
behaviors, such as eating for stress relief, and suggestions on
how to deal with these challenges.25
tolerate clear liquids,
drink three liquid meal supplements per day without
reporting nausea or vomiting,
ambulate independently, and
void without difficulty.2
Discharge patient education should include verbal and written
instructions about the initial dietary progression from clear
liquids to the incorporation of high-protein liquid meal replacements. The nurse should focus on reinforcing appropriate
meal selection that can be provided in a liquid form. This type
of meal allows the new pouch to heal, promotes hydration, and
provides initial behavioral modification.
The nurse and patient should discuss his or her current
medication regimen and review any new or required medications and their dosing schedule. It is important for the nurse to
discuss incision care and to help ensure that the patient has
appropriate help with this if indicated. Signs and symptoms
that must be reported to the physician include
a temperature of more than 101 F (38 C),
pain not controlled by prescribed medication,
bleeding from the surgical sites, and
inability to tolerate or swallow liquids.
Follow-up appointments (including those with the patient’s
surgeon, primary care provider, nutrition counselor) should be
provided to the patient and any support persons, as well as
contact information for postoperative support groups and any
restrictions on driving and other activities.16
Patients should have a well-stocked kitchen with a variety of
clear liquids to provide adequate hydration (eg, 1 oz of fluid
every hour) and stimulate gastric and intestinal function. For
the next three weeks following surgery, the patient’s meal
plan should consist of 8 oz of fluid an hour and include a
low-sugar, low-calorie (600 to 800 calories/day), highprotein (60 g/day) supplement. The goal of the diet is to
promote behavior modification and provide the time needed
for the pouch and anastomosis to heal after surgery. Patients
who are not compliant with postoperative intake guidelines
run the risk of stretching the pouch, esophageal obstruction,
gastroesophageal reflux, vomiting, aspiration pneumonia, or
wound dehiscence. Complications should be immediately
reported to the bariatric team.
126 j AORN Journal
The next stage of the diet allows the patient to progress to a
full diet. Long-term recommendations include eating five or
six small meals rather than three large ones, eating slowly and
chewing well, avoiding fluids with meals, and avoiding fried
foods and foods high in fat or sugar content. Long-term
complications unique to the laparoscopic adjustable gastric
band are port disconnection, band erosion, and pouch dilatation.16 Most late complications are easily repaired as long as
care providers recognize symptoms early.20 Symptoms of these
late complications may include vomiting and reflux.16,25
POSTOPERATIVE CHALLENGES
Many bariatric patients experience redundant skin in the
abdominal-perineal area, inner thighs, breast, and under the
arms following excessive weight loss. Patients are advised to
wait 18 to 24 months before scheduling a consult with a
plastic surgeon to achieve the first maximum weight loss.
However, many insurance companies will not approve surgery
to remove excess skin without documentation of frequent
skin-fold irritation, infection, or limitation of movement.16
For example, appropriate documentation of an incisional
hernia after open bariatric procedures may help to qualify a
patient for insurance coverage. Not all patients choose to
pursue esthetic procedures because of the expense, the need
for additional time off from work, and discomfort based on
the affected area. For bariatric patients who choose to
undergo plastic surgery, the most common complaint from
patients after the procedure is pain at the drain site.26 After
the drains are removed and healing is complete, patients
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August 2015, Vol. 102, No. 2
Perioperative Care of the Bariatric Patient
(male and female) often are proud to reveal the metamorphosis
that they have worked very hard to achieve.
OUTCOMES OF BARIATRIC SURGERY
Although the success of bariatric surgery can be evaluated using a
variety of outcome measures, weight loss tends to be the most
commonly used metric to evaluate success.27 Gagnan and
Karwacki Sheff 25 suggest that patient success is equivalent to a
50% loss of excess body weight and describe failure as a weight
loss of less than 30% excess body weight at one year postsurgery.
Average weight loss described in the literature can vary from a
weight loss of 50% to 80% for restrictive procedures (eg, gastric
band, sleeve gastrectomy) and weight loss of 60% to 80% for
malabsorptive procedures (eg, gastric bypass, biliopancreatic
diversion).25 Initial and long-term success largely depend on
patient motivation, compliance with diet and exercise, and the
type of procedure.28 Additionally, patients may attribute
personal success not only to the percentage of weight loss, but
also to improvement of comorbidities and reduction of
medications taken. The American College of Surgeons and the
Society for Metabolic and Bariatric Surgery29 recommend that
patients who have undergone weight-loss surgery be followed up
for five years and undergo yearly bloodwork to identify possible
vitamin and mineral deficiencies (eg, vitamin B12, vitamin D,
calcium, iron, folate).
CONCLUSION
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Bariatric surgery is an effective treatment for patients with
obesity who seek to achieve and sustain weight loss. To maintain
weight loss, bariatric surgical patients must sustain their motivation, set goals, find sources of encouragement, and participate
in long-term follow-up with health care providers. To safely care
for this patient population, perioperative nurses must be
knowledgeable about the effects of obesity on treatment options
and understand the considerations unique to addressing obesity
in the perioperative setting, including creating an environment
free of prejudicial attitudes.30 Accurate and appropriate nursing
care and interventions for patients undergoing bariatric surgery
are vital to optimal and sustained clinical outcomes.
15.
16.
17.
18.
References
1. Neil J. Perioperative nursing care of the patient undergoing bariatric revision surgery. AORN J. 2013;97(2):211-226.
2. Ide P, Farber E, Lautz D. Perioperative nursing care of the bariatric
surgical patient. AORN J. 2008;88(1):1-54.
3. Ide P, Fitzgerald-O’Shea C, Lautz D. Implementing a bariatric
surgery program. AORN J. 2013;97(2):196-206.
4. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice
guidelines for the perioperative nutritional, metabolic, and
nonsurgical support of the bariatric surgery patientd2013
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19.
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21.
update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for
Metabolic & Bariatric Surgery. Endocr Pract. 2013;19(2):337-372.
Walsh A, Albano H, Jones DB. A perioperative team approach to
treating patients undergoing laparoscopic bariatric surgery. AORN
J. 2008;88(1):59-64.
Adult obesity. The Harvard School of Public Health. http://
www.hsph.harvard.edu/obesity-prevention-source/obesity-trends/
obesity-rates-worldwide/. Accessed March 18, 2015.
Kaser N, Kukla A. Weight-loss surgery. OJIN. 2009;14(1).
manuscript 4.
Mulligan A, Young LS, Randall S, et al. Best practices for perioperative nursing care for weight loss surgery patients. Obes Res.
2005;13(2):267-273.
Pfeil M, Pulford A, Mahon D, Ferguson Y, Lewis MP. The patient
journey to gastric band surgery: a qualitative exploration. Bariatr
Surg Pract Patient Care. 2013;8(2):69-76.
AMA adopts new policies on second day of voting at annual
meeting. American Medical Association. http://www.ama-assn
.org/ama/pub/news/news/2013/2013-06-18-new-ama-policies
-annual-meeting.page. Accessed May 4, 2015.
Thompson J, Bordi S, Boytim M, Elisha S, Heiner J, Nagelhout J.
Anesthesia case management for bariatric surgery. AANA J. 2011;
79(2):147-160.
McGraw CA, Wool DB. Bariatric surgery: three surgical techniques,
patient care, risks, and outcomes. AORN J. 2015;102(2):141-152.
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood
and adult obesity in the United States, 2011-2012. JAMA. 2014;
311(8):806-814.
Childhood and adolescent obesity. American Society of Metabolic
and Bariatric Surgeons. https://asmbs.org/patients/adolescent-obesity.
Accessed May 4, 2015.
Pan L, Blanck HM, Sherry B, Dalenius K, Grummer-Strawn LM.
Trends in the prevalence of extreme obesity among US preschoolaged children living in low-income families, 1998-2010. JAMA.
2012;308(24):2563-2565. http://www.cdc.gov/obesity/downloads/
jama_highlights_final_data_source_added_011013.pdf. Accessed
April 21, 2015.
Xanthakos SA. Bariatric surgery for extreme adolescent obesity:
indications, outcomes, and physiologic effects on the gut-brain
axis. Pathophysiology. 2008;15(2):135-146.
Mulligan A, McNamara AM, Boulton HW, Trainor LS, Carol
Raiano C, Mullen A. Best practice updates for nursing care in
weight loss surgery. Obesity. 2009;17(5):895-900.
Association of periOperative Registered Nurses. AORN bariatric
surgery guideline. AORN J. 2004;79(5):1026-1040. 1043-1044,
1047-1052.
Lehman Center Weight Loss Surgery Expert Panel. Commonwealth
of Massachusetts Betsy Lehman Center for Patient Safety and
Medical Error Reduction Expert Panel on Weight Loss Surgery:
executive report. Obes Res. 2005;13(2):205-226.
Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:563-582.
SCIP Care Bundles. The Centers for Disease Control and Prevention. http://search.cdc.gov/search?query¼SCIPþcareþbundles
&utf8¼%E2%9C%93&affiliate¼cdc-main. Accessed May 4, 2015.
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22. Guideline for preoperative patient skin antisepsis. In: Guidelines for
Perioperative Practice. Denver, CO: AORN, Inc; 2015:43-66.
23. Lautz DB, Jiser ME, Kelly JJ, et al. An update on best practice
guidelines for specialized facilities and resources necessary for
weight loss surgical programs. Obesity (Silver Spring). 2009;
17(5):911-917.
24. Dunham M. Caring for patients undergoing bariatric surgery.
Nursing. 2013;43(10):44-50.
25. Gagnon LE, Karwacki Sheff EJ. Outcomes and complications after
bariatric surgery. Am J Nurs. 2012;112(9):26-36. http://www
.nursingcenter.com/lnc/cearticle?tid¼1420858#sthash.KTOhBrzL
.dpuf. Accessed March 18, 2015.
26. Richardson WS, Plaisance AM, Periou L, Buquoi J, Tillery D. Longterm management of patients after weight loss surgery. Ochsner J.
2009;9(3):154-159.
27. Madura JA 2nd, DiBaise JK. Quick fix or long-term cure? Pros and
cons of bariatric surgery. F1000 Med Rep. 2012;4:19. http://
f1000.com/reports/m/4/19/. Accessed May 4, 2015.
28. Trainer L. Weight loss surgery patients benefit from reliable information provided in a sensitive manner. 2010. http://nursing
.advanceweb.com/EBook/PdfLoader.aspx?pdf¼C:%5CMerionWeb
Files%5CWebResources%5CEBook%5C2012%5COctober%5CRN
02101512%5CRN02101512_interactive.pdf. Accessed May 4,
2015.
29. Resources for optimal care of the metabolic and bariatric surgery
patient 2014. American College of Surgeons & American Society
for Metabolic and Bariatric Surgery. http://www.mbsaqip.org/docs/
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Resources%20for%20Optimal%20Care%20of%20the%20MBS%
20Patient.pdf. Accessed March 18, 2015.
30. Wakefield W, Rubin JP, Gusenoff JA. The life after weight loss
program: a paradigm for plastic surgery care after massive weight
loss. Plastic Surg Nurs. 2014;34(1):4-9.
Jennifer L. Fencl, DNP, RN, CNS-BC, CNOR, is a
clinical nurse specialist, operative services, at Cone
Health, Greensboro, NC. Dr Fencl has no declared
affiliation that could be perceived as posing a potential
conflict of interest in the publication of this article.
Angela Walsh, MA, BSN, RN, CNOR, is a perioperative clinical educator and bariatric clinic liaison at Boston
Medical Center, Boston, MA. Ms Walsh has no declared
affiliation that could be perceived as posing a potential
conflict of interest in the publication of this article.
Dawn Vocke, MSN, MBA, RN, CNOR, is the unit
director operating room and sterile processing at the
University of Pittsburgh Medical Center, Pittsburgh, PA.
Ms Vocke has no declared affiliation that could be
perceived as posing a potential conflict of interest in
the publication of this article.
www.aornjournal.org
EXAMINATION
Continuing Education:
The Bariatric Patient: An
Overview of Perioperative Care
2.1
www.aorn.org/CE
PURPOSE/GOAL
To provide the learner with knowledge specific to obesity and how to provide care for patients undergoing bariatric surgery.
OBJECTIVES
1.
2.
3.
4.
Discuss obesity trends in the United States.
Identify the classifications for obesity.
Describe comorbidities that accompany obesity.
Discuss the social ramifications of being obese.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE.
QUESTIONS
1. The United States has seen a steady decrease in the number
of persons defined as obese in the past three decades.
a. true
b. false
2. Which of the following statements reflect obesity trends
in the United States?
1. 10% of the US population is considered overweight.
2. 60% of the US population is considered overweight.
3. Approximately 30% of the US population is considered morbidly obese.
4. Approximately 30% of the US population is considered obese.
5. More than 15 million Americans are considered
morbidly obese.
a. 4 and 5
b. 1, 2, and 3
c. 1, 2, 3, and 4
d. 2, 4, and 5
3. As the incidence of obesity in Americans has steadily
increased, billions of dollars are being spent to address
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both the direct (eg, managing comorbidities) and indirect
(eg, effects of obesity on mobility, quality of life, lost
future earnings) costs of obesity.
a. true
b. false
4. How are the levels of weight categorized?
1. An ideal weight BMI ranges from 18.5 kg/m2 to
24.99 kg/m2.
2. An obese weight is a BMI of 30 kg/m2.
3. Severe obesity BMIs range from 35 kg/m2 to 39 kg/m2.
4. Morbid obesity BMIs are 40 kg/m2.
5. A normal BMI is 15 kg/m2.
a. 4 and 5
b. 1, 2, and 3
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
5. Obesity has serious effects on a patient’s health,
contributing to significant comorbidities, including
1. diabetes.
2. cardiovascular disease.
3. hypertension.
AORN Journal j 129
Fencl et al
4. sleep apnea.
5. musculoskeletal issues.
6. stroke.
a. 1, 3, and 5
b. 2, 4, and 6
c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6
6. Despite obesity’s significant contribution to comorbidities, it is not seen as a chronic medical condition, but is
seen as a lifestyle choice.
a. true
b. false
7. A loss of 5% to 10% of a person’s body weight can
provide significant benefits, such as
1. lower blood pressure.
2. lower cholesterol levels.
3. improvement of diabetes.
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 1, 2, and 3
130 j AORN Journal
August 2015, Vol. 102, No. 2
8. In a country that relates beauty, intelligence, and success
with thinness, being overweight has emotional, financial,
and social consequences.
a. true
b. false
9. It is not uncommon for overweight individuals to
experience
1. little stress.
2. excessive stress.
3. social typecasting.
4. social acceptance.
a. 1 and 3
b. 2 and 4
c. 2 and 3
d. 1, 3, and 4
10. Because the combination of genetics, lifestyle, and hormonal factors common in obesity can negatively affect an
individual’s health and quality of life, obesity should be
considered a
a. lifestyle choice.
b. food addiction.
c. disease state.
d. mental state.
www.aornjournal.org
LEARNER EVALUATION
Continuing Education:
The Bariatric Patient: An
Overview of Perioperative Care
2.1
www.aorn.org/CE
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing education
credit, you must complete the online Examination and
Learner Evaluation at http://www.aorn.org/CE. Rate the items
as described below.
8.
Will you change your practice as a result of reading this
article? (If yes, answer question #8A. If no, answer
question #8B.)
8A.
How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding why
change is needed.
2. I will work with management to change/implement
a policy and procedure.
3. I will plan an informational meeting with physicians
to seek their input and acceptance of the need for
change.
4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
incorporated as best practice.
5. Other: __________________________________
8B.
If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others about the
purpose of the needed change.
3. I do not have management support to make a
change.
4. Other: __________________________________
9.
Our accrediting body requires that we verify the
time you needed to complete the 2.1 continuing education contact hour (126-minute)
program: _________________________________
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Discuss obesity trends in the United States.
Low
1.
2.
3.
4.
5.
High
2.
Identify the classifications for obesity.
Low
1.
2.
3.
4.
5.
High
3.
Describe comorbidities that accompany obesity.
Low
1.
2.
3.
4.
5.
High
4.
Discuss the social ramifications of being obese.
Low
1.
2.
3.
4.
5.
High
CONTENT
5.
To what extent did this article increase your knowledge
of the subject matter?
Low
1.
2.
3.
4.
5.
High
6.
To what extent were your individual objectives met?
Low
1.
2.
3.
4.
5.
High
7.
Will you be able to use the information from this article
in your work setting?
1.
Yes
2.
No
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