Morbid Obesity Peri-Operative Management - Case Study Example

Clinical Case Conference Report Introduction The focus of this case is on a patient who was obese and underwent open gastric bypass surgery to promote dramatic weight loss and assist the patient increase her overall health and decrease the risk of early mortality from comorbidities. The patient (Ms. A) was a 40 year old woman with 3 children (ages 12, 8 and 5) and underwent laparoscopic Roux-en-Y gastric bypass procedure (LRYGB) for health reasons. She weighed 344.8 pounds (morbid obesity) and had a BMI of 57.5. The patient’s medical comorbidities included; type 2 diabetes, high blood pressure, and cardiovascular disease, in addition to obstructive sleep apnea. The patient also has been diagnosed with depression and chronic low self esteem related to body image. Due to depression, Ms. A had been on lamotrigine for five months and was stable. In addition, the patient meets criteria for binge eating disorder and according to her; she is an “emotional feeder who loves eating”. Ms. A has a history of adult-onset obesity and several earlier structured and unstructured weight loss trials which were all unsuccessful in regard to her weight loss. The patient was at her highest weight with a corresponding BMI of 57.5 kg/m2. Discussion Patient’s Medical Condition(s) The patient had obesity a condition associated with various comorbidities such as diabetes, heart diseases, endocrinopathies, osteoarthritis and hypertension. According to Thompson et al (2011), the mechanisms that underlie obesity comrbidities are complex and normally interrelated. This patient had diabetes and the ensuing complications included type 2 diabetes, high blood pressure, cardiovascular disease, and obstructive sleep apnea. The cardiovascular risk factors such as central obesity, hyperglycemia and high blood pressure in the patient are known as metabolic syndrome (Thompson et al, 2011). Therefore, since the patient had metabolic syndrome, she was a higher risk for coronary artery disease and having severe cardiovascular events (Thompson et al, 2011). The patient had type 2 diabetes which is prevalent in individuals with diabetes because of insulin resistance and hyperinsulinemia. Hyperinsulinemia often is as a result of sodium retention, too much circulating catecholamines, as well as elevated blood volume (Abeles, 2010). Additionally, the patient had high blood pressure. Obesity is a major factor for developing hypertension due to concentric ventricular hypertrophy which develops with time from elevated systemic vascular resistance. Therefore, the prevalence of hypertension rises proportionally with increase in BMI (Thompson et al, 2011).The patient also had obstructive sleep apnea which is a respiratory abnormality that can result from obesity. Respiratory abnormalities in people with obesity can lead to atelectasis and fast occurring hypoxemia. The respiratory changes might also cause polycythemia and cor pulmonale (Thompson et al, 2011). The Pre-operative Period Pre-operative assessment of the patient for bariatric surgery was done by a multidisciplinary team and as per Abeles (2010), the assessment focused on identifying, treating and optimising adjustable health concerns of the patient. A comprehensive history and physical examination, vital signs and baseline laboratory assessment were done and informed consent was obtained from the patient. Since Ms. A has a history of CAD, she was referred to a cardiologist and underwent a dobutamine stress echocardiogram to examine her cardiac function. Additionally, since the patient had obstructive sleep apnea, she underwent polysomnography and received treatment pre-operatively and during the entire peri-operative period. Treatment modalities included constant positive airway pressure, non-invasive positive-pressure ventilation, as well as bilevel positive airway pressure. The physician also evaluated her pulmonary function to examine if she needed post-operative controlled ventilation. The patient also underwent an electrocardiogram along with chest radiograph tests to further examine her cardiopulmonary risk. Since the patient had diabetes, her serum glucose level was maintained lower than 150 mg/dL and Hb A1c value was maintained lower than 7% in order to decrease surgical risk (Alvarez et al, 2010). However, the patient continued with her normal medications apart from the insulin and oral hypoglycaemic medications throughout the preoperative period. The patient was put on antibiotic regimen and this was meant to reduce the risk of postoperative wound infection and she was also administered with histamine-2-blockers as an aspiration prophylaxis. A systematic airway assessment was done to establish if there was any likelihood of a difficult airway (Abeles, 2010). Lastly, the patient held a discussion with the surgeon on realistic expectations, lifestyle modifications, diet changes, and exercise. Laboratory Tests The following laboratory tests were performed to evaluate if the patient was fit for the surgery Complete blood cell count Comprehensive metabolic panel Liver function tests Glucose/hemoglobin A1c Prothrombin time/partial thromboplastin time Lipid profile After consultations between the RN, physicians, cardiologist and surgeon; the patient was found a viable candidate for laparoscopic Roux-en-Y gastric bypass procedure (LRYGB). The surgery was scheduled and the operation was performed successfully without any complication. Care within the Post-anesthesia Care Unit After the surgery, the patient was taken to post-anesthesia care unit (PACU) for recovery. While in PACU, Ms. A was administered with intravenous (IV) vitamin enriched hydration at 200 mL/hr. The purpose of the fluid hydration was to enable the patient maintain sufficient urine output as well as adequate cardiac output (Alvarez et al, 2010). The patient’s blood pressure increase instantly after the surgery and this increased the time she spent in the PACU. To lower and stablise the blood pressure, the vitamin enriched hydration was reduced at 125 mL/hr (Alvarez et al, 2010). She was also given intravenous 5 mg of metoprolol tartrate to stablise the blood pressure. To prevent thrombotic post-operative complications, the patient was administered with subcutaneous heparin and sequential compression devices stayed on from the time the patient was administered with anaesthesia (Abeles, 2010). After three hours, the patient was moved to a bariatric-focused medical-surgical unit. Care in the Medical-Surgical Nursing Unit When Ms. A arrived in the medical-surgical unit, the admitting nurse greeted her and helped her to ambulate from the stretcher to a bedside chair. Walton (2011) explains that when a healthcare provider greets a patient, it sets a tone for their relationship and thus greeting establishes instant rapport and enables the patient to develop trust important for provision of information and acceptance of medical information as well as adherence to therapeutic regimens (Walton, 2011). The nurse also assisted the patient which indicates she was emphatic with the patient. Empathy is important in nursing because it makes the patient feel understood and less alone and contributes to better health outcomes (Lombardo & Eyre, 2011). The nurse then carried out a comprehensive physical assessment to examine any abnormalities and find out if she was within the recommended parameters and also to determine the appropriate nursing care. According to the assessment, the patient had a left forearm IV with D5 1/2 normal saline solution (NSS) with 30 mEq of potassium infusing at 125 mLs/hr. The nurse also established that the patient had not been inserted with urinary catheter and also a nasogastric tube had not been put in during the surgery. Additionally, the nurse identified four laparoscopic incisions that were open to air. The Jackson-Pratt drain was integral and was draining bloody fluid appropriately. The patient had clear breath sounds although the sounds reduced bilaterally at the bases. The nurse also performed a cardiac assessment that showed that the parameters were within the normal limits but the blood pressure was a bit higher and the heart rate was 104beats/min. On the other hand, pain assessment showed that the patient needed intravenous morphine administration hourly as required due to pain. After four hours, the patient became more alert and the nurse advised her to take 30 mLs of sugar-free fluids after each fifteen minutes. However, the nurse emphasised that the patient should take the liquid during the whole allocated time but in case she has nausea and feels full she should stop. During the night, the patient’s oxygen saturations reduced to 88-89%. According to the protocol, the hospital’s respiratory therapist responded and adjusted the settings on the device. The purpose of this was to attain saturations above 92% (Mulligan et al, 2012). As expected, by morning the patient’s oxygen saturations had returned to normal. On the initial postoperative day, the patient’s IV fluids were stopped because she could tolerate clear liquid without vomiting or experiencing nausea. Since the pain was still high, her IV morphine was changed to an oral dosage of 5-10mLs of oxycodone/ acetaminophen administered after each four hours for pain management. The patient could ambulate without help within the room and needed minimal help within the unit hallways. The patient’s medications consisted of; Heparin: 5,000 units SQ TID, Oxycodone/acetaminophen: 5–10 mLs PO q4h PRN for pain and Metoprolol tartrate: 50 mg PO q12h every day. Rationales The priority assessments included thorough cardiovascular and respiratory assessments. The assessments consisted of heart and lung sounds as well as affected vital signs such as heart rate, respirations, blood pressure, and oxygen saturations. Since the patient had obstructive sleep apnea, she was at a higher risk for respiratory failure and the patient constantly received positive airway pressure (Camden, 2009). This allowed prevent alveolar collapse during expiration and also allowed alveolar conscription during inspiration and also displaced the tongue and soft tissues and hence prevented airway obstruction (Benotti et al, 2009). Continuous cardiac monitoring was done since the patient was at a higher risk for acute myocardial ischemia, heart failure, and abrupt death due to the post-operative LRYGB. The IV site was monitored and assessed often to ensure that there was no risk of infection (Camden, 2009). The patient was on morphine and Oxycodone/acetaminophen for pain management which are opioids. The rationale for using opioids in the patient is that the patient has obstructive sleep apnea whereby the respiratory depressant effects are more prominent and hence opioid sparing effects assist in avoiding respiratory complications (Churchin & Aguiar, 2010). The pain management medications were administrated basing on the patient ideal body weight. The patient was only supposed to take sugar free fluids in minimal quantities after the surgery because the slow and steady introduction of small liquid volumes instigates movements within the GIT system (Churchin & Aguiar, 20100. The limiting diet is also important in preventing the horrid effects of vomiting, dumping syndrome, nausea and gastric reflux and also maintains the anastomosis and patient’s satiety. Consumption of foods and liquids with high sugars causes dumping syndrome which leads to quick clearing of contents in gastric into the small bowel and this causes the unpleasant side effects because pyloric sphincter is not used to digest the food contents (Petering & Webb, 2009). Dumping syndrome may result to severe side effects such as tachycardia, diarrhoea, diaphoresis constricted pain and vomiting. As the patient’s diet move to more intricate stages within the next three-four months, the patient can prevent having dumping syndrome by continuing taking foods with low sugar levels or sugar free foods (Petering & Webb, 2009). The patient should also continue taking small quantities of fluids slowly prior and after taking meals and ensuring that the solid foods are chewed thoroughly to prevent the surgical pouch that was created during the surgery from enlarging (Snyder et al, 2010). Patient/Family Education The patient and her family were educated on the appropriate foods and liquids that the patient should take to prevent complications of vomiting and diarrhoea. The patient was advised to stay on clear and full liquids, take puree and soft foods and regular diet for the first months to avoid stretching of the created gastric pouch (Gagnon & Sheff, 2012). The patient was also advised to avoid taking carbonated, alcoholic, and sugary beverages since they can irritate and upset GIT. Additionally, the bariatric nurse educated the patient on signs of symptoms of probable post-operative surgical adverse events. The patient should also be educated on available support resources like as follow-up appointments, support groups, as well as online forums. The lifelong support resources will ensure that the patient adhere to dietary and exercise treatment and maintains good mental health and also lowers the risk of complications. The family and patient were also taught about medication’s side effects as this will help the patient prevent and manage the side effects effectively (LABS, 2009). Discharge Plan The first intervention should be on post-operative diet. The patient’s readiness to discuss nutritional habits should be assessed since learning improves when the patient is ready and keen to take part in learning (Churchin & Aguiar, 2010). The patient should also be instructed to eat 48–64 ounces of fluid daily according to prescribed diet. This will ensure that the patient is adequately hydrated (Churchin & Aguiar, 2010). The patient should also be advised to follow the prescribed diet since this prevents gastric upset and promotes weight loss (Green, 2012). The patient should also be advised to avoid carbonated liquids and high fat/sugar foods since these foods cause dumping syndrome, gastric enlargement and pain (Green, 2012). The expected outcome is that the patient shows compliance with prescribed diet. The second intervention should be on pain. The patient should be educated on coping mechanisms such as alleviating anxieties that increase pain tolerance. The patient’s pain level should be assessment often during the hospital stay to identify the quality, intensity, regularity, and length of pain. According to Gagnon & Sheff (2012) this prevents the pain from becoming intense and intolerable. The patient’s pain relief strategy preferences should be identified to place care measures into her ownership (Gagnon & Sheff, 2012). . Article Discussion This article discusses medical and nursing care for a bariatric surgery patient. This article contributed to the understanding the pathophysiologic changes of the patient’s diabetic condition and understanding the surgical procedure and anesthesia management for the patient. Additionally, the article enlightens on possible side effects that result from the surgery such as where the patient had shorter and reduced oxygen saturations due to her pre-existing condition of obstructive sleep apnea. Additionally, hypoventilation is very common in patient with obesity due to decrease in tidal volumes and accumulation of carbon dioxide because of extra weight encroaching on the diaphragm which decreases the enlargement of both lung and chest wall (LABS, 2009). Still, medications used in anaesthesia and pain management increase the risk of respiratory compromise and thus this placed the patient at a higher risk of both hypoxia and cardiac dysrhythmias (Thompson et al, 2011). Accordingly, the nurse should have elevated the head of the patient’s bed higher than 30 degrees and also placed her in reverse Trendelenberg position in order to improve respiratory efforts. The article also shows that the use of both nasogastric tube and urinary catheter was eliminated during the surgical process because according to Thompson et al (2011) inserting naso-gastric tube is not recommended in LRYGB procedure and studies have also shown that is an unnecessary practice in gastric bypass surgeries (Gagnon & Sheff, 2012). The urinary catheter was not inserted to lower the probability of hospital-acquired urinary tract infections which are common in catheter insertions. Additionally, since the patient had to walk to the bathroom to empty the bladder, this decreased the risk of post-operative venous thromboembolism (VTE) complications on the patient (Kaser & Kukla, 2009). However, since there are several comorbidities allied to obesity that can complicate anaesthetic management, the article should have include the importance of an anesthetist to carrying out a comprehensive preoperative assessment since this enable risk factors associated with anesthesia to be identified and hence effectively plan for intraoperative management(LABS, 2009). Patient education covered the nutrition aspects and pain management using pharmacologic treatments. The patient should also be taught regarding nonpharmacologic and pharmacologic treatments. According to Gagnon & Sheff, (2012) educating the patient regarding alternative treatments for pain management decreases the use of polypharmacy and overdose/ overuse (Gagnon & Sheff, 2012). Summary and Conclusion The patient was a 40 year old female with diabetes and underwent laparoscopic Roux-en-Y gastric bypass procedure (LRYGB) to facilitate weight loss. She also had type 2 diabetes, high blood pressure, cardiovascular disease, and also obstructive sleep apnea; these are comorbidities associated with obesity. Before the operation was performed, detailed history and physical assessments, vital signs and baseline laboratory tests were done. This helped in establishing if the patient was a viable candidate for the surgery. The surgery was performed successfully and after the surgery continuous assessments were done as well as continuous monitoring to ensure that her vital signs were within the normal limits and any resulting complications were treated appropriately. The priority assessments included thorough cardiovascular and respiratory assessments since these are the most critical aspects for patients with obesity who undergo major surgeries. The patient and the family were educated on the appropriate dietary prescriptions to ensure that the patient did not develop any complications and that the created gastric pouch does not stretch as a result of inappropriate food/liquid consumption. The patient and the family were also educated on pain management. In regard to diet, the short term outcomes are that that the patient will verbalise knowledge of post-operative nutritional prerequisites. The long term outcomes include the patient will show adherence to post-operative diet by not developing any complications and that the patient will lose weight as targeted. In regard to pain, the short term outcomes were that the patient would demonstrate pain control by taking pain medications at suitable doses and intervals. The long term outcomes were that the patient verbalised that the pain was minimal to none according to pain scale and that the patient had minimal side effects and remained on warranted pharmacological medications. Comments Since the patient had depression associated to negative body image, it would be necessary to provide the patient with emotional support through listening and accepting her thoughts and fears and provide care in a non-discriminatorily so as to ensure the patient gets constant care from all healthcare providers and family members during the post-operative period. References Abeles D, Tari B & Shikora SA, 2010, Preparation and preoperative evaluation/management. New York, NY: Cambridge University Press. Alvarez A, Perez-Protto SE, Carey K, Sinha A, 2010, Morbid Obesity Peri-operative Management, New York, NY: Cambridge University Press; 2010. Benotti P, Still D, Wood GC, et al., 2009, Preoperative weight loss before bariatric surgery. Arch Surg, 144(12):1150-1155. 10. Camden S, 2009, Obesity: An emerging concern for patients and nurses, OJIN: The Online Journal of Issues in Nursing, 14(1). Churchin M & Aguiar P, 2010, Laparoscopic gastric bypass. In: Elisha S, eds. 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