Bariatric Surgery Preoperative Class...stay here the entire time! •All rooms are thoroughly...

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Bariatric Surgery

Preoperative Class

Guidelines for Virtual Class

• Ensure your internet/wifi connection is good

• Stay in a quiet place to minimize distractions

• Your choice to use the camera function!

• Don’t do anything embarrassing on camera ☺

• Stay on mute until we open up for questions

• Use the chat function or write down questions during

the presentation so you don’t forget

Your Jefferson Stratford Team!

• Surgeons

• Bariatric Program Coordinator

• Perioperative Nurse Practitioner

• Dr. Neff, Dr. Fakulujo, Dr. Goldstein,

Dr. Balsama

• Kimberly Brody-Muckenfuss, BSN, RN

• Megan Sabin, APN

• Paulette Palogruto, APN

Your Jefferson Stratford Team!

• Nurses (navy blue scrubs)

Dawn Lynn Nancy

• Nursing Techs (gray scrubs)

• Dietitians

• Respiratory Therapists

• Physical Therapists

• Home Care Nurse

• Certified Bariatric Nurses

I'm Not Only The Coordinator But I'm a Patient Too....

Preparing for Surgery

• Preoperative diet

• Start 2 weeks before surgery date

• Goals: reduce liver size, prepare body/mind for surgery and new lifestyle

• Daily diet consists of:

• Protein smoothie (breakfast)

• Salad (lunch)

• Bariatric power plate (dinner)

• 50% vegetable, 25% lean protein, 25% whole grain

• Approved snacks (1-2/day)

• 64 ounces of water

Preparing for Surgery

• Preoperative diet

• Avoid:

• Oil, butter, cheese, cream, milk,

ghee (clarified butter)

• Creamy sauces/dressings

• Junk food – chips, sweets

• Bread, pasta, crackers, rice

• Alcohol, caffeine, carbonated drinks

Preparing for Surgery

• You may be required to see a physician/nurse

practitioner or nurse prior to surgery in our

Pre-Admission Testing department

• History and physical exam, lab draw, instructions

regarding medicines and how to prepare for surgery

Preparing for Surgery

• Please discuss all of your

medications with your provider

• Surgery can affect certain medicines

• Some medicines may need to

be stopped for a specific

period of time prior to surgery

• Also an opportunity to discuss

what medicines may need to

be changed or might actually

be stopped after surgery

What About the Coronavirus Pandemic?

• Our top priority is patient and staff safety!

• All patients undergoing surgery will be tested for COVID-19

• New safety procedures are in place

• “COVID-FREE” zones - you will stay here the entire time!

• All rooms are thoroughly cleaned

• Staff is being monitored closely

• Testing is available to them as well

Preparing for Surgery

• Day before surgery

• Clear liquids

• Water/enhanced waters

• Broth

• Popsicles

• Protein water

• Protein shakes made with water

• Hydrate, hydrate, HYDRATE

• Nothing to eat/drink after midnight!!!

Preparing for Surgery

• Take any medicines the night before or morning of surgery as instructed

• If after midnight, please only take with a small sip of water

• It is normal to feel anxious, nervous, scared

• Surgery is a monumental step!

• We are here to help ease your fears and nerves

What to bring to the hospital?

• Personal hygiene items as desired

• Pillow/blanket

• Pajamas/robe

• Footwear to be comfortable walking the hallways

• Recommend slip-on shoes or slippers that have a good grip

• Phone/tablet as well as charging cable!

• Please be careful with electronics – know where they are at all times as they can easily be

misplaced in the hospital!

• Recommend an extra long charging cable

**PLEASE DO NOT Bring Valuables**

You are responsible for your valuables!

What to bring to the hospital?

• If you have sleep apnea and utilize

CPAP, PLEASE bring this with you!• Know your settings and write them down as well!

• We do have sterile water in the hospital that you

can use

• Confirm what you can bring to the hospital the day before surgery

Regarding Visitors…

• With the pandemic, it is an ever-evolving situation, when

you call for scheduled surgical time, ask for current visitor

policy.

• Please know your surgeon and staff will be in communication

with your family members to provide information and

updates

Your stay at Jefferson – what to expect?

• Call the hospital the day before your surgery to get your arrival time• 856-346-7908

• Arrive at Admissions 2 hours before your scheduled surgery time

• You will be taken to a semi-private room, where you will:• Complete/sign any required

paperwork• Change into a hospital gown• Have vital signs checked and an IV

placed• Receive a heparin shot in your

belly

Your stay at Jefferson – what to expect?

• When everything is ready, you

will be brought to the OR

• How long is surgery?

• Gastric sleeve:

approximately 1 to 1 ½

hours

• Gastric bypass (Roux En Y):

approximately 2 to 3 hours

• Revision: approximately 2

to 4 hours

Your stay at Jefferson – what to expect?

• Once your surgery is completed you will be brought to the recovery

room (PACU – Post Anesthesia Care Unit)

• Time to wake up!

• Vital signs will be monitored frequently

• How will you feel?

• Mouth and throat may feel tight and dry

• Sensation of pressure in lower chest

• May feel nauseated; vomiting at this point is rare

• May begin to feel pain

• Medicines to treat your symptoms will be given!

Your stay at Jefferson – what to expect?

• There is a rare possibility

you could have a drain

placed in your belly during

surgery; this is typically

removed at the surgeon’s

office after you have been

discharged from the

hospital

Your stay at Jefferson – what to expect?

• You will stay in PACU until you are stable enough to be admitted to the medical/surgical unit, 4 East

• Amount of time in PACU is variable

• On rare occasions a patient may need to be admitted to the Intensive Care Unit or the intermediate step-down unit if closer monitoring of vital signs and oxygen levels is required

WELCOME TO 4 EAST

Surgery is done! Now what?

• You will get settled into your room

• Within 4 hours:

• Pee!!!

• Rest – use this time to take a nap

• Get out of bed and walk!

• You will get medicine in your IV

• Pain and anti-nausea medicines as needed

• IV fluids to keep you hydrated

BARI-BUDDY

4 EAST

• HALL OF FAME

Managing Pain

• Pain is often described as more of a strong ache than a stabbing pain• Please speak up if your pain is

not controlled!

• Help us manage your pain by using this scale as a guide →

• Postoperative pain is typically from incisions and gas used to inflate your abdomen during your surgery

Managing Pain

• Pain control medicines:

• IV medicines at first

• Some options include Toradol, Morphine, Dilaudid

• Most pain medicine is prescribed as needed, so you will

need to ask for medicine

• Switched to oral medicines the day after surgery

• Opioids versus non-opioids

• Try to minimize use of opioids due to potential for abuse/addiction

• Can also contribute to nausea and make you too drowsy

Managing Nausea/Vomiting

• Nausea is common, but it varies to the severity of which you may experience it• Anti-nausea medicines mostly

prescribed as needed, so you will need to ask for it

• Vomiting sometimes occurs, but it is mostly dry heaves/retching

• Please let your nurse know anytime you vomit!

• Why?• Stomach has been cut;

anesthesia/opioids; anxiety

What to expect the day after surgery?

• Blood work (usually early morning)

• A visit from your surgeon and the surgical residents

• A visit from the perioperative nurse practitioner

• Depending on your type of surgery, you may have a study called an Upper

GI series the next morning

• This test involves swallowing a liquid contrast solution and x-rays to

look for any leaks or obstructions

• A visit from the hospital dietitian

• A visit from a physical therapist if needed

Starting the Bariatric Diet

• Divided into stages:

• Stage 1: Clear liquids

• Stage 2: Full

liquids/purees

• Stage 3: Soft (fork-

tender) diet

• Stage 4: Regular diet

Starting the Bariatric Diet

• Start Stage 1 the morning after surgery

• Start with one 30 mL (1 oz.) cup every 30 minutes and gradually increase to 2-3 per hour as tolerated

• Typical tray: Broth, lemon ice, sugar-free gelatin, G2 (Gatorade)

• Important to remember:

• No straw – air intake associated with straw use causes fullness

• No carbonation – bubbles can cause pain

• No caffeine – causes dehydration

Starting the Bariatric Diet

• Stage 1 (clear liquids): Days 1-4

• Water, ice pops, broth, protein shakes made with water, coconut water,

diluted no-added sugar apple juice, non-caffeinated herbal tea

• Some patients may stay in this stage a little longer if needed

• Clear protein drink at home helps meet hydration and protein goals

• Try various kinds during preoperative diet to see what you like

Starting the Bariatric Diet

• Stage 2 (full liquids/purees)

• Advance from Stage 1 to Stage 2 on day 5 if feeling well and hydrating

well

• Goal is usually 60-90 grams of protein/day; individualized goals will be

set by your dietician

• Meals should be a total of ¼ cup 3 times per day

• Foods to try: Sugar-free yogurt, cream of wheat, strained or pureed low fat

soups, unsweetened applesauce, whipped cottage cheese, scrambled eggs

(thin consistency/“wet”)

Vitamin/Supplements

• Vitamins/supplements will still be “on hold” when you are

discharged from the hospital

• Your surgeon’s office will recommend when you should start

taking specific vitamins/supplements – typically when you

advance to Stage 2

Postoperative Complications

• Sometimes things happen after surgery – unfortunately it’s a risk

that no surgery is without

• We will be monitoring you carefully for any signs of complications

• These are rare but treatable when they happen

• There are complications YOU can help prevent:

• Dehydration

• Blood Clots

• Pneumonia

• Infection

YOU Prevent Dehydration

• Prevention starts immediately!

• Currently we start you on clear liquids the morning following surgery

• Start your sipping! 1oz within every 30 mins.

• Keep track of your intake and set and alarm

• Your throat may be sore and you may feel a sense of tightness when you swallow

(this is normal!)

• You can try cold and warm liquids – some patients prefer one or the other

• No caffeine!

YOU Prevent Dehydration

• In the beginning, it will feel like work to remember to sip and to meet your goal of 64 oz. per day!• Do your best

• Minimum of 48 oz.

• If you are overwhelmingly nauseated, please tell your nurse

• The number ONE reason for readmission back to the hospital is dehydration!

Signs and Symptoms of Dehydration

• Progressive weakness and

profound fatigue

• Muscle cramps

• Dizziness upon standing

• Nausea/vomiting or dry

heaves/retching

• Low urine output and very dark in

color

• Headaches

YOU Prevent Blood Clots

• Wear your compression boots while in the hospital

• Keep on at all times while in the bed or chair

• They inflate air to prevent blood from pooling in your legs

• Walking begins when you get to your room from recovery!

• Move your legs around if you are lying in bed

• Keep walking at home!

• Goal is 20 minutes of each waking hour

• Exercise will absolutely help in your recovery and improve your overall results!

YOU Prevent Blood Clots

• Lovenox injections

• You will be treated in the hospital with a blood thinner, most likely

Lovenox, that you will also take at home for a period of time (usually

10 to 14 days)

• Your nurse will go over with you how to give yourself the injection:

• Given once daily – try to give this to yourself around the same time each day

• Rotate injection sites on the belly

• Do not push out the air bubble from the syringe

• Do not rub the area afterwards

Signs and Symptoms of a Blood Clot

• New-onset symptoms in leg,

usually one-sided

• Can include: pain/tenderness, swelling,

redness, warmth

• Blood clots can travel to the

lungs, where they can cause:

• Shortness of breath, difficulty

breathing, heart beating fast,

chest pain

YOU Prevent Pneumonia

• Use your incentive spirometer 10 times per hour (approx. every 6 minutes or 2 times at each TV commercial) • Cough and deep breathe every

30 minutes with Bari Bear pillow

• Frequent walking after surgery

• Once you get home, it is important to continue to use your incentive spirometer, cough/deep breathe, and walk frequently to prevent pneumonia!

Signs and Symptoms of Pneumonia

• Congested/productive

cough

• Shortness of breath

• Fever, chills, body

aches, fatigue

• Headache

YOU Prevent Infection

• Wash your hands frequently!

• Keep your incisions clean and dry

• When showering, stand with back towards the water and allow soap/water to run over your belly – no rubbing or scrubbing! Pat the area dry when finished; do not apply any lotions or

creams!

• No tub baths or swimming until incisions are fully healed

• Avoid people that are ill and limit visitors in your home

• Avoid crowds and only go out in public if absolutely necessary

• Consider wearing a cloth mask in public, even if current state orders are relaxed

• Practice careful and consistent respiratory hygiene

• Disinfect commonly used surfaces daily

Signs and Symptoms of Infection

• Increased pain,

tenderness, redness,

swelling, and/or warmth

at incision sites

• Pus draining from incisions

• Fever, chills, body aches,

fatigue

What to expect at discharge?

• Once you are tolerating your stage 1 diet, your pain is controlled

appropriately, you are not struggling with intractable nausea, and

you are stable from both a surgical and medical standpoint, you

can expect to be discharged

• For the majority of our patients, this is the day after surgery!

• However, everyone is different and sometimes patients require

another night’s stay

What to expect at discharge?

• You will be given a prescription for pain medicine if needed

• You will also have prescriptions for anti-nausea medicine and a blood thinner injection (most likely Lovenox)

• Important to note:• Some of your chronic medicines

may be adjusted or discontinued at discharge

• If changes are made, a new prescription can be sent to your pharmacy

What to expect at discharge?

• Home care

• Available to you if needed

• Nursing, physical therapy, occupational therapy

• Follow-up phone calls

• Hospital

• Dietitian

• Nurse practitioner

Why am I still having nausea/vomiting?

• Remember, the area under the diaphragm (muscle under

lungs that helps you breathe) is tight and swollen for 2-3

weeks after surgery

• You are learning how to eat and drink all over again

• You can expect it to take 1 month before you begin to feel

comfortable

Why am I still having nausea/vomiting?

• Possible causes:

• Eating too fast

• Start drinking slowly: 30 mL (1 oz.) per 30 minutes and progress to 3 ounces per 30 minutes as

tolerated

• Not chewing well

• Take your time while eating and be sure to chew slowly and carefully

• Eating too much… eyes are bigger than your new stomach!

• Make adjustments with how much you eat – go slow!

• Drinking with meals

• Remember to separate eating meals and drinking liquids by 30 minutes

• Advancing diet too quickly

• Follow the guidelines given to you by your dietitian!

• Take the anti-nausea medicines if needed!

Medicines After Surgery

• Take your medicines as directed upon discharge

• Take your pain medicine as needed

• Pain should improve with each day

• Tylenol is the safest over-the-counter medicine for pain

• Give yourself the blood thinner injection every day until told to

stop

• You can use milk of magnesia or MiraLAX for constipation if

needed

• Bowel habits are likely to be affected after surgery

Medicines After Surgery

• DO NOT take NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) or aspirin

containing products unless directed by your surgeon

• Can cause stomach upset and ulcers

• Includes: Motrin/Advil (ibuprofen), Aleve (naproxen), Excedrin, Pepto-Bismol,

Alka-Seltzer

• If you have any questions about a medicine, please call your surgeon’s office!

Other Things to Consider

• Change in menstrual cycle/fertility after surgery

• Recommend using a form of birth control

• Wait at least 12-18 months before getting pregnant

• Avoid alcohol for 3-6 months after surgery

• Do not smoke!

When To Call Your Surgeon’s Office

• If you have a temperature above 101 degrees

• Heart rate sustained above 100-120 beats per minute

• Check radial pulse to confirm

• Increased belly pain/shoulder pain

• Increased nausea, particularly if unresponsive to medicine

• Persistent vomiting/inability to keep liquids down

• Any signs/symptoms of infection

Your surgeon’s office will give you instructions on how to proceed

When To Call 9-1-1

• Sudden unrelieved chest pain

• Sudden shortness of breath/trouble breathing

• Sudden trouble walking, speaking, seeing

• Confusion or disorientation

• Severe allergic reaction

• Sudden severe pain

Come to Jefferson in Stratford if possible!

Importance of Follow-up

• Keep a relationship with your bariatric team!

• There is a correlation with long term follow-up to losing the weight and keeping

it off!

• Annual lab studies are critical to keeping you healthy

• As time goes by, metabolism can change, and dietary adjustments are

needed

• Major life events can also affect wellness

• There is a possibility of related issues developing:

• Acid reflux/indigestion, ulcers, pouch stretching

• We want to be sure you STAY WELL and continue to meet your goals!

Take Advantage of What We Offer!

• Support Group

• Fitness Classes

• Social Media

• Private Facebook group

• Instagram

• Other Events

Available virtually!!

LET'S TEST OUR KNOWLEDGEBariatric Preoperative Education Class Assessment Quiz

True or False

1) Weight loss surgery is a guarantee that I will lose weight and the loss will be

permanent

2) I need to follow-up with my bariatric surgeon every year after surgery because

things may change and I may develop a vitamin deficiency.

3) Bariatric surgery is only a tool, I will need to eat healthy choices and move more after surgery

TRUE OR FALSE4) Taking NSAIDS (Motrin, Advil, Aspirin, Aleve) after surgery can cause a

bleeding ulcer

5) I should inspect my wounds daily for drainage, redness, or very large

bruises and inform my surgeon if needed

6) I should expect to vomit frequently after surgery

7) I will never have to increase physical activity after surgery, I’ll just

lose the weight

8) Dehydration is the number ONE reason for return to the ER and is

preventable

TRUE OR FALSE9) Early walking around is important to prevent blood clots after

surgery

10) I won’t need to use the incentive spirometer (breathing

exercises) when I get home after surgery

11) How many ounces of fluid should I be drinking daily after

surgery

12) How many grams of protein daily, once you have progressed to

Stage 2 of the diet stage

Questions?