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8/18/2019 Pathway Bariatric Surgery
1/16
National University Health System
Division of Upper Gastrointestinal Surgery
Page 1 of 16
MAQ-FORM-SUR-011 R1-12-13
Bariatric Surgery
Peri-operative Care Pathway
Consultant Surgeon:
Patient’s Sticker
Date of Admission:
Date of Surgery:
Estimated length of stay:
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Pre-Op Counselling Yes NA
Details of recommended procedure Yes NA Financial Counselling Yes NA
Risks associated with it Yes NA Financial constraints Yes NA
Complications Yes NA
Benefits of procedure Yes NA
Other alternative to treatment Yes NA Endocrinologist Yes NA
Long term follow up Yes NA Psychiatrist Yes NA
Patients role in treatment Yes NA Yes NA
Dietitian Yes NA
Physiotherapist Yes NA
AOCC Yes NA
Emergency contact:
1 Name:
Full blood count Yes No Number:
Renal panel 1 with fasting glucose Yes No
Liver function Yes No 2 Name:
Lipid Panel 1 Yes No Number
Iron Panel Yes No
Calcium Panel 1 Yes No
C-Peptide Yes No
Insulin Yes No
Uric Acid Yes No
HbA1c Yes No
Thyroid Function Yes No
25 Oh Vitamin D Yes No
Vitamin B12/ Folate Yes No
Serum Cortisol Yes No
Bone Mineral Density Yes No
Ultrasound HBS Yes No
Chest X-Ray Yes No
Electrocardiogram Yes No
Date & time:
3. Review Oral Medications
Listing Nurse: (Name stamp & signature)
1. Operative consent details explained including:
2. Explain estimated Length of Stay to patient / family members
Subspecialty reviews
UGI nurse
4. Order PAT tests (check box if required to be done)
Discharge Planning:(Anti-coagulants, anti-hypertensive and anti-Diabetic)
Listing Nurse (T ick when done)Doctor's Guidelines & Protocol Before Operation
(Tick when done)
Patient Label
Clinical Pathway for Bariatric Surgery
DRG 950,524
Expected Length of Stay (ELOS): 3 days
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MAQ-FORM-SUR-011 R1-12-13
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_________________________________
_________________________________________
Yes / No
Lifestyle Modification / Medications / Surgery / Alternative Therapy
Self / Family Physician / Tertiary care / Alternative Therapist
Meals per day: ______________ ____________________
Likes to have: High Calorie drinks / Fried Food / Sweets / Bulk / Normal
Type of Exercise: Walking / Cycling / Swimming / Other:_____________________
Duration and Frequency: ____________________________________________________
Hypertension IHD Migraine
Diabetes Mellitus (Type 1 / 2) NASH Benign Intracranial Hypertension
Hyperlipidemia GERD Others:
Obstructive Sleep Apnea PCOS _______________________
OsteoArthritis Gout
Asthma Depression
Previous abdominal surgery: __________________________________________
Alcohol: Yes / No
Smoking:
Patient's Sticker
Diet History:
Comorbidity:
Exercise History:
If yes, attempts methods:
Attempts supervised by:
Drug Allergy:
Name of Consultant: ______________________
Age: ______
Bariatric Surgery
Pre Admission Clerking Sheet
Weight History:
Other History:
Snacks per day:
Yes / No / Ex-smoker
Duration of weight gain (years):
Previous attempts at weight loss:
Menstrual History: Regular / Irregular / Menopause
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MAQ-FORM-SUR-011 R1-12-13
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___________ Pulse rate: ____________
___________ BP: ____________
BMI: ___________
Respiratory System:
__________________________________________________________________
Abdomen:
__________________________________________________________________
Cardiovascular System:
__________________________________________________________________
Laparoscopic / Open / Robotic
Sleeve / Bypass / Gastric Band / BPD / Duodenal switch / others: ______________________
Comments:
_____________________________________________________________________________
For further peri-operative instruction, see attached Bariatric Surgery Pathway.
Confirming Doctor:
Name: __________________ Name: _____________________
MCR number: __________________ MCR number: _____________________
Date: __________________ Date: _____________________
Clerking Doctor:
Planned Procedure:
Physical Examination:
Height:
Weight:
AOCC:
Page 5 of 16
MAQ-FORM-SUR-011 R1-12-13
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* Paracetamol allergy: Use standard drugs
Upon
Discharge
* NSAIDS allergy or Renal Impairment: NO pre-emptive analgesia will be given
Pre-Op
Once Oral starts: Crushed PO Paracetamol 1gm 6 hourly/ PRN
* NSAIDS allergy or Renal Impairment: IV Paracetamol 1gm ONLY
IV Paracetamol 1gm X 6 hourly STRICTLY X 2 doses, followed by
PRN basis
Breakthrough pain: IV Tramadol 50mg in 100 mls of normal saline, administer
over 30 mins. Maximum: 50mg 8 hourly for 24 hours
** If allergy to Paracetamol, please do not follow this protocol
Peri-Operative Analgesia Protocol for
Bariatric Surgery
Arcoxia 120mg 1 - 2 hours before operation
* SDA case: Prescribe by Surgical HO on-call,
nurse to administer 1 - 2 hour before op
If Arcoxia is given: IV Paracetamol 1gm (First Dose)
PO Paracetamol 1gm 6 hourly/ PRN for 5 days
Induction
Post Op
If Arcoxia NOT given: Suppository Voltaren X 2 and IV Paracetamol 1gm
* Paracetamol allergy: Prescribe NSAIDs or Opoid
Page 6 of 16
MAQ-FORM-SUR-011 R1-12-13
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Clinical Pathway for Bariatric Surgery
WARD BED
Date:
Time
Must do:
Check Operation consent obtain Yes No
Review oral medication Yes No GXM
others
Yes No
Trace old notes and X-rays Yes No
Arrange HD / ICU bed Yes No
Yes No
Yes No
Patient Label
(Anti-coagulants, anti-hypertensive and
hypoglycemic agent)
(Tick when done)
UNIT
Pre-Op Assessment
Doctor's OrdersMultidisciplinary Notes
Nill by mouth from 12 midnight
Pre-Op Investigations (If needed)
PT/APTT/INR
Complete Page 1 of Pathway
Peri-Operative Anagelsia Protocol
DR's Name Stamp and signature:
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MAQ-FORM-SUR-011 R1-12-13
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MAQ-FORM-SUR-011 R1-12-13
ND AM PM ND
Complete Nursing Assessment Pre-Treatment Counseling done
Monitor Vital signs BD Pre-Op Assessment done
Ensure all investigation results are available Pre-Op chest education
Consent up
OT chit faxed
NBM 12 midnight Yes
TED stockings applied No
anagelsia
Other Treatment/ Remarks:
Time Multidisciplinary Notes Treatment Orders
ND
Name Stamp and Signature with date:
Desired Outcomes:
Activities - Physiotherapist
Desired Outcome:
Patient/ Family understand pre-op education
Patient Education:
Activities - Nursing (Tick when Done)
(reason/ action: ____________
PMNurses' Initials:
Educate patient/ family on post op wound care,Diet advise & importance of exercise
Patient verbalise understanding of ELOS, pre &post op teaching & is ready for surgery
AM:
Pre-Op Assessment
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Clinical Pathway for Bariatric Surgery
WARD BED
Date:
Time
Consent Up
All investigations results reviewed
Time
Mandatory Orders: Optional:
Nil by mouth Monitor Hypocount as per protocol
IV Fluids 1.5 liters over 24 hours Continuous ECG monitoring
IV Proton Pump inhibitor 40mg BD Prescribe anti-coagulant
Pneumatic Calf Compression Continue nocturnal CPAP
Nurse head up 30 degrees
Follow Peri-Operative Anagelsia Protocol
IV Ondansetron 4mg TDS/PRN
Update patient and family
If Diabetic, to use SCSI protocol (MICU)
DR's Name Stamp and signature:
Patient Label
DO NOT INSERT NASOGASTRIC TUBE WITHOUT SURGEON'S CONSENTDoctor's orders
UNIT
Doctor's orders
Op Day
Gastrograffin swallow & meal POD
_______
Monitor urine output ____ hourly (keep at
0.5 mls/kg/hr)
If hypoxic, alert primary team/ on callSit out of bed / Ambulate
Multidisciplinary Notes
Hourly Parameters with SpO2 monitoring for 6 hours,
then 4 hours if stable
Oxygen nasal prong 3 liters/minute (titrate to keep SpO2
> 93%)
Prior to OT:
Multidisciplinary Notes
Post Op Review
NBM maintained
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MAQ-FORM-SUR-011 R1-12-13
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AM PM ND
Nil by mouth maintained
Complete operation checklist
Ensure Pre and Post Op education is given
Activities - Nursing (Post Op) (Tick when done) AM PM ND
Monitor Vital Signs as ordered
Monitor Urine output as ordered
Monitor signs of bleeding
Nurse patient at 30 degrees
Check IV site for extravasation
Pain assessment & management
Patient verbalise adequate pain control (if No, state reason: ____________)
Post op vital signs are stable (if No, state reason: ____________________)
Time
Activities - Nursing (Prior to OT) (Tick when done)
Nurses' Initials: ND
Treatment OrdersMultidisciplinary Notes
AM PM
Desired Outcomes:
Op Day Assessment
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AM PM ND
Monitor Vital Signs as ordered Chest physio, limb exercises
Monitor Urine output as ordered Incentive Spirometry
Keep on liquid diet Sit out of bed
Check IV site for extravasation Ambulate with assistance ________ m
Pain assessment & management Score
to be recorded by ND staff Max (pain
score):________ Min (pain
score):_________
1st POD
Stable vital signs (if No, state
reason:_____________________)
Activities - Nursing (tick when done) Activities - Physiotherapist (tick when done)
Other treatment / remarks:
Patient Education
Post Bariatric home, diet and wound
care advice
Desired Outcomes:Patient verbalised adequate pain control
(if No, state
reason:_____________________)
Observe signs & symptoms of wound
infection
AM PM NDNurses' Initials:
Time Multidisciplinary Notes Treatment Orders
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MAQ-FORM-SUR-011 R1-12-13
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Clinical Pathway for Bariatric Surgery
BED
Date:
Time
Home Today
PO Paracetamol 1gm for 1 week
Medical/ Hospitalisation leave for _________ weeks
Doctor's Discharge activities:
Follow up appointment
Date: ____________________ Time: ____________________
HbA1c
C-Peptide
Insulin
Fasting insulin
Others:
Change to waterproof dressing
Exercise as per physiotherapist advice
Post Bariatric surgery and dietary advice given to patient
Phone Consult 2 - 3 days after discharge
Wound care information sheet is given
WARD
2nd POD
Vitamins Package for 1 month
Weight Management Clinic (COMS)
UNIT
Multidisciplinary Notes (tick when done) Doctor's Orders
Review anti-hypertensive, Statins, Diabetic medications and
others
Patient Label
Complications During Stay: (Tick if have)
Home care instructions is given
For Diabetic patient: Blood tests to be done on arrival/ 1 day before
appointment day
Please Specify: ____________________________________
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AM PM ND
Monitor Vital Signs as ordered
Monitor urine output
Check IV site for extravasation
Keep on liquid diet
Desired Outcomes:
Home Care instructions leaflet given
Time Treatment orders
Patient able to ambulate (if
No, state reason: ____________________)
Nurses' Initials:
2nd POD
Multidisciplinary Notes
Observe for signs and symptoms of wound
infection
Pain assessment & management Pain
score to be recorded by ND staff Max: __________ Min: ___________
Patient verbalise adequate pain control (if
No, state reason:_____________________)
Activities - Nursing (tick when done) Activities - Physiotherapist
Stable vital signs (ifNo, state reason:_____________________)
Page 14 of 1
MAQ-FORM-SUR-011 R1-12-13
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Case Manager / Clinical Pathway Referral
Pt’s Label
Unit Ward Bed
Consultant In-Charge: _______________ Referred by: _________________ Date: ____________
Please tick ( √ ) and fax it to Case Managers at 6775-6757
A) Notification of Clinical Pathway :
□ Bariatric Surgery
B) Clinical Pathway Patient Requiring Case Management Services(Please √ accordingly on the reasons / criteria below):
□
Caregivers not available Patient requiring ADL assistance but has good family support
□ Referral to Step-down care services
□ Significant decline in ADL related to medical reasons
□ Readmission/s within last 15 days due to medical reasons
□ Experience the following for a prolonged period of time
Acute confusion or cognitive impairment History of frequent falls
□ Others (please specify): ___________________________________
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PHONE CONSULT FOR Bariatric Surgery 2-3 DAYSPOST DISCHARGE
UNIT WARD BED
Date: _______________
Patient’s Label
Upon Completion, Fax this form to Case Manager at 6775 6757
Page 16 of 1
----------------------------------------------------------------------------------------------------------------------------------------
Surgeon / Consultant-in-charge : ________________ Admitted On : _______________________
Principal Diagnosis : __________________________ Surgery On : _______________________
Principal Operation : __________________________ Discharged On: _______________________
PHONE CONSULT BY UGI NURSE / HOUSE OFFICER
Temperature Afebrile Febrile (Remarks:___________________________________)
Tolerating diet? Yes No (Remarks:______________________________________)
Dressing is clean and dry? Yes No (Remarks:______________________________________)
Mobilizing? Yes No (Remarks:______________________________________)
Pain control? Pain Score : ________________________________________________________
Called By
DR’s Name/MCR: __________________________________________
Remarks / Advices Given :
__________________________________________________________________________________ __________________________________________________________________________________ ______________________________________________________
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