POST-SURGICAL ASSESSMENT AND COMPLICATIONS FOR THE BARIATRIC PATIENT

Metric

Weight:

kilogram (kg) 1 kg = 2.2 lbs

Calculating body mass index (BMI)

BMI: Weight (kg)/[Height (m)]2

BMI: Weight (lb)/[Height (in)]2 X 703

Converting weight in pounds to kilograms

Weight in pounds / 2.2 = weight in kilograms

Converting height in feet to meters

Height in feet x .3 m = height in meters

Conversions and calculations

Length:

meter (m) 1 m = 3.28 feet

Post-Surgical Assessmentfor the Bariatric Patient

ASSESSMENT DESIRED RESPONSE NOT WNL: CONSIDER

Neurological – Awake – Alert – Oriented x3

∙ Medication issues

∙ Sepsis

Cardiac – Heart rate regular – Brisk capillary refill – Pedal pulses present – No edema present – Extremities warm & pink

∙ PE

∙ DVT

∙ Sepsis

Pulmonary – Regular rate and rhythm – Clear breath sounds in all lung fields – No pain on inspiration – No shortness of breath – Able to breathe deeply – No cough or sputum; no hemoptysis

∙ GI Leak

∙ PE

∙ Pneumonia

∙ Uncontrolled pain

∙ Sepsis

∙ Pickwickian syndrome

Integumentary – Operative site(s) clean, dry, and intact– No redness, pain, heat, or swelling– No bleeding at operative site(s)– Record drain output– Incision edges well approximated

∙ Hemorrhage

∙ Wound infection

∙ Wound dehiscence

GI – Abdomen soft – Bowel sounds present – Abdominal pain controlled – No nausea/vomiting

∙ Obstruction/ stenosis

∙ Sepsis

∙ Uncontrolled pain

∙ Hemorrhage

Urinary – Monitor intake and output – Urine clear, yellow; not blood-tinged – Patient able to void

∙ Hemorrhage

∙ GI leak

∙ Rhabdomylosis

Post-Surgical Complicationsfor the Bariatric Patient

COMPLICATION SIGNS & SYMPTOMS

GI Leak TachycardiaTachypneaFever“Sense of doom”Pain in the left shoulder/chest/abdomenOliguriaHiccupsSwollen or painful legs

PE DyspneaTachypneaPain in the chest/back/shoulderPleuritic painHemoptysisCardiac arrhythmia

DVT Redness/heat/swelling of extremityPain in extremityDecreased pedal pulsesDoppler studies

Sepsis TachycardiaHyperventilationFever or hypothermiaChillsShakingHypotensionConfusion/decreased mental statusAbnormal WBC ( or )

Wound Infection RednessPainHeatSwellingPurulent/foul drainage from incision

Herniation HeartburnSour or bitter taste in mouth

COMPLICATION SIGNS & SYMPTOMS

Pneumonia Fever Increased sputum production Cough Respiratory distress Positive sputum culture Positive chest X-ray

Hemorrhage Weak rapid pulse Slow and shallow breathing Cold, clammy skin Excessive bleeding from incision Excessive drain output – frank blood

Pickwickian Syndrome

Hypoventilation Prolonged drowsiness Twitching Cyanosis Periodic breathing Secondary polycythemia Right sided heart failure

Stricture Nausea, vomitingSevere abdominal pain, especially after eatingMay mimic gallbladder disease

Ulcers Nausea, vomitingSlight tachycardia and dyspnea (dependent on blood loss)Decreased hemoglobinMelena

Bowel Obstruction/ Stenosis

Abdominal painAbdominal distentionDecreased bowel sounds

Rhabdomyolysis Severe muscle pain in back and/or in buttocksElevated serum creatinine Brownish pigment in urine

Post-Surgical Complicationsfor the Bariatric Patient

As a Nurse, You Know What to Do.

DO NOT Discount what the patient may tell you. Listen to your patient — they often have a clear understanding of what is going on even if they cannot express it well.

DO NOT Insert an NG tube without visualization.

DO NOT Administer medications based on actual body weight.

1. Winter MA, Guhr KN, Berg GM. Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation. Pharmacotherapy. 2012; 32(7):604-612. doi: 10.1002/j.1875-9114.2012.01098 x Epub 2012 May 10.

Use Adjusted Body Weight (ABW) for medication dosing (ABW = Ideal Body Wt. + 0.4 (actual wt. – ideal body wt.)1

Here’s a Reminder of What Not to Do.

Normal Digestive Tract

Sleeve Gastrectomy

Roux-en-Y ProcedureGastric Bypass

Biliopancreatic Diversionwith Duodenal Switch

Adjustable Banded Gastroplasty

Thrombosis Risk Assessment Tool

STEP 3: Total risk factor score (baseline + additional)

STEP 1: Risk factors associated with clinical setting:

Choose no more than one of the below listed disease states or associated hospital service to determine the baseline risk factor score.

Score 1 factorn Minor surgery

Score 2 factors n Major surgery (>45 min) n Laparoscopic surgery (>45 min)n Patients confined to bed (>72 hr)n Immobilizing plaster castn Central venous access

Score 3 factors n Major surgery with

- Myocardial infarction or - Congestive heart failure or - Severe sepsis/infection

n Medical patient with additional risk factors

Score 5 factors n Elective major lower extremity

arthroplastyn Hip, pelvis, or leg fracturen Stroken Multiple trauman Acute spinal cord injury (paralysis)

Baseline risk factor score: (if score = 5, go to step 4)

STEP 2: Risk factors associated with patient:

Clinical (score 1 factor unless noted)n Age 41 to 60 yearsn Age over 60 years (2 factors)n History of DVT/PE (3 factors)n History of prior major surgeryn Pregnancy/postpartum (<1 mo)n Malignancy (2 factors)n Varicose veinsn Inflammatory bowel diseasen Obesity (>20% of ideal body wt)n Oral contraceptives or hormone

replacement therapy

Hypercoagulable States (Thrombophilia) Inherited (score 3 factors for each)

n Factor V Leiden/Activated protein C resistance

n Antithrombin III deficiencyn Protein C or S deficiencyn Dysfibrinogenemian Homocysteinemia

Acquired (score 3 factors for each)n Lupus anticoagulantn Antiphospholipid antibodiesn Myeloproliferative disordersn Disorders of plasminogen

and plasmin activationn Heparin-induced

thrombocytopenian Hyperviscosity syndromen Homocysteinemia

Total additional risk factor score:

Thrombosis Risk Assessment Tool

STEP 4: Recommended prophylactic regimens for each risk group:

STEP 5: Please check the modality(s) chosen from the list below, and sign/date.

Graduated compression stockings (GCS)

Intermittent pneumatic compression (IPC)

Plantar pneumatic compression Adjusted dose heparin (ADH) Low molecular weight heparin (LMWH) (Regimen: __________)

Low dose unfractionated heparin (LDUH) (Regimen: __________ )

Oral anticoagulant (Regimen: _________________ )

Other ( _______________________ ) No prophylaxis

* Combining GCS with other prophylactic methods (LDUH, LMWH or IPC) may give better protection than any modality alone.

† Data demonstrates benefit of plantar pneumatic compression in total joint arthroplasty. Plantar pneumatic compression can also be used when IPC is not feasible, including leg trauma.

Contraindication to anticoagulants? Yes No

If yes, explain: _______________________________________________________

Examining Physician’s Signature:

Date:

Based on: Claggett GP, Anderson FA, Geerts W, et al: Prevention of venous thromboembolism. Chest 1998;114:531S-560S.; 1997 International Consensus Statement: Prevention of Venous Thromboembolism, Guidelines According to Scientific Evidence; and Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F. Clinical assessment of venous thromboembolic risk in surgical patients. Semin Thromb Hemost. 1991;17 Suppl 3:304-12. Provided as an educational service by Medtronic, 15 Hampshire Street, Mansfield, MA 02048 medtronic.com/covidien. For International locations please see medtronic.com/covidien.

LOW RISK

(1 factor)No Specific Measures

Early Ambulation

MODERATE RISK

(2 factors)IPC or

LDUH (q12h) or LMWH or

GCS

HIGH RISK

(3 – 4 factors)GCS* and

IPC or LDUH (q8h) or

LMWH

HIGHEST RISK

(5 or more factors)GCS* and

IPC† + (LDUH or LMWH) or ADH

or LMWH Oral Anticoagulants

Nursing Pocket Reference Cards Publication/Article References:

∙ Long, Phipps, Cassmeyer. Medical-Surgical Nursing. Third Edition. Mosby-Year Book, Inc.; 1993.

∙ Peterson, V. Just the Facts: A Pocket Guide to Basic Nursing. Mosby-Year Book, Inc.; 1995.

∙ Conversions and Calculations. Nurses Drug Handbook. [insert web address].

∙ Price, Bobbie Lou; ASBS Allied Health Essentials Course, June 2003; Post-Operative Complications Following Bariatric Surgery.

∙ Tarnoff, Michael; Autosuture Bariatric Training Course, June 2003; Bariatric Surgery — Historical Perspectives; Laparoscopic Gastric Bypass-Recognition and Management of Complications.

∙ Schauer PR, Ikramuddin S, Gourash W, et al. Ann Surg. 2000;232(4):515-529.

∙ Venous Thromboembolism Risk Factor Glossary J.A. Caprini, M.D., F.A.C.S., Gary D. Motykie, M.D., Lukas P.Zebala, B.S., Christopher E. Lee, B.S., Laurie J. Sullivan, M.B.A., Stella Caprini, Theresa Courtney, R.N. Department of Surgery Evanston Northwestern Healthcare, Evanston, IL and Northwestern University Medical School, Chicago, IL. Provided as an educational service by Medtronic, Mansfield, MA 02048

The contents of this document are provided as a resource and should not be perceived as diagnosis of a condition or practicing nurse care. No products or services are being sold.

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