Patients Sticker

National University Health System

Division of Upper Gastrointestinal Surgery

Bariatric Surgery
Peri-operative Care Pathway

Consultant Surgeon:

Date of Admission:
Date of Surgery:
Estimated length of stay:

MAQ-FORM-SUR-011

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Guidelines using of the Bariatric Surgery Clinical Pathway

1. Inclusion Criteria
Patients listed for bariatric surgery shall be placed on this clinical pathway. The pathway will start at the clinic and
continue in the ward. The pathway will be initiated either by doctors or listing nurses.
2. Exclusion Criteria
Patients who are unfit or refuse surgery are to be taken off the pathway.
3. The healthcare team shall use the pathway to:
Hand over report during inter-shift report / during doctors ward round.
Discuss plan of care, critical events and progress of the patients.
Discuss discharge plans /ELOS /patient /familys needs.
4. Documentation guide
For Doctors
Tick and sign standard orders as required.
Enter additional orders in the space provided.
For Nurses and other allied healthcare team:
The following symbols shall be indicated in the boxes provided.

Done / achieved (care activities are carried out as planned)

Not done / not achieved. Reasons for non-compliance, together with an action and follow-up
plan, shall be documented in the patients progress notes.

Not Applicable

No box shall be left blank.

All amendments on the pathway shall be dated and signed.
All healthcare team members shall use the following legend, within Action column.
Legend: D- dispatched, F- Form faxed, R- Requested, C- Completed.

If there is a problem with documentation of the pathway, the consultant or Case Manager-in-charge shall be
consulted.

5. All healthcare team shall initial on the pathway.

6. Variance documentation & outcome measurement
Doctor /PT /SN-in-charge of the patient shall document all variances
Key indicators (variances & outcomes) stated in the pathway shall be tracked and monitored by end of each shift.
If the outcome is not met, please indicate reason & action taken in Nurses Notes.
If patient is taken off the pathway due to significant variances or ordered by the doctor,
the reason shall be recorded, and resume back to the usual documentation.
7. The pathway is continued in the Doctors Notes of the records. It replaces the current Treatment and Progress notes
and Continuation sheets. Additional blank Pathway Continuation sheets may be added if required. Please DO NOT use
the usual Continuation or Treatment and Progress notes
8. Upon discharge, the unutilized pathway pages or continuation sheets should be removed from the patients case
notes.
9. DO NOT remove the pathway from the patients case notes.

MAQ-FORM-SUR-011

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Clinical Pathway for Bariatric Surgery

DRG 950,524
Expected Length of Stay (ELOS): 3 days

Patient Label

Doctor's Guidelines & Protocol Before Operation

(Tick when done)

Listing Nurse (Tick when done)

1. Operative consent details explained including:

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

Subspecialty reviews

Other alternative to treatment

Yes

NA

Endocrinologist

Yes

NA

Long term follow up

Yes

NA

Psychiatrist

Yes

NA

Patients role in treatment

Yes

NA

UGI nurse

Yes

NA

Dietitian

Yes

NA

Physiotherapist

Yes

NA

AOCC

Yes

NA

2. Explain estimated Length of Stay to patient / family members

3. Review Oral Medications
(Anti-coagulants, anti-hypertensive and anti-Diabetic)

Discharge Planning:
Emergency contact:

4. Order PAT tests (check box if required to be done)

Full blood count

Yes

No

Renal panel 1 with fasting glucose

Yes

No

Liver function

Yes

No

Lipid Panel 1

Yes

No

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

MAQ-FORM-SUR-011

Name:
Number:

Name:
Number

Listing Nurse: (Name stamp & signature)

Date & time:

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Bariatric Surgery
Pre Admission Clerking Sheet
Patient's Sticker

Name of Consultant: ______________________

Drug Allergy:

_________________________________

Age: _______
Weight History:
Duration of weight gain (years):

_________________________________________

Previous attempts at weight loss: Yes / No

If yes, attempts methods:

Lifestyle Modification / Medications / Surgery / Alternative Therapy

Attempts supervised by:

Self / Family Physician / Tertiary care / Alternative Therapist

Diet History:
Snacks per day:

Meals per day: ______________

Likes to have:

____________________

High Calorie drinks / Fried Food / Sweets / Bulk / Normal

Exercise History:
Type of Exercise:

Walking / Cycling / Swimming / Other:_____________________

Duration and Frequency: ____________________________________________________

Comorbidity:
Hypertension

IHD

Migraine

Diabetes Mellitus (Type 1 / 2)

NASH

Benign Intracranial Hypertension

Hyperlipidemia

GERD

Others:

Obstructive Sleep Apnea

PCOS

_______________________

OsteoArthritis

Gout

Asthma

Depression

Other History:
Previous abdominal surgery:

__________________________________________

Alcohol:

Yes / No

Smoking:

Yes / No / Ex-smoker

Menstrual History: Regular / Irregular / Menopause

MAQ-FORM-SUR-011

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Physical Examination:
Height:

___________

Pulse rate:

____________

Weight:

___________

BP:

____________

BMI:

___________

Respiratory System:
__________________________________________________________________
Abdomen:
__________________________________________________________________
Cardiovascular System:
__________________________________________________________________

Planned Procedure:
Laparoscopic / Open / Robotic
Sleeve / Bypass / Gastric Band / BPD / Duodenal switch / others: ______________________
AOCC:
Comments:
_____________________________________________________________________________
For further peri-operative instruction, see attached Bariatric Surgery Pathway.

Clerking Doctor:

Confirming Doctor:

Name:

__________________ Name:

_____________________

MCR number:

__________________ MCR number:

_____________________

Date:

__________________ Date:

_____________________

MAQ-FORM-SUR-011

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Peri-Operative Analgesia Protocol for

Bariatric Surgery
Arcoxia 120mg 1 - 2 hours before operation

Pre-Op

* SDA case: Prescribe by Surgical HO on-call,

nurse to administer 1 - 2 hour before op
* NSAIDS allergy or Renal Impairment: NO pre-emptive analgesia will be given

If Arcoxia is given: IV Paracetamol 1gm (First Dose)

Induction

If Arcoxia NOT given: Suppository Voltaren X 2 and IV Paracetamol 1gm

* NSAIDS allergy or Renal Impairment: IV Paracetamol 1gm ONLY
* Paracetamol allergy: Use standard drugs
IV Paracetamol 1gm X 6 hourly STRICTLY X 2 doses,
PRN basis

Post Op

followed by

Breakthrough pain: IV Tramadol 50mg in 100 mls of normal saline, administer

over 30 mins. Maximum: 50mg 8 hourly for 24 hours
Once Oral starts: Crushed PO Paracetamol 1gm 6 hourly/ PRN
* Paracetamol allergy: Prescribe NSAIDs or Opoid

Upon
Discharge

PO Paracetamol 1gm 6 hourly/ PRN for 5 days

** If allergy to Paracetamol, please do not follow this protocol

MAQ-FORM-SUR-011

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Clinical Pathway for Bariatric Surgery

UNIT

WARD

BED

Patient Label

Pre-Op Assessment
Date:

Time

Multidisciplinary Notes
Must do:

Doctor's Orders
(Tick when done) Pre-Op Investigations (If needed)

Check Operation consent obtain

Yes

No

PT/APTT/INR

Review oral medication

(Anti-coagulants, anti-hypertensive and
hypoglycemic agent)

Yes

No

GXM

Nill by mouth from 12 midnight

Yes

No

Trace old notes and X-rays

Yes

No

Arrange HD / ICU bed

Yes

No

Complete Page 1 of Pathway

Yes

No

Peri-Operative Anagelsia Protocol

Yes

No

others

DR's Name Stamp and signature:

MAQ-FORM-SUR-011

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Pre-Op Assessment
Activities - Nursing (Tick when Done)

Activities - Physiotherapist

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

Desired Outcome:

OT chit faxed

Patient/ Family understand pre-op education

NBM 12 midnight

Yes

TED stockings applied

No

(reason/ action: ______________)

anagelsia

Patient Education:
Educate patient/ family on post op wound care,
Diet advise & importance of exercise

Other Treatment/ Remarks:

Desired Outcomes:
Patient verbalise understanding of ELOS, pre &
post op teaching & is ready for surgery

Nurses' Initials:

AM:

PM

ND
Name Stamp and Signature with date:

Time

MAQ-FORM-SUR-011

Multidisciplinary Notes

Treatment Orders

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Clinical Pathway for Bariatric Surgery

UNIT

WARD

BED

Op Day

Patient Label

Date:

Prior to OT:
Time

Multidisciplinary Notes

Doctor's orders

Consent Up
All investigations results reviewed
NBM maintained

Post Op Review
Time

Multidisciplinary Notes

Doctor's orders

DO NOT INSERT NASOGASTRIC TUBE WITHOUT SURGEON'S CONSENT

Mandatory Orders:
Hourly Parameters with SpO2 monitoring for 6 hours,
then 4 hours if stable

Optional:
Gastrograffin swallow & meal POD
_______

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

Oxygen nasal prong 3 liters/minute (titrate to keep SpO2

> 93%)

Monitor urine output ____ hourly (keep at

0.5 mls/kg/hr)

Pneumatic Calf Compression

Continue nocturnal CPAP

Sit out of bed / Ambulate

If hypoxic, alert primary team/ on call

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:

MAQ-FORM-SUR-011

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Op Day Assessment
Activities - Nursing (Prior to OT) (Tick when done)

AM

PM

ND

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)

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

Desired Outcomes:
Patient verbalise adequate pain control (if No, state reason: ____________)
Post op vital signs are stable (if No, state reason: ____________________)
Nurses' Initials:

Time

MAQ-FORM-SUR-011

AM

Multidisciplinary Notes

PM

ND

Treatment Orders

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Clinical Pathway for Bariatric Surgery

UNIT

WARD

BED

Patient Label

1st POD
Date:

Time

Multidisciplinary Notes

Doctor's Orders

Monitor vital signs 4 hourly unless otherwise specified

Gastrograffin swallow and meal POD ___

Start liquid diet as per dietitian

Prescribe anti-coagulant

Off IV fluids if taking well

Incentive Spirometry & breathing exercise

Prescribe following medications if started oral fluids

(Vitamins package as per eIMR template)

Ted stocking / Calf compression

Rabeprazole 10mg OM X 2 weeks

Multi-vitamins (Chewable) 1 tab OM
Mecobalamin 500 mcg X 2 tabs
Ferrous Polymaltose Drops 50mg

Discharge activities:
Follow up appointment:

Calcium Carbonate (chewable) 2 tabs (1250mg)

Weight management clinic (COMS)

Lynae

Date:____________ Time: ___________

Paracetamol 1gm X 1 week unless specified

Review all previous medication (Anti-hypertensive, Statins,
DM meds)

For Diabetic patient: Blood tests to be done on

arrival/ 1 day before appointment day

D - 1 unless otherwise specified

HbA1c

Monitor Hypocount as per protocol

C-Peptide
Insulin
Fasting Glucose
Medications:
Vitamins package
Myotein powder as per dietician order
Hospitalisation leave for ______weeks
Exercise as per physiotherapist advice
Post Bariatric surgery and dietary advice
given to patient
Home care instructions given
DR's Name Stamp and signature:

MAQ-FORM-SUR-011

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1st POD
Activities - Nursing (tick when done)

AM

PM

ND

Activities - Physiotherapist (tick when done)

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

Other treatment / remarks:

Pain assessment & management Score

to be recorded by ND staff
Max (pain
score):________
Min (pain
score):_________
Observe signs & symptoms of wound
infection

Patient Education
Post Bariatric home, diet and wound
care advice

Desired Outcomes:
Patient verbalised adequate pain control
(if No, state
reason:_____________________)
Stable vital signs (if No, state
reason:_____________________)
Nurses' Initials: AM

Time

MAQ-FORM-SUR-011

PM

ND

Multidisciplinary Notes

Treatment Orders

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Clinical Pathway for Bariatric Surgery

WARD

UNIT

BED

2nd POD

Patient Label

Date:

Time

Multidisciplinary Notes (tick when done)

Doctor's Orders

Home Today
Review anti-hypertensive, Statins, Diabetic medications and
others
PO Paracetamol 1gm for 1 week
Vitamins Package for 1 month
Medical/ Hospitalisation leave for _________ weeks
Doctor's Discharge activities:
Follow up appointment
Weight Management Clinic (COMS)
Date: ____________________ Time: ____________________
For Diabetic patient: Blood tests to be done on arrival/ 1 day before
appointment day
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
Home care instructions is given
Wound care information sheet is given
Complications During Stay: (Tick if have)
Please Specify: ____________________________________

MAQ-FORM-SUR-011

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2nd POD
Activities - Nursing (tick when done)

AM

PM

ND

Activities - Physiotherapist

Monitor Vital Signs as ordered

Monitor urine output
Observe for signs and symptoms of wound
infection
Check IV site for extravasation
Pain assessment & management
score to be recorded by ND staff
__________ Min: ___________

Pain
Max:

Keep on liquid diet

Desired Outcomes:
Patient verbalise adequate pain control
(if
No, state reason:_____________________)
Stable vital signs
(if
No, state reason:_____________________)
Patient able to ambulate
(if
No, state reason: ____________________)
Home Care instructions leaflet given
Nurses' Initials:

Time

MAQ-FORM-SUR-011

Multidisciplinary Notes

Treatment orders

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Case Manager / Clinical Pathway Referral

Unit

Ward

Bed
Pts Label

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): ___________________________________

MAQ-FORM-SUR-011

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PHONE CONSULT FOR Bariatric Surgery 2-3 DAYS

POST DISCHARGE
UNIT

WARD

Patients Label

BED
Date: _______________

Upon Completion, Fax this form to Case Manager at 6775

6757

----------------------------------------------------------------------------------------------------------------------------------------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
DRs Name/MCR:

__________________________________________

Remarks / Advices Given :

___________________________________________________________________________________
___________________________________________________________________________________
______________________________________________________

MAQ-FORM-SUR-011

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