welcome to the bariatric preoperative class!...• protein smoothie (breakfast) pg. 20 • mix and...

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


• 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


• 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


• 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


• 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!!!


• 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


• 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


• 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!


• 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


• 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


• 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


• 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


• 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


• 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


• 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

• Instagram

• Other Events

Available virtually!!

Questions?

Please contact:

• Megan Sabin - [email protected]

• Paulette Palogruto - [email protected]

welcome to the bariatric preoperative class!...• protein smoothie (breakfast) pg. 20 • mix and...

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