welcome to the bariatric preoperative class!...• protein smoothie (breakfast) pg. 20 • mix and...
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Welcome to the Bariatric Preoperative Class!
Guidelines for Virtual Class• Please sign-in to the chat with your
first and last name • Go to main tool bar and press CHAT. If
chat is not there go to MORE… and you will see the chat function there
• Ensure your internet/wifi connection is good
• Stay in a quiet place to minimize distractions
• 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
• Perioperative Nurse Practitioner
Dr. Neff, Dr. Fakulujo, Dr. Goldstein, and Dr. Balsama
Megan Sabin, APN, and Paulette Palogruto, APN
Your Jefferson Stratford Team!
• Nurses (navy blue scrubs)
• Certified Bariatric Nurses
Nancy
• Nursing Techs (gray scrubs)
• Dietitians
• Respiratory Therapists
• Physical Therapists
• Home Care Nurse
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) pg. 20
• Mix and Match Salad (lunch) pg. 21
• Bariatric power plate (dinner) pg. 22
• 50% vegetable, 25% lean protein, 25% whole grain
• Approved snacks (1-2/day) pg. 23
• 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 surgery 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 and then 4-6 per hr 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) 5-15 days
• 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! 1-2 oz per hour, increasing to goal of 4-6 oz per hour
• 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 (4-6 oz/hour) per day!
• Do your best
• 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 15-20 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 may also take at home for a period of time
• 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 a mild stool softener 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 100.4 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
• Other Events
Available virtually!!
Questions?
Please contact:
• Megan Sabin - megan.sabin@jefferson.edu
• Paulette Palogruto - paulette.palogruto@jefferson.edu
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