Facilitating Students' Competence in Caring for the Bariatric Surgical Patient: The Case Study Approach

Abstract

Bariatric surgery is a safe and highly effective option for treating the disease of morbid obesity. Given that the numbers of morbidly obese adults exceed one in twenty in the United States, bariatric surgery is no longer an uncommon surgical procedure and will likely continue to become increasingly common. Therefore, it is imperative that nursing programs prepare prelicensure students to deliver high-quality, competent care to bariatric surgical patients. These patients have complex collaborative care needs that can be best taught utilizing an active learning format, such as the case study format. This article presents an exemplar case study that can be used to teach nursing students about the unique needs of the bariatric surgical patient. The pre-operative, peri-operative, post-operative, and continuing care needs of the bariatric surgical patient are addressed using a nursing process framework and critical thinking exercises.

Introduction

The United States has become an “obesogenic” nation, according to the Centers for Disease Control and Prevention (CDC).¹ This assertion is substantiated by a doubling in the numbers of American adults who are obese since 1980.² In particular, 32.6% of American adults are overweight, 34.3% are obese, and 5.9% are morbidly obese.¹

Obesity contributes to approximately 112,000 preventable deaths annually.² Direct costs associated with obesity-related morbidity now exceed $61 billion annually.³ Obesity is associated with heightened risks for hypertension, hypercholesterolemia, type 2 diabetes, arteriosclerotic cardiovascular disease, obstructive sleep apnea, non-alcoholic fatty liver disease, cholecystitis and cholelithiasis, osteoarthritis, and some neoplasms that include breast, endometrial, prostate, renal, and colon cancers.^2,3 In particular, the recent steep rise in the numbers of obese American adults correlates with the epidemic rise in the prevalence of American adults with type 2 diabetes, which is now at 8%, a tripling in numbers since 1980.² Those who are morbidly obese, or whose body mass indices (BMI) exceed 40 Kg/m², are at particular risk for suffering many of these morbid conditions.

Though the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Centers for Medicare and Medicaid Services (CMS) both assert that obesity is a disease,³ not all laymen and clinicians share this view. Obese adults are commonly viewed as lazy, unsuccessful, overindulgent, and lacking self-control.^4,5,6 While behaviors may share a role in the genesis of obesity, there are many other key factors that favor the development of obesity, which can be categorized as environmental, genetic, metabolic, cultural, and socioeconomic.^1,2 Therefore, the root causes of the obesogenic American way of life are truly complex and multifactorial.

Much recent media publicity has revolved around implementing primary prevention strategies to thwart the onset of obesity-related morbidity among adults through eliminating obesity among children. Indeed, Michelle Obama has recently launched the much-lauded “Let's Move” campaign.⁷ While there is hope that the prevalence of adult obesity in the United States will eventually decline as a result of this campaign, the needs of today's obese adults must be met through secondary and tertiary risk reduction strategies in order to improve both their length and quality of life.

Bariatric surgery is the most effective treatment option for morbidly obese adults in that it frequently results in long-term weight loss, improvement or sometimes complete resolution of comorbid conditions such as type 2 diabetes, improved quality of life, and longer life.^8,9,10 Moreover, bariatric surgery may be indicated in adults with BMIs in excess of 35 Kg/m² with one or more significant obesity-related comorbid conditions,¹¹ and may result in parallel successes. In these instances, the overall benefits of bariatric surgery outweigh the potential surgical and post-operative risks.¹² Indeed, the overall benefits of bariatric surgery in terms of inducing remission or improvement in diseases such as type 2 diabetes, obstructive sleep apnea, hypertension, hypercholesterolemia, and non-alcoholic liver disease are so profound that bariatric surgery is now viewed as a highly effective type of metabolic treatment.¹³

Given that bariatric surgery is a safe and highly effective option for treating the disease of morbid obesity and of obesity with comorbidity, and given that the numbers of morbidly obese adults exceed one in twenty in the United States, bariatric surgery is no longer an uncommon surgical procedure and will likely continue to become increasingly common. Therefore, it is imperative that nursing schools prepare prelicensure students to deliver high-quality, competent care to the bariatric surgical patient.

Nursing students must learn key concepts and theories of obesity and the principles that guide its treatments within a disease management framework that mirrors the framework used to learn about other diseases, such as coronary artery disease. Pathophysiological principles, risk factors, clinical manifestations, and assessment and diagnostic findings for the obese patient should all be addressed within the nursing process framework. In addition, given that many clinicians harbor misperceptions regarding obese persons and may be prone to stigmatize them,⁴ students' feelings and perceptions regarding obesity should be explored, and theories that explain the complex pathogenesis of obesity should be proffered, much in the same way that students tend to be taught about alcoholism and addictive disorders and how to best care for patients with these diseases. Indications for bariatric surgery and the care of the bariatric surgical patient should be part of all prelicensure nursing curricula.

Although seminal obesity-related content and the care of bariatric surgery patients may be addressed with students in the traditional lecture format, the complex holistic needs of these patients might not be readily apparent to students in the lecture hall. Sandstrom¹⁴ asserts that nursing students have more difficulty understanding the complexity of chronic diseases when they are taught in the traditional lecture format, which encourages passive learning. Rather, active learning methods are more effective in facilitating critical thinking skills in these students. One method of active learning that can facilitate critical thinking, problem solving, and confidence in clinical practice is the case study format.^14,15

The case study presented in this article was developed by the authors to teach prelicensure students enrolled in a first-level medical-surgical course of a baccalaureate nursing program. This case incorporates several different critical thinking exercises developed to enhance the students' understanding of best practices to utilize when rendering care to a bariatric surgery patient at different points in time during the pre-operative and immediate post-operative timeframe, and in successfully providing continuing care for the bariatric surgery patient post hospital discharge.

Teaching Material and Methods: The Case Study

Case study part 1: Pre-operative background and screening

Ella, a 32-year-old Latina measuring 5'6” and weighing 223 pounds, works full-time as a cosmetologist at a local hair salon. She has been working with the Weight Loss Management Center and her primary care provider over the past year and a half to achieve a healthy lifestyle. During her treatment at the Weight Loss Management Center, she has failed to see significant results, yielding a total loss of 12 pounds. She has been referred to the Bariatric Center for a surgical consultation for gastric bypass.

At the time of Ella's consultation, the nurse practitioner noted the following obesity-related comorbidities in her medical record: sleep apnea, hypertension, and dyslipidemia. Ella's body mass index was 36 kg/m², which relates to Obese Class II in the International Weight Class.¹⁶ She stated that she was “heavy and fat” most of her young adult life. The dietary consultation assured that Ella was motivated and determined to meet program standards if selected for surgery. Her commitment to a rigorous dietary regimen for the past 18 months has demonstrated she desires to meet her weight loss goals by making the necessary lifestyle changes. The psychological consultation revealed that Ella was sexually abused as a juvenile at the age of 12 by an adult male neighbor. Currently it is apparent, through verbal discussions with Ella, that she has a healthy relationship with her husband and has been happily married for six years. She is also a mother to a three-year-old son. She verbalized that she has not received any psychological therapy within the past 12 years. The surgeon and nurse practitioner thoroughly discussed the above information and extensively reviewed her knowledge and expectations of the procedure (Table 1).

Table 1.

Critical Thinking Exercise for Case Study, Part 1

Potential questions to ponder	Potential responses
Is Ella a candidate for gastric bypass surgery? If so, explain how Ella has demonstrated readiness for gastric bypass surgery.	Ella appears to be a viable candidate for gastric bypass for she has demonstrated commitment to a long-term weight loss plan over the past year and has not achieved the desired results. She meets clinical practice guideline criteria for bariatric surgical candidates as her BMI is between 35 and 40 kg/m² with one or more obesity-related chronic health conditions.^8,11,16
What issues about Ella's history concern you, if any, making you question if she is ready for a surgical weight loss option?	During the consultation, the history of Ella being a victim of sexual abuse during her childhood was revealed. Though this is worth noting, as adult obesity has been correlated to childhood sexual victimization, this is not a reason to discount her from gastric bypass surgery as she has been able to overcome the psychological ramifications as evident by her successful marriage.¹⁷

Case study part 2: The peri-operative and post-operative period

After the nurse practitioner consulted with the surgeon, Ella was found to be a viable candidate for the laparoscopic Roux-en-Y gastric bypass procedure (LRYGB). Her surgery was scheduled two months after the date of her consultation. The LRYGB was performed without complications (Figure 1).

FIG. 1.

Roux-en-Y gastric bypass. A horizontal row of staples across the fundus of the stomach creates a pouch with a capacity of 20 to 30 mL. The jejunum is divided distal to the ligament of Treitz, and the distal end is anastomosed to the new pouch. The proximal segment is anastomosed to the jejunum.

Care in the post-anesthesia care unit

Ella recovered in the post-anesthesia care unit (PACU) and received intravenous (IV) vitamin-enriched fluid hydration at 200 mL/hour to maintain adequate urine and cardiac output. Her blood pressure fluctuated immediately post procedure, which lengthened her time in the PACU. To decrease and stabilize her blood pressure, fluid hydration was decreased to 125 mL/hour and she was administered 5 mg of metoprolol tartrate through her IV. Sequential compression devices (SCDs) remained on since induction of anesthesia and subcutaneous heparin was ordered to prevent thrombotic complications post-operatively. After two hours she was then transferred to a bariatric-focused medical-surgical unit.

Care on the medical-surgical nursing unit

Upon arrival to the medical-surgical unit, the admitting nurse greeted Ella and assisted her with ambulating from the stretcher to a bedside chair. A thorough physical assessment was then performed by the nurse. The nurse identified a left forearm IV with D5 1/2 normal saline solution (NSS) with 30 mEq of potassium infusing at 125 mLs/hour. The nurse also noted that a urinary catheter and nasogastric tube were not inserted during the procedure. Five small laparoscopic incisions were identified and were well approximated and open-to-air. A single Jackson-Pratt drain was intact, draining bloody fluid. Breath sounds were clear but decreased bilaterally at the bases. Cardiac assessment was within normal limits except for a slightly elevated blood pressure and heart rate of 102 beats/minute. Pain assessment revealed the continued need for morphine to be administered intravenously every hour as needed for pain (Table 2).

Table 2.

First Critical Thinking Exercise for Case Study, Part 2

Potential questions to ponder	Potential responses
Identify what priority assessments you would perform.	The primary nurse caring for Ella should plan on performing a thorough cardiovascular and respiratory assessment, paying particular attention to heart and lung sounds and affected vital signs (heart rate, blood pressure, respirations, and oxygen saturation). Cardiac monitoring is also suggested, as post-operative LRYGB patients are at increased risk for dysrhythmias, acute myocardial ischemia, heart failure, and sudden death.^11,18 Ella's surgical incisions, drain, and IV site should also be evaluated and monitored on a frequent basis during the post-operative period.
What type of nursing interventions would you employ?	The onset of post-operative complications for the bariatric surgery patient may be thwarted through traditional post-operative nursing interventions such as pain management, pulmonary toilet, early ambulation, fluid balance maintenance, skin care, and venous thromboembolism (VTE) prophylaxis.^11,19 The nurse also provides exceptional therapeutic communication, patient education, and emotional support, which aid the patient and family in the recovery process.
What is the rationale for eliminating the use of a nasogastric tube and urinary catheter during the procedure?	The insertion of a nasogastric tube is contraindicated in the LRYGB procedure and has also been determined as an unnecessary practice in open Roux-en-Y gastric bypass procedures.¹¹ The pouch that is created in the stomach during the LRYGB is positioned higher than what was originally created in the traditional Roux-en-Y procedure.²⁰ Patients are instructed after surgery to carry a medical emergency card that cautions emergency medical personnel to refrain from inserting a nasogastric tube without guidance by imaging or the care of a surgeon. The urinary catheter is not placed during the procedure to decrease the likelihood of hospital-acquired urinary tract infections. Patient ambulation is enhanced by encouraging walks to the bathroom, which decrease post-operative venous thromboembolism (VTE) complications.¹¹

A few hours later, after Ella is more alert and easily arousable, the nurse instructs Ella that she is to drink 30 mLs of sugar-free fluids every 15 minutes. The nurse reinforces that she should sip the liquid over the entire allotted time period and that she should stop if she feels full or is nauseated (Table 3).

Table 3.

Second Critical Thinking Exercise for Case Study, Part 2

Potential question to ponder	Potential response
Why should Ella drink only sugar-free fluid post surgery in small amounts?	The slow and constant introduction of small volume liquids initiates movement in the gastrointestinal system. This restrictive diet prevents the unpleasant effects of dumping syndrome, gastric reflux, and vomiting while maintaining the anastomosis and patient's satiety.^11,21,22 Dumping syndrome occurs when high-sugar liquids and foods are consumed. This action causes a rapid emptying of gastric content into the small bowel, resulting in unpleasant side effects, since the pyloric sphincter is no longer utilized for digestion. Common signs and symptoms of dumping syndrome include tachycardia, cramping pain, vomiting, diarrhea, and diaphoresis.^18,23 As the diet progresses to more complex stages over the next 3–4 months, dumping syndrome can be prevented by continuing the practice of consuming only sugar-free or low-sugar items. Maintaining the habit of drinking small amounts of liquids slowly before or after meals and chewing solid foods thoroughly prevents stretching of the surgical pouch created during the LRYGB procedure.

Potential question to ponder

Potential response

Why should Ella drink only sugar-free fluid post surgery in small amounts?

The slow and constant introduction of small volume liquids initiates movement in the gastrointestinal system. This restrictive diet prevents the unpleasant effects of dumping syndrome, gastric reflux, and vomiting while maintaining the anastomosis and patient's satiety.^11,21,22 Dumping syndrome occurs when high-sugar liquids and foods are consumed. This action causes a rapid emptying of gastric content into the small bowel, resulting in unpleasant side effects, since the pyloric sphincter is no longer utilized for digestion. Common signs and symptoms of dumping syndrome include tachycardia, cramping pain, vomiting, diarrhea, and diaphoresis.^18,23 As the diet progresses to more complex stages over the next 3–4 months, dumping syndrome can be prevented by continuing the practice of consuming only sugar-free or low-sugar items. Maintaining the habit of drinking small amounts of liquids slowly before or after meals and chewing solid foods thoroughly prevents stretching of the surgical pouch created during the LRYGB procedure.

As the evening progresses, Ella prepares for bedtime by ambulating to the bathroom and setting up her BIPAP machine that she brought from home. Overnight, Ella's oxygen saturations decreased to 89–90%. A respiratory therapist responds, per protocol, and adjusts the settings on the machine to achieve saturations over 92%. Ella's oxygen saturations return to normal readings by the early morning hours (Table 4).

Table 4.

Third Critical Thinking Exercise for Case Study, Part 2

Potential question to ponder	Potential responses
What could explain the short-term decrease in Ella's oxygen saturations?	Ella had some low oxygenation values at night related to her preexisting condition of sleep apnea. In addition, hypoventilation is common among obese patients as tidal volume decreases and carbon dioxide builds up due to additional weight impinging upon the diaphragm, decreasing lung and chest wall expansion.¹⁸ Anesthesia and pain management medications intensify this state of respiratory compromise and place the patient at an increased risk of cardiac dysrhythmias and hypoxic events.¹⁸ The nurse caring for Ella can elevate the head of her bed to greater than 30 degrees and place her in a reverse Trendelenberg position to improve respiratory efforts.¹⁸

Potential question to ponder

Potential responses

What could explain the short-term decrease in Ella's oxygen saturations?

Ella had some low oxygenation values at night related to her preexisting condition of sleep apnea. In addition, hypoventilation is common among obese patients as tidal volume decreases and carbon dioxide builds up due to additional weight impinging upon the diaphragm, decreasing lung and chest wall expansion.¹⁸ Anesthesia and pain management medications intensify this state of respiratory compromise and place the patient at an increased risk of cardiac dysrhythmias and hypoxic events.¹⁸ The nurse caring for Ella can elevate the head of her bed to greater than 30 degrees and place her in a reverse Trendelenberg position to improve respiratory efforts.¹⁸

On the first post-operative day, Ella's IV fluids were discontinued for she tolerated clear liquids without complaints of nausea or vomiting. Her IV morphine was switched to an oral liquid dose of 5–10 mLs of oxycodone/acetaminophen every four hours to manage her pain. She was able to ambulate independently around the room and with minimal assistance in the unit hallways. Her medications included the following:

Heparin: 5,000 units SQ TID

Oxycodone/acetaminophen: 5–10 mLs PO q4h PRN for pain

Metoprolol tartrate: 50 mg PO q12h daily

Case study part 3: Continuing care of the bariatric surgery patient

Discharge education and considerations

The surgeon rounds around noontime on the first post-operative day and is delighted to see how Ella has progressed over the past 24 hours post procedure. Discharge orders are written, and the nurse begins to prepare Ella for discharge to home. Discharge instructions will focus on adherence to the special diet, medication regimen, and identification of pending complications with protocols that assure appropriate follow-ups.

Student assignment: Identify appropriate functional health patterns and priority nursing diagnoses. Then construct a plan of care for Ella with three priority nursing diagnoses (Table 5 and 6).

Table 5.

Potential Functional Health Patterns and Nursing Diagnoses Used for the Bariatric Surgery Patient

Gordon's ²⁴ functional health patterns	NANDA nursing diagnosis
Nutritional-metabolic	Imbalanced nutrition, less than body requirements
	Risk for nausea
	Risk for deficient fluid volume
	Risk for electrolyte imbalance
	Risk for impaired skin integrity
Cognitive-perceptual	Acute pain
Activity-exercise	Risk for delayed surgical recovery
	Risk for activity intolerance
Self-perception/self-concept	Risk for situational low self-esteem Risk for disturbed body image
Health perception/health management	Readiness for enhanced therapeutic regimen management

Table 6.

Example of Post-Discharge Care Plan for the Bariatric Surgery Patient

Interventions	Rationale	Expected outcomes
Nursing diagnosis: Imbalanced nutrition, less than body requirements
• Assess patient readiness to discuss nutritional habits and recommendations.	• Learning is enhanced when the patient is ready and willing to participate.	• Patient verbalizes knowledge of post-operative nutritional requirements.
• Instruct patient to consume 48–64 ounces of fluid per day as per prescribed diet.	• Maintaining adequate hydration avoids dehydration.	• Patient demonstrates compliance with post-operative diet adherence by remaining free of complications.
• Instruct patient to follow a five-phase post-LRYGB diet as prescribed.	• Advance diet slowly to prevent gastric upset and promote weight loss. Diet phases consist of clear liquids, full liquids, and pureed, soft, and regular foods.²²
• Instruct patient to avoid carbonated liquid and high-fat, high-sugar foods, and to consume sugar-free liquids.	• Avoiding these foods prevents dumping syndrome, gastric distention, and pain.
• Evaluate patient response to nutritional education.	• Ensure patient will comply with post-operative instructions.
Nursing diagnosis: Acute pain
• Affirm with patient that pain is actual and assist her with coping mechanisms.	• Alleviate fears, tensions, and anxieties, which will increase pain tolerance.	• Patient demonstrates pain control by taking analgesic medications at appropriate doses and intervals.
• Assess patient pain level every four hours with a pain scale while in the hospital by noting location, quality, intensity, frequency, and duration of pain.	• Evaluating pain levels and associated signs and symptoms will prevent severe pain from becoming severe and unbearable.	• Patient verbalizes pain is minimal to none using a pain scale.
		• Patient experiences minimal adverse effects and remains on warranted pharmacologic agents.
• Identify patient's pain relief strategy preferences.	• Identifying patient preferences for pain reduction places care measures into patient ownership.
• Teach the patient about nonpharmacologic and pharmalogic treatments.	• Educating about alternative therapies for pain management reduces the use of polypharmacy and overdose/overuse.
• Teach patient and family about potential adverse effects of pharmacologic agents, including prevention and management.	• Anticipating potential adverse effects of pharmacologic agents will prevent interruption in pain management.
Nursing diagnosis: Risk for situational low self-esteem
• Provide patient care in a nondiscriminatory manner.	• Maintains patient rights.	• Patient receives consistent care from all caregivers and family members throughout the post-operative period.
• Preserve patient confidentiality and privacy.
• Advocate for the patient when necessary.	• Provides emotional support to patient by listening to and accepting patient's thoughts and fears.
• Encourage patient to verbalize own thoughts and fears.
• Support patient's significant others in maintaining patient's autonomy and dignity.

Ella must introduce liquids and solid foods slowly back into her diet to prevent the early complication of vomiting and diarrhea.^22,23 The nutritional regimen consists of five phases: clear liquids, full liquids, puree, soft foods, and regular diet. The phases are introduced over a three- to four-month period of time^11,22 to avoid gastric distention and stretching of the newly formed gastric pouch. The nurse instructs Ella to avoid carbonated, alcoholic, and sugary beverages and to limit drinking of fluids to before or after meals. Failure to comply with these recommendations can cause gastric irritation and upset.

Bariatric surgery changes the body's ability to absorb and digest all contents that enter the gastrointestinal tract. This affects not only dietary needs but also pharmacological digestion and absorption. Since Ella is post-operative LRYGB, her primary care provider and surgeon will need to re-examine her pharmacological regimen to maintain therapeutic levels and avoid over- or underdosing events with prescribed medications. Sustained-release (SR) medications are not to be prescribed or taken by the post-operative LRYGB patient since they are not able to be absorbed correctly.^3,11 Routine post-discharge medications include oral pain medications and vitamin supplements. Non-steroidal anti-inflammatory drugs (NSAIDS) should be avoided as use of these medications places the patient at a higher risk for developing gastric ulcers at the site of anastomosis. Furthermore, a proton pump inhibitor may be prescribed to decrease the likelihood of the development of gastric ulcers.³ Medication ordered post-operatively should be administered through the IV route until an IV site is no longer available. The preferred medication administration route at discharge is oral liquids. If the ordered medication is not available in a liquid form, the medication should be crushed well and mixed into a small amount of fluid until Ella can tolerate a pureed diet. Swallowing pills whole is not recommended as the surgical pouch created during the LRYGB procedure can become easily blocked.³ Vitamin supplements and protein-enriched fluid shakes are recommended to decrease the risk of nutritional deficiencies post-operatively that may occur due to the changes in absorption and digestion.^21,22

The bariatric nurse needs to include in Ella's discharge instructions signs and symptoms of potential post-operative surgical adverse events. Post-operative complications of bariatric surgery can be classified into two categories: early and late.¹⁸ Early complications occur within the first 30 days post-operatively and include the following: anastomotic leak, venous thromboembolism (VTE), vomiting, diarrhea, surgical site infection, and rhabdomyolysis. Nutritional deficiencies, abdominal hernias, stoma strictures, gastric ulcers, and cholelithiasis are late complications which develop after the first post-operative month to years later. Venous thromboembolism, such as deep vein thrombosis (DVT) or pulmonary embolism (PE), are the most prevalent post-operative complications despite current best practice prevention efforts with use of sequential compression devices, anticoagulant administration, and early ambulation.²⁵ The most critical and life-threatening early complication is an anastomotic leak occurring at the staple line. The onset is commonly within the first 48 hours after surgery. Identification of a leak at the site of the anastomosis is difficult without upper GI contrast studies and combined computerized tomography imaging²⁶ as signs and symptoms remain generalized with complaints of abdominal and back pain or pressure with restlessness and tachycardia. Commonly seen late complications consist of bowel obstruction leading to hernia formation and nutritional deficiencies related to malabsorption.²²

The last critical component of Ella's discharge conversation should devote a considerable amount of time in discussing available resources such as follow-up appointments, support groups, and online forums. These methods have been directly correlated to weight loss and weight management success after gastric bypass surgery. Utilizing lifelong support resources ensures dietary and exercise treatment adherence, maintains a state of good mental health, and reduces post-operative procedural complications.¹⁶

Discussion

The case study format for teaching nursing students about the unique care needs of the bariatric surgery patient can only be successful if students present to the classroom environment adequately prepared. This is an active learning type of format, and requires preparation and full participation on the part of the students. Students must receive appropriate reading and studying assignments in advance of class and be prepared to synthesize concepts learned with the case or cases presented.

Holding students accountable for this level of preparation may seem daunting to novice faculty. However, there are strategies that faculty may employ to assure active student participation. Dividing students into small working groups assigned to tackle different critical thinking problems for presentation to their peers, who then evaluate each other's success at identifying appropriate answers and best practices, can be a highly effective method that assures students' active learning. For those course sections with high enrollments, dividing the class into small working groups may not be practical. Fortunately, technological advances can provide a reasonable alternative. Integration of classroom response systems, colloquially referred to as clickers, can assure that active student participation occurs, albeit in a mostly multiple-choice type of format to questions.

Out-of-class assignments that challenge students to provide care for patients utilizing the nursing process in the tried-and-true care plan format may also be encouraged. While the exemplar case study used in this article highlights a continuing plan of care for the bariatric surgery patient, alternate care plans could be assigned that highlight the care of the bariatric surgery patient during the screening phase, the peri-operative phase, or the immediate post-operative phase of treatment.

Finally, students should not only be introduced to best practices to assure best outcomes for bariatric surgery patients, but also have an appreciation for the field of bariatric nursing. Most baccalaureate nursing curricula offer a senior-level professional leadership course that introduces students to a plethora of career options. The specialty area of bariatrics should be introduced to these students as a viable and attractive career option. The option to eventually pursue specialty certification in bariatrics and its requirements should be introduced and cultivated.

Conclusion

The disease of obesity is much more prevalent in the United States today than it had been just a few decades ago. Obesity-related morbidity and mortality are considerable. Yet, there is little evidence that nursing curricula have incorporated obesity education content into coursework and clinical practicum experiences, even though obesity can be identified as America's “Public Health Enemy Number One.” Though this article gives one example of how to teach the care of the bariatric surgery patient using an active learning format into a first-level medical-surgical nursing course, merely addressing the disease of obesity in any curriculum through utilizing this one module is woefully insufficient.

Nursing students must learn that obesity is a disease in pathophysiology. They must learn of weight-lowering medications in pharmacology courses, as well as the effects that other medications can have on patients' weight. They must learn of the toll that obesity may take on patients throughout the life span in their pediatrics and gerontology courses, the emotional toll that obesity may take on persons in mental health courses, as well as comorbid psychological risk factors that may predispose certain persons to obesity, and they must learn of the adverse effects obesity may have on the gravid woman and the neonate. Societal, cultural, and economic risks for obesity should be identified during community health courses, as well as methods that may ameliorate these risks. In addition to learning about obesity in the classroom, practicum experiences for students should include rotations in weight management centers and bariatric services programs, and with support groups such as Overeaters Anonymous.

Finally, throughout their program of study, students should be encouraged to examine their own beliefs and attitudes toward obesity so that they can move beyond any preexisting prejudices or misperceptions and deliver the best care to patients diagnosed with obesity.

Footnotes

Acknowledgments

The authors would like to thank Maureen Miletics, RN, BSN, MS, CBN, Director of Bariatrics Services, St. Luke's Hospital–Allentown Campus, Allentown, Pennsylvania, for serving as a consultant in the development of this article.

The case study presented in this article was developed for teaching purposes for pre-licensure baccalaureate students and represents a composite of several different patients who received nursing care in a bariatric surgical center.

Disclosure Statement

No competing financial interests exist.

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