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01.07 Bariatric Surgeries

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Overview

  1. Most effective way to correct morbid obesity
    1. Elective surgery
  2. Different surgical approaches
    1. Restrict gastric capacity
    2. Restrict absorption
  3. Requires teaching to ensure success
    1. Diet
    2. Lifestyle

Nursing Points

General

  1. Pre-operative
    1. Coaching for lifestyle and diet changes
    2. Diet change
      1. High protein, low fat
    3. Consider surgical risk factors
  2. Post-operative
    1. Standard post-surgical care
      1. Ambulation
      2. Diet advancement
      3. Wound assessment
    2. Post-surgical diet
      1. Vitamin supplements
      2. High protein, low-fat
    3. Dumping syndrome
      1. Occurs after procedures that limit absorption
      2. Causes diarrhea
      3. Can cause serious malnutrition
      4. Sometimes patients must have surgery reversed
    4. Common surgical complications
      1. Wound complications
        1. infection
        2. dehiscence
      2. Malnutrition
        1. Supplements can help
        2. Can be irreversible and lifelong
      3. Hernia
  3. Patient education
    1. Essential to ensure success
    2. Common techniques
      1. Diet journaling
      2. Support groups

Assessment

  1. Pre-Operative
    1. Surgical risk factors
    2. Readiness to change
      1. Adherence to prescribed diet
      2. Participation in support groups
      3. Attendance at pre-op appointments
  2. Post-Operative
    1. Routine post-surgical care
    2. Diet advancement
    3. Education

Therapeutic Management

  1. Immediately post-operative
    1. Pain control
    2. Diet advancement
    3. Ambulation
  2. Long term considerations
    1. Plastic surgery
      1. Excess skin poses hygeine concerns
    2. Monitor for malnutrition
    3. Monitor for weight gain

Nursing Concepts

  1. Nutrition
    1. Requires pre- and post-surgical diet changes
    2. Can lead to lifelong defecits
  2. Gastrointestinal/Liver Metabolism
    1. Surgery alters the anatomy of GI tract
    2. Can lead to alterations in absorption of nutrients
  3. Patient Education
    1. Essential to positive outcome

Patient Education

  1. Diet
    1. High protein, low-fat
    2. Easily digestible
    3. Implement vitamins and supplements
  2. Lifestyle
    1. Increase activity level to lower risk of weight gain
  3. Monitor for complications
    1. Increased abdominal pain
    2. Changes in stool
    3. Nausea/vomiting

Reference Links

Video Transcript

Hey there! My name is Meg and today we are going to learn about bariatric, or weight loss, surgeries.

The most important thing to remember about bariatric surgery is that, while it is an elective and effective procedure, it is still a surgery! For your patient to have a successful life after surgery, they will need excellent education from their provider and nursing staff. The education you give your patient will depend on the surgical approach the provider uses. Along with education, ensuring your patient is engaged and involved in their plan of care is essential. 

As I mentioned, there are many many different types of bariatric surgery. We are going to focus on the two most common approaches you will see in practice. The first type is restricting the capacity of stomach. These procedures help the patient to reduce weight by reducing gastric capacity and there are two commonly done. Our first example is commonly referred to as a Lap Band. The band you see on this diagram creates a small pouch that produces early satiety, or in normal terms- makes your patient feel full more quickly! It makes sense, right? You eat less, you lose weight. The lap band is a tool to produce that feeling of fullness. With that, patients will need to be coached to eat smaller, more frequent meals so as not to malnourish them. The band is adjustable and can be loosened or tightened to meet the patient’s needs. The other common surgery done to restrict gastric capacity is the gastric sleeve. This procedure is irreversible and involves removing around 80% of the stomach. The procedure is called a “sleeve” because the remaining stomach is shaped like a sleeve. It follows the natural curve of stomach so I think it looks a little more like a banana! The important thing to remember here is that both procedures allow patients to lose weight by making them feel full more quickly.

So, the other approach is really a combination approach. These two surgeries restrict gastric capacity like the lap band and gastric sleeve, but also alter the route of GI tract to limit the absorption of nutrients. The most common of these approaches is the Roux-en-Y, where the surgeon creates a small stomach pouch by stapling the stomach closed and then bypassing the remainder of the stomach and duodenum. This is more commonly known as a gastric bypass. This effectively removes much of the body’s opportunity to absorb nutrients, thus inducing weight gain. This procedure is more complex than the lap band or gastric sleeve procedure, but is also very effective. The next approach, the duodenal switch, is newer must is being done more and more. This procedure involves performing a gastric sleeve and then also connecting a piece of small bowel to the stomach and creating a shorter route to the colon. The rest of the small bowel is rerouted to carry bile to one shared section before the colon. This smaller section of small bowel limits the amount of fat the gut can absorb. As you can tell, these surgeries are very complex and carry some risk of side effects which we will review on the next slide.

So remember – bariatric surgery is elective, but it is still a surgery! That means complications are possible. These complications are listed in terms of when they happen after surgery, going from soonest to latest. Ileus occurs when the patient’s bowel does not wake up after surgery- this can happen with any abdominal surgery, but it’s less likely when the surgery is done laparoscopically. Wound complications can also happen pretty soon after surgery – sometimes wounds open up, or dehisce, and can also get infected. The risk for both of these is higher in obese patients because adipose tissue heals slowly and is more prone to infection. Finally, dumping syndrome. This is incredibly common after Roux-en-Y and Duodenal switch. Because these procedures bypass the pyloric valve at the exit of stomach, patients can experience rapid dumping of gastric contents into the bowel. This rapid movement through the gut can make the patient anxious and normally gives them diarrhea and severe abdominal cramping. Because the contents move through the gut so fast, the body cannot absorb nutrients. This can cause pretty profound malnutrition, and if interventions to stop it do not work, some patients have to have their procedures reversed. So as you can see, it is important for you to be aware of these complications and educate and support your patients through the process.

Now we have reached the most important piece – patient education. Your patient needs you to share your knowledge to ensure they are successful. We will discuss the continuum of care and when the components of diet, lifestyle, and complications will be most pertinent for you to share with your patient.

Our first step of patient education is pre-operative. This is probably the most important and impactful phase of patient education. Without pre-op education and counseling, the patient is not likely to succeed. Your patient will need to buy into the lifestyle changes that will occur after surgery. Providers often have the patients begin their post-op diet beforehand to gauge the patient’s ability and motivation to change. Many providers also suggest diet journaling and support group attendance, both of which commonly carry throughout the patient’s lifespan. The surgeon will also request the patient increase exercise levels to improve cardiovascular health. It is not uncommon for patients to remain in this pre-operative prep period for a year before the surgeon will proceed with the surgery. That’s how important the education and counseling you give to your patients is!

After surgery, you will support your patient’s pain control while also motivating them to advance their diet and activity levels. Pain management after any abdominal surgery is incredibly important, and we manage that pain with fewer and fewer opioids- advising your patient to take their medications as prescribed will be incredibly important to maintaining pain control. If your patient’s surgery was laparoscopic, they will also probably have a lot of gas pain, as the surgeon often injects air into the abdominal cavity to more easily visualize the patient’s anatomy. Diet advancement is also key to helping the patient adapt to their new stomach. Early ambulation improves wound healing, helps wake up your patient’s gut, and can even help with pain control. That’s right! Early ambulation helps to address many of the common complications we discussed earlier in this lesson.

Finally, once our patient is at home and returning to their new normal life, it is essential to monitor your patient’s adherence to their diet, but also incredibly important to make sure they are not missing any appointments. Maintaining patient engagement is essential to success. Once your patient is fully out of the perioperative period and has demonstrated long-term weight loss, they may be a candidate for plastic surgery to re-contour their body and remove any excess skin. Of course- that surgery comes with its own set of risks, however is incredibly important for body image and also to  prevent any skin infections under excess skin folds.

So, what are our priority nursing concepts for bariatric surgery? Bariatric surgery affects the way your patient will metabolize and absorb their nutrients. Nutrition is key- both diet changes and the risk of malnutrition are major players following bariatric surgery. And finally, most important of all, patient education! You, the patient’s nurse, make the biggest impact on a patient undergoing a bariatric surgery.

Ok, so let’s review our key points. For your patient to be successful, they will need your top-notch peri-operative care- that means pre- and post-surgery as well as post-discharge. Patient education and engagement will drive success. With your help, the patient is much much more likely to lose weight and keep it off. And finally, educating patients on the lifelong positive and negative effects of bariatric surgery prepares them to live their best life moving forward.

Well folks that’s all for bariatric surgeries! Remember, this is more than just a surgery – it is a lifestyle change! Now, go out and be your best selves today, and as always, happy nursing!

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