best nursing practice for gastric bypass surgery

According to the Centers for Disease Control (CDC), statistics show that of adults in the United States, 20 years of age and older, over 60 million people are obese(Marquerite, 2006, p.1-2).Options to resolve this problem include preventative medicine, diet, exercise, and education. Yoon- heui coffman

Nursing best practice:
Post-op care for the gastric bypass patient
According to the Centers for Disease Control (CDC), statistics show that of adults in the United States, 20 years of age and older, over 60 million people are obese (Marquerite, 2006, p.1-2). Options to resolve this problem include preventative medicine, diet, exercise, and education. After all of these options have been exhausted with a health care professional, gastric bypass surgery should be considered. According to Marquerite, Roux-en-Y gastric bypass (RYGB), Biliopancreatic diversion (BPD), and Laparoscopic adjustable gastric banding (LAGB) are the three main types of gastric bypass surgery (Marquerite, 2006, p.3). Short-term complications include marginal ulcers and stenosis at the gastrojejunal anastomosis necessitating dilatation, anastomotic leakage, and gastrointestinal hemorrhage. Other complications are wound infection, incision hernia, pneumonia, pulmonary embolus, and prolonged nausea or vomiting. Long-term complications include regained weight or inadequate weight loss and nutritional deficiencies (Marquerite, 2006, p.3-4). Most morbidly obese patients report experiences of humiliation, embarrassment, insults, and blatant verbal abuse regarding their weight from their treating physicians. Obesity promotes incredible feelings of worthlessness, powerlessness, and a poor quality of life (Reto, 2003, p. 140-141). Therefore, in order for gastric bypass surgery to be successful, post-operative nursing intervention must integrate the following three approaches: physiological, psychosocial, and educational restoration.
Physiological facts
There are several important physiological facts when considering gastric bypass surgery. In obese patients, the increased size of normal structures and fat deposits interferes with the mechanics of numerous body functions. Fat deposits in the diaphragm and intercostals muscle cause decreased functional residual capacity, expiratory reserve volume, and forced expiratory volume. Sleep apnea also occurs due to airway narrowing (Hurst, Blanco, Boyle, Douglass, & Wikas, 2004, p. 77). Research has shown that prophylactic use of biphasic positive airway pressure (BiPAP) at a level of 12/4 postoperatively reduces pulmonary dysfunction and accelerates preoperative pulmonary function in obese patients (Davidson, Kruse, Cox, & Duncan, 2003, p. 110). Continuous positive airway pressure (CPAP) helps to prevent atelectasis by improving tidal volume during sleep (Davidson et al., 2003, p. 107). Therefore, it is necessary for proper respiratory care such as CPAP and BiPAP to prevent obesity hypoventilation syndrome.
If we consider wound infection, adipose tissue is poorly vascularized and may cause delayed healing of open wounds, so infection control and daily inspection of skin are needed (Hurst et al., 2004, p. 78-80). Obese patients are at risk for developing pressure ulcers and yeast infection. With each turning, skin folds are assessed, cleansed, and dried as needed. All lines and tubes are visually inspected to make sure they are not trapped in a skin fold (Hurst et al., 2003, p. 113). Monitoring for cellulitis, frequent turning and repositioning are all helpful (Hurst et al., 2004, p. 80). Difficulty getting out of bed in the early postoperative period may worsen the situation. Nurses can help with personal hygiene performance and need to encourage the patient to begin early ambulation.
Another important physiological issue is blood clotting. The morbidly obese are at higher risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) because of immobility stasis in addition to polycythemia related to chronic respiratory insufficiency (Davidson et al., 2003, p. 109). Low molecular weight Heparin such as Dalteparin (Fragmin) injection with careful monitoring of prothrombin time (PT) and partial prothrombin time (PTT) is needed to help prevent clot formation (Davidson et al., 2003, p. 111). Use of a sequential compression device and early ambulation can be helpful to decrease pain and enhance recovery (Hurst et al., 2004, p. 80).
Psychosocial facts
Empathetic nursing care is also needed. Studies show that patterns of eating connect to mood, anxiety, stress, and other hidden reasons (Reto, 2003, p. 140- 142). Overeating and obsessions with food allow for the redirecting and narrowing of thoughts, attention, and affect as well as shutting out thoughts (Reto, 2003, p.145). At the time of bariatric surgery, patients may deem themselves as taking “desperate, last resort measures” and hence becomes self-loathing, shameful, and even express suicidal ideation (Hurst et al., 2004, p. 78). Nonjudgmental, supportive, and sensitive staffs are important to promoting partnership with patients (Hurst et al, 2004, p. 79). These patients may believe that it is impossible for others to understand their life. Negative stereotype regarding the morbidly obese patient can interfere with professionalism. Regardless of how a nurse feels about obesity, one should not allow personal attitudes to influence the way care is delivered to an obese client.
Cultural influences also need to be considered. Sociocultural factors that promote thinness and self-concept relating to beauty cause binge eating disorder. The combination of a growing fast food business, multibillion dollar fashion industry, and diet programs lead to unhealthy eating habits (Reto, 2003, p.140-142). Cultural factors such as forced feeding where young children required cleaning their plates contribute obese society (Reto, 2003, p.144). Parents lacking in parenting skill may succumb to their children’s insistent request in unhealthy food (Reto, 2003, p.145). Some patients may compensate for past psychological trauma by developing a very strong personality, while others have low self- esteem. Nursing staff need to discuss fat bias openly and try to understand each patient personally.
Educational facts
Obesity can alter the pharmacokinetic properties of medications. Highly lipophylic drugs require dose calculations based on actual weight, while minimally lipophylic drugs require dosage calculations based on a patient’s ideal weight (Hurst et al., 2004, p. 77). Diabetics, for example, may need insulin dose and or oral hypoglycemic medications adjusted frequently to match the caloric intake and weight loss of the patient. It is important to identify the changing form of medication, dosage alteration, and new medication administration with the patient. Patients also should be encouraged to share any side effects of medications due to polypharmacy.
Patients are at risk for developing deficiencies of iron, B12, folate, and calcium because ingested food bypasses the duodenum, the primary site of absorption of theses nutrients (Elliot, 2003, p. 134). Patients need to take multivitamins on a life-long basis and will address the changes in dietary intake as well as in vitamin and mineral absorption (Marquerite, 2006, p.5). When sugar is consumed, it can cause dumping syndrome which consists of hypoglycemia, bloated sensation, and watery diarrhea. Patients should avoid sugar, caffeine, carbonated drinks and consume high- protein supplements or shakes (Elliot, 2003, p. 136). Diet modification can help restore fluid/ electrolyte balance, prevent dumping syndrome, and ensure the nutritional balance. Therefore, all weight loss patients should have a dietary consultation prior to discharge.
Planning exercise as conditions permit with help from physical therapist (PT)/ occupational therapist (OT) will bring a maximum effect after surgery. According to Marquerite, many well- known medical associations recommend a minimum of 150 minutes of physical activity per week over three to seven days (Marquerite, 2006, p.4). Many morbidly obese individuals, due to size, energy limitations, and/ or co- morbid conditions, may benefit from a planned and monitored, exercise program. Short and long term goals should be set to achieve optimal levels of activity (Marquerite, 2006, p.4-5). Regular physical activity promotes physical and psychological health. It can enhance cardiopulmonary functioning, musculoskeletal fitness, weight control, and psychological well- being.
Conclusion
Gastric bypass surgery is a complicated procedure that involves many risk factors to consider. Weight loss maintenance will not be achieved if we neglect these considerations. Physiologic developmental changes, behavioral aspects, family and social support, cultural origin, and environmental issues are important things for each patient and must be incorporated into the plan of care. Nurses are effective in providing postoperative care for gastric bypass patients when they provide holistic, physical, and psychological care, while collaborating in patient education.


References

Davidson, E., Kruse, W., Cox, H. & Duncan, R. (2003, Apr). Critical care of the morbidly obese. Nursing Quarterly, 26(2), 105- 116. Retrieved October 25, 2007 from Ebsco database.


Marquerite, S. (2006, Oct). Breaking through obesity with gastric bypass surgery. The Nurse Practitioner, 31(10), 12-23. Retrieved October 25, 2007 from CINHL database.


Hurst, S., Blanco, K., Boyle, D., Douglass, L., & Wikas, A. (2004, Mar). Bariatric implications of critical care nursing. Dimensions of Critical Care Nursing, 23(2), 76-83. Retrieved Oct 27, 2007 from Ebsco database.


Reto, C. (2003, June). Psychological aspects of delivering nursing care to the bariatric patient. Critical Care Nursing Quarterly, 26(2), 139-149. Retrieved Nov 1, 2007 from Proquest database.


Elliot, K. (2003, Apr). Nutritional considerations after bariatric surgery. Critical Care Nursing Quarterly, 26 (2), 133-138. Retrieved Nov 9, 2007 from CINHL database.








Nur 211

Intervention 1

Non judgmental and non- stereotypical nursing attitudes are needed with dealing with patients. Regardless of how a nurse feels about obesity, one should not allow personal attitudes to influence the way care is delivered to an obese client.

Disadvantage1;
Obesity seems still seen as somebody’s fault.

In modern societies, slenderness generally is associated with social acceptability, success, and beauty. One study found that individuals who were obese who underwent simulated job interviews were rated less qualified for jobs and viewed as having poorer work habits, as well as more emotional and interpersonal problems than participants in a control group (Murray, 2003, p. 990). The problem is health care providers often have negative perceptions of people who are obese. According to Brownnell, a study of over 400 physicians identified patient characteristics that aroused feelings of discomfort or dislike(Brownell, 2001, p.789- 792). So, there is a stereotype that obese people ought to just pull themselves together and stop eating so much and exercising more. As a nurse, one should be aware of this unconscious prejudice and discrimination towards obese patients.

Murray, D. (2003, Dec). Morbid obesity-psychosocial aspects and surgical interventions. Association of Operating Room Nurses, 78(6), 990-995. Retrieved Jan 1, 2008 from Ebsco database.

Brownwell, K. & Puhl, R. (2001, Dec). Bias, discrimination, and obesity. Obesity Research, 9(12), 788-805. Retrieved Jan 1, 2008 from Pubmed database.


Disadvantage 2;

There is minimum protection of obese individuals’ civil rights, to include the potential lack of insurance coverage.

Many reimbursement systems do not categorize obesity as a disease so physicians often have difficulties getting reimbursement for their services for the gastric bypass surgery. No federal laws exist to prohibit discrimination against obese individuals, and only a few states prohibit employment discrimination on the basis of weight. While many courts do not recognize obesity as an actual impairment, obese individuals must often use impairment claims (Brownell, 2001, p.793- 794). Whether it is advantageous for obesity to be considered a disability is a matter of debate, but it is important to consider patient’s rights and treat equally as a nurse.



Brownwell, K. & Puhl, R. (2001, Dec). Bias, discrimination, and obesity. Obesity Research, 9(12), 788-805. Retrieved Jan 1, 2008 from Pubmed database.


Intervention2

Diet modification and a plan of exercise are needed for post-op gastric bypass surgery patient to maintain weight loss.


Disadvantage1;
Lack of education opportunity and resources are common in many obese patients.

According to Najman, being overweight or obese is highly associated with lower socioeconomic status (Najman, 2006, p.977-980). Low socioeconomic status may influence a variety of factors including health insurance, local schools and their resources, local food stores and the extent to which they carry healthful foods, the price of food, tendency to watch television and participate in other sedentary activities, and access to gyms and health clubs (Vieweg, 2007, p.1-7). Education strategies considering specific population like SES (socioeconomic status) to reduce health inequalities can help solve this problem.

Najman, J. (2006, Dec). Socioeconomic disadvantage and changes in health risk behaviors in Australia: 1989-90 to 2001. Bulletin of the World Health Organization, 84(12), 976-979. Retrieved Jan 1, 2008 from Ebsco database.

Viewer, V., Johnston, C., Lanier, J., Fernandez, A., & Pandurangi. A.(2007, Jan). Correlation between High Risk Obesity Groups and Low Socioeconomic Status in School Children. Southern Medical Journal, 100(1), 8-13. Retrieved Jan1, 2008 from Proquest database.


Disadvantage 2
Patients who do not comply with prescribed health instructions are a common problem that can cause frustration for health care providers.

Compliance with behavior and lifestyle changes, that are needed to lose weight and maintain weight loss, can be extremely difficult because of genetic background, environmental pressures, and ingrained, life-long behaviors (Vieweg, 2007, p.1-7). Nurse should have realistic expectations and be aware of the considerable barriers. Nurses can help patients identify barriers, explore how these can be removed, and devise new strategies to achieve the same objectives.

Viewer, V., Johnston, C., Lanier, J., Fernandez, A., & Pandurangi. A.(2007, Jan). Correlation between High Risk Obesity Groups and Low Socioeconomic Status in School Children. Southern Medical Journal, 100(1), 8-13. Retrieved Jan1, 2008 from Proquest database.

Brown, I. (2006, Jan). Nurses’ attitudes towards adult patients who are obese. Journal of Advanced Nursing, 53(2), 221-232. Retrieved Jan1, 2008 from CINHL database.