Chapter 48 Obesity LEARNING OBJECTIVES

Use the nursing process as a framework for care of patients who undergo bariatric surgical procedures.

Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: Deficient knowledge about the dietary limitations during the immediate preoperative and postoperative phases Anxiety related to impending surgery Acute pain related to surgical procedure Risk for deficient fluid volume related to nausea, gastric irritation, and pain Risk for infection related to anastomotic leak Imbalanced nutrition: less than body requirements related to dietary restrictions Disturbed body image related to body changes from bariatric surgery Risk for constipation and/or diarrhea related to gastric irritation and surgical changes in anatomic structures from bariatric surgery COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Hemorrhage Venous thromboembolism Bile reflux Dumping syndrome Dysphagia Bowel or gastric outlet obstruction Planning and Goals Preoperative goals include that the patient will become knowledgeable about the preoperative and postoperative dietary routine/restrictions and will have decreased anxiety about the surgery. Postoperative goals include relief of pain, maintenance of homeostatic fluid balance, prevention of infection, adherence to detailed diet instructions to include progression of food intake as well as fluid intake (to prevent dehydration), knowledge about vitamin supplements and the need for lifelong follow-up, achievement of a positive body image, and maintenance of normal bowel habits (ASMBS, 2013a; Mechanick et al., 2013). Nursing Interventions ENSURING DIETARY RESTRICTIONS The nurse counsels the patient anticipating bariatric surgery to ingest nothing but clear liquids for a specified period of time preoperatively and postoperatively (typically about 24 to 48 hours before and after surgery). Nutritional support for patients scheduled for bariatric surgery is tailored to meet each patient's individual need to ensure optimal consumption of micronutrients. Bariatric diets usually follow a progression from clear liquids to full liquids to soft solids and eventually solid foods. This slow progression is necessary to maximize weight loss, and to prevent complications such as nausea, vomiting, bile reflux, and diarrhea. The patient's diet will be limited upon discharge from the hospital; because of this, patients scheduled for bariatric surgery are given guidelines prior to surgery on which foods and liquids they may consume postoperatively so that they may stock up on these items at home before they are admitted to the hospital. These typically include sugar-free drinks, gelatins and puddings, flavored electrolyte drinks, fat-free milk, protein drinks, sugar-free applesauce, and low-fat soups(Cole, Beckman, & Earthman, 2014; Isom, Andromalos, Ariagno, et al., 2014; Mechanick et al., 2013). REDUCING ANXIETY The nurse provides the patient preparing for bariatric surgery anticipatory guidance as to what to expect during the surgery and postoperatively. In addition, the nurse may encourage the patient to join a bariatric surgery support group preoperatively, with the intent that the patient will continue to participate in this group postoperatively. Most bariatric surgery centers sponsor patient support groups that meet in person or online. These support groups provide a forum where patients contemplating bariatric surgery may talk with patients who have had the surgery and may provide them with guidance and tips that can help to lessen their anxiety (Mechanick et al., 2013). RELIEVING PAIN After surgery, analgesic agents may be given as prescribed to relieve pain and discomfort. Patients are usually prescribed opioid agents via patient-controlled analgesia (PCA) pumps; the nurse should educate the patient about its use and monitor its effectiveness. It is especially important to provide adequate pain relief so that the patient can perform pulmonary care activities (deep breathing and coughing) and leg exercises, turn from side to side, and ambulate. The nurse assesses the effectiveness of analgesic intervention and consults with other members of the health care team if pain is not adequately controlled (Patil & Melander, 2015) (see Chapter 12). Positioning the patient in a low Fowlers position promotes comfort and emptying of the stomach after any type of gastric surgery, including bariatric procedures. ENSURING FLUID VOLUME BALANCE Patients who have had bariatric surgery usually receive intravenous (IV) fluids for the first several hours postoperatively. Once they are awake and alert on the surgical unit, they are encouraged to begin intake of sugar-free oral fluids. Introducing small volumes of these liquids is believed to stimulate GI peristalsis and perfusion and thwart gastric reflux. Sugar-free fluids are preferred because they are not implicated in causing dumping syndrome (see later discussion). With a typical regimen, patients are encouraged to slowly sip 30 mL of these fluids every 15 minutes. Patients should stop ingesting fluids, however, if they feel nauseated or full. Antiemetic agents may be prescribed to relieve nausea and prevent vomiting, which could cause strain on the surgical site and cause either a hemorrhage or anastomotic leak (Mechanick et al., 2013). PREVENTING INFECTION/ANASTOMOTIC LEAK Disruption at the site of anastomosis (i.e., surgically resected site) may cause leakage of gastric contents into the peritoneal cavity, causing infection and possible sepsis. Patients at risk for this particular complication tend to be older, male, and with greater body mass. In addition, anastomotic leak is more commonly associated with open rather than laparoscopic procedures. Patients with anastomotic leaks typically exhibit nonspecific signs and symptoms that include fever, abdominal pain, tachycardia, and leukocytosis. This may progress to sepsis and possibly septic shock if not recognized and treated early (see Chapter 14). The nurse must be astute in recognizing these manifestations and alerting the patient's primary provider should they occur (Dunham, 2013; Patil & Melander, 2015). A patient suspected of having an anastomotic leak may have an upper GI series that includes follow-up computed tomography (CT) scan with contrast dye, which may find leaking contrast dye, thus confirming the diagnosis. Treatment varies depending on the timing (early or late postoperatively) and severity of the leak. CT-guided drainage of the area may be appropriate for a less severe leak in the later postoperative phase of recovery, but an early or severe leak requires immediate open surgical intervention to repair the leak (Jacobsen, Nergard, Leifsson, et al., 2014). ENSURING ADEQUATE NUTRITIONAL STATUS After bowel sounds have returned and oral intake is resumed, six small feedings consisting of a total of 600 to 800 calories per day are provided, and consumption of fluids between meals is encouraged to prevent dehydration. The nurse instructs the patient to eat slowly and stop when feeling full. Eating too much or too fast or eating high-calorie liquids and soft foods can result in vomiting or painful esophageal distention. Gastric retention may be evidenced by abdominal distention, nausea, and vomiting. A nutritionist is typically consulted to assist with diet restrictions and diet progression (Mechanick et al., 2013) (see Chart 48-7). Common dietary deficiencies in patients who have had bariatric surgery include malabsorption of organic iron, which may require supplementation with oral or parenteral iron, and a low serum level of vitamin B12; the patient may be prescribed monthly vitamin B12 intramuscular injections to prevent pernicious anemia (Dunham, 2013; Isom et al., 2014) (see Chapter 33 for further discussion). SUPPORTING BODY IMAGE CHANGES Most patients post bariatric surgery report greatly improved perceptions of their body image, as well as improved quality of life. However, some patients report lingering dissatisfaction with their body images. In particular, some patients may report dissatisfaction related to loose skin folds and may eventually seek elective body-contouring surgical options (e.g., breast reductions, breast lifts, abdominoplasty). The nurse provides support to the patient who reports dissatisfaction with body image post weight loss by acknowledging the patient's feelings as real, sharing that these perceptions are not unusual, and providing links to live or online supports groups or counselors, as necessary (Gilmartin, 2013; Pfeil, 2014; Schauer, Woodruff, Hotz, & Kegler, 2014). ENSURING MAINTENANCE OF BOWEL HABITS Patients may complain of either diarrhea or constipation postoperatively. Diarrhea is more common an occurrence post bariatric surgery, particularly after malabsorptive procedures (Mechanick et al., 2013). Both may be prevented if the patient consumes a nutritious diet that is high in fiber. Steatorrhea also may occur as a result of rapid gastric emptying, which prevents adequate mixing with pancreatic and biliary secretions (Mechanick et al., 2013). In mild cases, reducing the intake of fat and administering an antimotility medication (e.g., loperamide [Imodium]) may control symptoms. Persistent diarrhea or steatorrhea may warrant further diagnostic testing, such as an upper endoscopy or colonoscopy with biopsies to rule out the presence of additional pathology, such as celiac diseases or Clostridium difficile infection(Mechanick et al., 2013) (see Chapter 47).

Identify strategies aimed at preventing and treating obesity, including lifestyle modification, pharmacologic therapy, and nonsurgical interventions.

Medical Management: Treatment of obesity generally includes lifestyle modification, pharmacological management, and nonsurgical or surgical interventions. Lifestyle Modification The first approach used to treat obesity consists of lifestyle modification aimed at weight loss and then weight maintenance. The U.S. Preventive Services Task Force (USPSTF) recommends that all adults with BMIs in excess of 30 kg/m2 be advised to engage in multicomponent behavioral interventions that include (Moyer et al., 2012): Setting weight-loss goals, Improving diet habits, Increasing physical activity, Addressing barriers to change, and, Self-monitoring and strategizing ongoing lifestyle changes aimed at a healthy weight. The most effective behavioral interventions are those considered high intensity; that is, they consist of 12 to 26 sessions annually, which may include individual counseling sessions between the primary provider and patient, group nutrition education sessions, and physical activity sessions, to name a few (Moyer et al., 2012). The USPSTF notes that modest weight loss of 5% total body weight can be associated with significant clinical improvements and benefits to patients with obesity (Moyer et al., 2012). A patient with obesity should be counseled to plan a caloric deficit of between 500 and 1000 calories daily from baseline,in order to achieve a 5% to 10% reduction in weight within about 6 months. This can be achieved through increasing physical activity and decreasing caloric dietary intake (Orringer et al., 2016). Limit or eliminate the following: Processed foods with limited nutritional value (e.g., packaged cakes, cookies, chips) High caloric beverages (sugar-sweetened, juices, cream-enhanced) Fast foods Vending machine foods Foods high in sugars (e.g., candies) and saturated fats (e.g., fried foods, hot dogs) Track the following: Daily food intake (food journals, diaries, smartphone, and tablet applications) Nutritional value and caloric content on food labels Encourage the following: Reduce portions; use smaller plates and measure foods Schedule and plan meals and snacks in advance for each day; prepack lunches and snacks when you are out of the home (e.g., for work) Eat at home more often than you would eat outside the home; when eating out, avoid fried foods and choose lean meats and vegetables and salads with condiments on the side Eat breakfast Limit snacks Eat a variety of nutritious foods; monitoring quality of foods consumed is as important as the quantity of foods consumed Drink plenty of water Stay within your daily caloric intake plan; do not become discouraged if one day you do not adhere to your plan. Nonsurgical Interventions Adult patients with obesity that does not respond to lifestyle interventions or antiobesity medications and who have either Class III/severe/extreme obesity (i.e., BMI in excess of 40 kg/m2) or Class II obesity (BMI 35-39.9 kg/m2) with obesity-related diseases or disorders (e.g., obstructive sleep apnea, type 2 diabetes) may be candidates for bariatric surgicalinterventions (see later discussion). As an alternative, some patients may elect to pursue minimally invasive interventions that were approved by the FDA in 2015. These types of interventions include vagal blocking (i.e., neurometabolic modulation) or intragastric balloon therapy (Ali, Moustarah, Kim, et al., 2015; Papasavas, El Chaar, Kothari, et al., 2016). Vagal blocking therapy involves placement of a pacemaker-like device (vBloc™) into the subcutaneous tissue in the lateral thoracic cavity with two leads that are laparoscopically implanted at the point where the vagus nerve truncates, at the gastroesophageal junction. A pre-programmed, pulsating signal is delivered for 12 hours daily. This signal causes intermittent "blocking" of the vagus nerve. Vagal blocking results in diminished gastric contraction and emptying, limited ghrelin secretion, and diminished pancreatic enzyme secretion; these cause increased satiety, decreased cravings, and diminished absorption of calories, all of which lead to weight loss (Papasavas et al., 2016). Results from a randomized controlled trial found greater initial and 18-month sustained weight loss with participants with obesity who received vagal blocking versus control sham device implantation (Ikramuddin, Blackstone, Bracatisano, et al., 2014; Shikora, Wolfe, Apovian, et al., 2015). There are few adverse effects noted with use of this device, which include GI symptoms (e.g., heartburn, belching). Patients must be educated to recharge the device twice weekly for about an hour with an external coil device. Intragastric balloon therapy involves endoscopic placement of a saline-filled balloon (ORBERA™) or a saline-filled dual balloon (ReShape™) into the stomach. The mechanism by which these devices result in weight loss is poorly understood, but thought to be related to increased feelings of satiety and decreased gastric emptying. Post-insertion, the intragastric balloon(s) remain in place for 3 to 6 months, and are then deflated and removed. Studies suggest greater weight loss with these than with sham therapy or with lifestyle interventions alone (Ali et al., 2015). Early adverse effects include complaints of nausea and vomiting, which are generally transient and do not require balloon removal. Balloon rupture can occur over the long term, however, which may infrequently lead to intestinal obstruction. In order to monitor for this serious complication, it is recommended that the balloons be impregnated with methylene blue pre-insertion so that patients with silent ruptures can report the presence of green urine to their primary providers and receive timely interventions to remove the deflated balloons before they cause obstruction. Patients who seem unlikely to return for follow-up appointments should not be candidates for intragastric balloons. Balloons should be removed within 6 months of placement; longer placement periods are associated with increased likelihood of rupture and intestinal obstruction (Ali et al., 2015).

Explain nursing management considerations for the patient with obesity using nonsurgical interventions.

Obesity can result in anatomical remodeling, including compression of the oropharynx and increased neck circumference and chest diameter. These changes can predispose the patient with obesity to obstructive sleep apnea (OSA; see Chapter 22), respiratory failure (see Chapter 21), and obesity hypoventilation syndrome. Obesity hypoventilation syndrome is characterized by daytime hypoventilation with hypercapnea (i.e., PaCO2 >45 mmHg) and hypoxemia (i.e., PaO2 <80 mmHg), and sleep-disordered breathing. Potential adverse effects of obesity hypoventilation syndrome can be mitigated by maintaining the patient in the low Fowler position, which maximizes diaphragmatic chest expansion. Continuous pulse oximetry monitoring many be advisable, as well as supplemental oxygen therapy (see Chapter 21) and frequent respiratory assessments (at least every shift). For the patient with a known diagnosis of OSA, ensuring that the patient utilizes prescribed therapy (e.g., oral appliance, continuous positive airway pressure [CPAP]) if newly hospitalized or in a different transitional care environment is important in order to ensure breathing effectiveness and avert respiratory failure (Berrios, 2016; Dambaugh & Ecklund, 2016; Sturman-Floyd, 2013). The patient with obesity may have central and peripheral circulatory compromise. Heart failure is more commonplace among patients with obesity (see Chapter 29). Hypertension is also more prevalent; the nurse must use appropriately sized blood pressure cuffs to obtain valid blood pressure readings (see Chapter 31). Peripheral blood flow can be compromised for the patient with obesity, resulting in stasis of blood flow, one of three components of Virchow triad, which are the broad categories of risk for venous thromboembolism (VTE) (see Chapter 30, Chart 30-7). Peripheral circulatory compromise not only can increase the risk for VTE formation (e.g., pulmonary embolism [PE] and deep vein thrombosis [DVT]), but it can also make finding venous access difficult when the patient with obesity requires intravenous (IV) therapy. Finding appropriate venous access can be exacerbated by the presence of increased adipose tissue in the extremities. Ultrasound guidance may be required in order to successfully gain IV access and place an IV cannula in the patient with obesity The patient with obesity may have differences in both pharmacokinetics (i.e., the movement of drug metabolites within the body) and pharmacodynamics (i.e., how drugs are metabolized and the effects of drugs) that can affect drug dosages, drug effectiveness, and patient safety. The effectiveness of many drugs is affected by the ratio of lean skeletal muscle mass to adipose tissue. The typical nursing protocol is that the patient who is immobilized and bedfast should be turned every 2 hours to prevent pressure ulcers Nonsurgical Interventions Adult patients with obesity that does not respond to lifestyle interventions or antiobesity medications and who have either Class III/severe/extreme obesity (i.e., BMI in excess of 40 kg/m2) or Class II obesity (BMI 35-39.9 kg/m2) with obesity-related diseases or disorders (e.g., obstructive sleep apnea, type 2 diabetes) may be candidates for bariatric surgical interventions (see later discussion). As an alternative, some patients may elect to pursue minimally invasive interventions that were approved by the FDA in 2015. These types of interventions include vagal blocking (i.e., neurometabolic modulation) or intragastric balloon therapy (Ali, Moustarah, Kim, et al., 2015; Papasavas, El Chaar, Kothari, et al., 2016). Vagal blocking therapy involves placement of a pacemaker-like device (vBloc™) into the subcutaneous tissue in the lateral thoracic cavity with two leads that are laparoscopically implanted at the point where the vagus nerve truncates, at the gastroesophageal junction. A pre-programmed, pulsating signal is delivered for 12 hours daily. This signal causes intermittent "blocking" of the vagus nerve. Vagal blocking results in diminished gastric contraction and emptying, limited ghrelin secretion, and diminished pancreatic enzyme secretion; these cause increased satiety, decreased cravings, and diminished absorption of calories, all of which lead to weight loss (Papasavas et al., 2016). Results from a randomized controlled trial found greater initial and 18-month sustained weight loss with participants with obesity who received vagal blocking versus control sham device implantation (Ikramuddin, Blackstone, Bracatisano, et al., 2014; Shikora, Wolfe, Apovian, et al., 2015). There are few adverse effects noted with use of this device, which include GI symptoms (e.g., heartburn, belching). Patients must be educated to recharge the device twice weekly for about an hour with an external coil device. Intragastric balloon therapy involves endoscopic placement of a saline-filled balloon (ORBERA™) or a saline-filled dual balloon (ReShape™) into the stomach. The mechanism by which these devices result in weight loss is poorly understood, but thought to be related to increased feelings of satiety and decreased gastric emptying. Post-insertion, the intragastric balloon(s) remain in place for 3 to 6 months, and are then deflated and removed. Studies suggest greater weight loss with these than with sham therapy or with lifestyle interventions alone (Ali et al., 2015). Early adverse effects include complaints of nausea and vomiting, which are generally transient and do not require balloon removal. Balloon rupture can occur over the long term, however, which may infrequently lead to intestinal obstruction. In order to monitor for this serious complication, it is recommended that the balloons be impregnated with methylene blue pre-insertion so that patients with silent ruptures can report the presence of green urine to their primary providers and receive timely interventions to remove the deflated balloons before they cause obstruction. Patients who seem unlikely to return for follow-up appointments should not be candidates for intragastric balloons. Balloons should be removed within 6 months of placement; longer placement periods are associated with increased likelihood of rupture and intestinal obstruction (Ali et al., 2015).

Describe the causes, classifications, and diseases and disorders associated with obesity.

The causes of obesity are complex and multifactorial, and include behavioral, environmental, physiologic, and genetic factors. While there are certain demographic groups who seem to be at risk for obesity and while there are notable familial patterns of obesity, identification of risk factors that specify odds of being diagnosed with obesity are not as clearly elucidated as those for other diseases, such as coronary artery disease and cerebrovascular disease. Diseases and Disorders Associated With Obesity Alzheimer disease, Anxiety and depression Asthma, Cancers (breast, cervical, colorectal, endometrial, esophageal, gallbladder, liver, ovarian, non-Hodgkin lymphoma, pancreatic, prostate, kidney, thyroid), Chronic low back pain Coronary artery disease (angina, acute coronary syndrome, myocardial infarction), Diabetes (type 2) Gallbladder disease (cholecystitis, cholelithiasis) Gastroesophageal Reflux Disease (GERD), Gout Heart failure, Hypercholesterolemia, Hypertension Nonalcoholic fatty liver disease ,Obstructive sleep apnea, Osteoarthritis, Respiratory infections, Stroke. Obesity is a chronic, relapsing disease characterized by an excessive accumulation of body fat and weight gain. These increases in body fat cause adiposopathy (i.e., dysfunction of adipose tissue), which promotes the development of metabolic, biomechanical, and psychosocial diseases and disorders. Dysfunctional adipose tissue cells release biochemical mediators that cause chronic inflammatory changes, which can lead to a multitude of diseases, including heart disease, hypertension, and type 2 diabetes. At the most fundamental level, obesity results from a metabolic imbalance, characterized by an excess of caloric consumption relative to caloric expenditures. Classification: Patient height and weight is measured to determine the body mass index (BMI). The BMI is the definitive measure used to determine whether or not a patient is overweight or has obesity; this is based upon a ratio of body weight in kilograms and height in meters (see Chapter 5, Table 5-1). Patients identified as overweight or pre-obese have a BMI of 25 to 29.9 kg/m2 and those with obesity have a BMI that exceeds 30 kg/m2. Those with a BMI exceeding 40 kg/m2 are considered to have severe or extreme obesity (previously referred to as morbid obesity) Overweight/Pre-obese 25-29.9 Class I Obesity 30-34.9 Class II Obesity 35-39.9 Class III (also called "extreme" or "severe") Obesity ≥40 Testing: Patients with obesity or who are overweight may have other diagnostic laboratory studies done to screen for cardiovascular diseases, such as cholesterol and triglycerides (see Chapter 27), for type 2 diabetes, such as fasting blood glucose and glycosylated hemoglobin (hemoglobin A1c) (see Chapter 51), or for nonalcoholic fatty liver disease, such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (Orringer, Harrison, Nichani, et al., 2016) (see Chapter 49). In some instances, obesity may be secondary to other diseases or disorders, such as hypothyroidism or Cushing syndrome

Compare and contrast surgical modalities indicated to treat patients with obesity in terms of preoperative, postoperative, and long-term management and complications.

Assessment Preoperatively, the nurse assesses for contraindications to major abdominal surgery. Previous attempts at losing weight are also assessed, including strategies such as nutritional counseling, dieting, or exercise programs. The nurse ensures the patient has received education and counseling regarding the possible risks and benefits of bariatric surgery including the complications, postsurgical outcomes, dietary changes, and the need for lifelong follow-up. The nurse also confirms that the patient has been screened for behavioral disorders that may interfere with postsurgical outcomes. Dietary counseling is initiated preoperatively to prepare for postoperative dietary changes The nurse ensures that preoperative screening tests are obtained and scrutinizes the results. Typical laboratory tests include a complete blood cell count CBC, electrolytes, blood urea nitrogen (BUN), and creatinine. See Appendix A on for normal values for these laboratory tests. Patients with obesity may have OSA, gastroesophageal reflux disease (GERD), heart disease, nonalcoholic fatty liver disease, diabetes (or prediabetes), and vitamin and mineral deficiencies; thus, other screening tests that may be obtained include a sleep study, upper endoscopy, electrocardiogram (ECG), lipid panel, AST, ALT, glucose, and hemoglobin A1c, as well as iron, vitamin B12, thiamine, folate, vitamin D, and calcium levels. Postoperatively, the nurse assesses the patient to ensure that goals for recovery are met and that the patient exhibits absence of complications secondary to the surgical intervention. See Chapter 19 for general assessment of the postoperative patient. MONITORING AND MANAGING POTENTIAL COMPLICATIONS After surgery, the nurse assesses the patient for complications from the bariatric surgery, such as hemorrhage, venous thromboembolism, bile reflux, dumping syndrome, dysphagia, and bowel or gastric outlet obstruction. Hemorrhage. Postoperative hemorrhage may be a complication following bariatric surgery. Intra-abdominal hemorrhage may be evident by frank, bright red oral or rectal bleeding, tarry melena, bloody output from the wound or drains, if present, as well as typical clinical manifestations of severe bleeding and hemorrhagic shock (e.g., tachycardia, hypotension, syncope) (see Chapter 14). Bleeding within the first 72 hours postoperatively is most likely caused by disruption in a staple or suture. Bleeding 72 hours to 30 days postoperatively is most likely from formation of a gastric or duodenal ulcer (Patil & Melander, 2015) (see Chapter 46). p. 1372p. 1373 Venous Thromboembolism (VTE). Patients who have bariatric surgery are at moderate to high risk of VTE, including both PE and DVT. Patients who are older, have higher BMIs, and have a prior history of a VTE or coagulation defect are at higher risk (Brethauer, 2013). ASMBS guidelines for VTE prevention specify that in the immediate postoperative period, patients who have had bariatric surgery should be prescribed mechanical compression (e.g., intermittent pneumatic compression devices) and prophylactic anticoagulation with subcutaneous low molecular weight heparin (LMWH) agents (e.g., dalteparin [Fragmin], enoxaparin [Lovenox]). The duration of time that mechanical compression and anticoagulation should continue postoperatively are not described, however, and are left to the discretion of the patient and primary provider. In addition to implementing this prescribed therapy, nurses caring for patients post bariatric surgery should encourage them to begin early ambulation to further deter the advent of VTE (Brethauer, 2013) (see Chapter 30). Bile Reflux. Bile reflux may occur with procedures that manipulate or remove the pylorus, which acts as a barrier to the reflux of duodenal contents. Reflux of bile can cause inflammation of the stomach (i.e., gastritis) or esophagus (i.e., esophagitis). Burning epigastric pain and vomiting of bilious material manifest this condition. Eating or vomiting does not relieve the symptoms. Bile reflux may be managed with proton pump inhibitors (e.g., omeprazole [Prilosec]) (Sifrim, 2013). Dumping Syndrome. Dumping syndrome is an unpleasant set of vasomotor and GI symptoms that commonly occurs in patients who have had bariatric surgery. For many years, it had been theorized that the hypertonic gastric food boluses that quickly transit into the intestines drew extracellular fluid from the circulating blood volume into the small intestines to dilute the high concentration of electrolytes and sugars, resulting in symptoms. Now, it is thought that this rapid transit of the food bolus from the stomach into the small intestines instead causes a rapid and exuberant release of metabolic peptides that are responsible for the symptoms of dumping syndrome (Patil & Melander, 2015). Symptoms of dumping syndrome typically occur 15 minutes to 2 hours after eating and include tachycardia, dizziness, sweating, nausea, vomiting, bloating, abdominal cramping, and diarrhea (Patil & Melander, 2015). These symptoms typically resolve once the intestine has been evacuated (i.e., with defecation). Later, blood glucose rises rapidly, followed by increased insulin secretion. This results in a reactive hypoglycemia, which also is unpleasant for the patient. Vasomotor symptoms that occur 10 to 90 minutes after eating are pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and even drowsiness. Anorexia may also result from dumping syndrome, because the patient may be reluctant to eat (Patil & Melander, 2015). Dysphagia. Dysphagia, or difficulty swallowing, may occur in patients who have had any type of restrictive bariatric procedure. If it occurs, it tends to be most severe 4 to 6 weeks postoperatively and may persist for up to 6 months after surgery. Dysphagia may be prevented by educating patients to eat slowly, to chew food thoroughly, and to avoid eating tough foods such as steak or dry chicken or doughy bread. Patients with severe dysphagia who have had gastric banding may benefit from having their bands adjusted. Patients who have had other restrictive procedures may experience relief of symptoms after having stomal strictures relieved endoscopically (Mechanick et al., 2013). Bowel and Gastric Outlet Obstruction. Bowel or gastric outlet obstruction may occur as a complication of bariatric surgery. The typical manifestations and treatments of gastric outlet obstruction are described in Chapter 46; however, there is a key difference in the treatment of a patient who has undergone bariatric surgery with a gastric outlet obstruction. It is contraindicated to insert a nasogastric (NG) tube in patients that have had bariatric surgery, even if they have a gastric outlet obstruction. Alternative treatment options may include endoscopic procedures aimed at relieving the obstruction, such as balloon dilation, or surgical revisions (Patil & Melander, 2015). PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Patients are usually discharged from the hospital within 4 days postoperatively (this may be within 24 to 72 hours for patients who have had laparoscopic procedures) with detailed dietary instructions (see Chart 48-7) as well as instructions about how to either begin or resume an appropriate exercise regimen. Instructions on making follow-up appointments with the bariatric surgeon for routine postoperative visits or for complications are shared with the patient (Mechanick et al., 2013). Educating Patients About Self-Care. The nurse provides education with the patient about nutrition, nutritional supplements, pain management, the importance of physical activity, and the symptoms of dumping syndrome and measures to prevent or minimize these symptoms. Patients who undergo laparoscopic or open RYGB procedures may have one or more Jackson-Pratt drains, which may remain in place after discharge. The nurse educates the patient or caregiver about how to empty, measure, and record the amount of drainage. Patients should be instructed to avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen [Motrin]) postdischarge, as they have been implicated in development of stomach ulcers (Mechanick et al., 2013). The nurse must emphasize the continued need for follow-up (even after weight-loss goals are met) and continued support group participation (Wykowski & Krouse, 2013). Continuing and Transitional Care. After bariatric surgery, all patients require lifelong monitoring of weight, comorbidities, metabolic and nutritional status, and dietary and activity behaviors because they are at risk for developing malnutrition or weight gain. Women of childbearing age who have bariatric surgery are advised to use contraceptives for at least 18 months after surgery to avoid pregnancy until their weight stabilizes. After weight loss, the patient may elect additional surgical interventions for body contouring. These may include breast reductions, lipoplasty to remove fat deposits, or a panniculectomy or abdominoplasty to remove excess abdominal skin folds (OAC, 2015b; Mechanick et al., 2013; Wykowski & Krouse, 2013). Quality and Safety Nursing Alert Insertion of NG tubes is contraindicated in the patient post bariatric surgery. This procedure may disrupt the surgical suture line and cause anastomotic leak or hemorrhage.

Evaluation: Patient outcomes

Evaluation Expected patient outcomes may include the following: Relief of painReports relief of painEngages in early mobilization activities as prescribed Maintenance of fluid balanceAble to tolerate progressive fluid intake without complaints of nausea or gastric refluxVoids 0.5 mL/kg/h Maintenance of asepsisNo evidence of infection (e.g., no fever, no leukocytosis, no complaints of abdominal pain) Achievement of nutritional balanceAble to consume small, frequent meals as prescribedAdheres to prescribed intake of vitamins and supplementsAchieves and maintains weight reduction goals Promotion of positive body imageVerbalizes continued satisfaction with weight reduction plan and its effect on body image Maintenance of usual bowel habitsNo evidence of diarrheaNo evidence of constipation Has no complications (e.g., no bleeding, VTE, bile reflux, dumping syndrome, dysphagia, or bowel or gastric outlet obstruction)