Pathway Bariatric Surgery

8/18/2019 Pathway Bariatric Surgery

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National University Health System

Division of Upper Gastrointestinal Surgery

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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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_________________________________

_________________________________________

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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___________ 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:

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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

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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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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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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:


Post Op Review

NBM maintained

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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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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


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:_____________________)

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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

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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 :

__________________________________________________________________________________ __________________________________________________________________________________ ______________________________________________________

Pathway Bariatric Surgery

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