Transcript OBESITY: Caring for the Patient of Size - Welcome to NC-NET

Denise Rivera, MSN, RN-BC, CBN
Obesity is a term used to describe body
weight that is much greater than what is
considered healthy
Obesity = Body Mass Index (BMI) of 30 or
higher.
Body Mass Index (BMI): A measure of an
adult’s weight in relation to his or her
height, specifically the adult’s weight in
kilograms divided by the square of his or
her height in meters.
Wt(kg)
Ht(m2)
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
10%–14
15%–19%
20%–24%
25%–29%
≥30%
In 2009-2010:
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35.7% of US adults were obese
◦ No significant difference between males & females
◦ 60 years of age or older were more likely to be obese
than younger adults
17% of youths were obese
◦ More boys than girls
Medical cost associated with obesity were estimated at
$147 billion
National Health and Nutrition Examination Survey 2009-2010
Multifactoral
◦Biological/Genetic
◦Environmental
◦Socioeconomic
◦Behavioral
◦Cultural background
Diabetes
Consequences
of
Obesity
Hyperlipedemia
Arthritis
Hypertension
Sleep apnea
Stroke
Cancer
Depression
Increase
Medical cost
OBESITY
Discrimination
Limited access
Isolation
Poor self
esteem

Language

Equipment / Furniture

Space
◦ Avoid identifications that indicate
obesity to others
◦ Sturdiness
◦ Weight limits
◦ Width
◦ Temperature
◦ Accommodation
Mobility/Transfer
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Assess patients functional status
Appropriate equipment
◦ Weight limits
◦ Width dimensions
◦ Know how to use
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Appropriate assistance
◦ Always use the appropriate number of people

Door Frames
Proper body mechanics for both patient and
caregiver essential to avoid injury.
Medications
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Obese patients react differently to medications due
to the high percentage of adipose tissue.
Absorption differs due to body composition and
physiological changes in transport and drug levels
may become sub therapeutic or toxic
Drugs that are soluble in adipose tissue should be
calculated with actual body weight. Drugs that are
distributed in lean tissue should be dosed
according to ideal body weight.
Medications
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Drugs that rely on normal gastric pH absorption
may be altered due to lower pH.
Cutaneous dosages may need to be adjusted as
cutaneous tissue is not well perfused in obese
patients
Use longer needle for IM injections
Assessments

Blood pressure- small cuff can result in falsely high
readings

Auscultation of heart and lung sounds more
challenging

Bowels sounds will take longer to distinguish

Peripheral pulse more difficult to palpate
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Skin at a higher risk for breakdown due to
moisture, friction, decrease perfusion.
Nutrition

Overweight does not mean well nourished
◦ Comprehensive assessment
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Lab values
Food preferences
Food diaries
Supplements
Psychological

Coping mechanisms
Education

Knowledge level
◦ Impact on health
◦ Learning style
◦ Treatment options
The obese patient needs a great deal of education
and support to be successful in a weight loss
program.
Increase risk

DVT- deep vein thrombosis
◦ Immobility
◦ Venous status
Treatment
◦ Anticoagulant prophylaxis
 Higher doses may be necessary to achieve adequate DVT
prevention
 Sequential compression device
 Ambulate
Increase risk

Respiratory complications
◦ Structural and functional change
◦ Length of time under anesthesia
◦ Narcotic use
Treatment
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Incentive Spirometer
Coughing & deep breathing
Supplemental oxygen
CPAP
Increased risk
 Skin Breakdown/Wound Healing
◦ Moisture
◦ Friction
◦ Cormorbidities
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Treatment
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Thorough skin assessments every shift
Meticulous skin care/wound care
Pressure relief
Maintain glucose control
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Recognized as a treatment for chronic obesity
Recognized as a treatment for Diabetes Type 2
Mortality risk low compared to other common
procedures
More popular
◦ Medical community
◦ Third party payors
◦ Patients

Common surgeries
◦ Adjustable Gastric Band
◦ Vertical Sleeve Gastrectomy
◦ Roux-n-Y Gastric Bypass
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Create a small stomach pouch
Restrict the amount of food a patient can
consume at one time
Commitment to lifestyle change
◦ Eating, drinking and exercise
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Eat more frequently, smaller amounts
Focus is on protein
Avoid drinking and eating at the same time
Exercise is an important in maintaining weight loss
Nutrition
 Small frequent meals with an emphasis on protein
 No straws or carbonated beverages
 Separate food and fluids
Medications
 Space out medications
Diagnostic studies
 Oral contrast
Medical Treatment
 No blind Nasogastric tubes
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Obesity is a chronic disease
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You will care for a patient of size
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Nurses should be sensitive to the unique
needs of the bariatric population
All patients deserve nondiscriminatory,
appropriate treatment and care
1.Mr. Smith, 36 year old with a BMI of 49 is in
for a physical examination. Mr. Smith has not
been to a physician in 3 years. He denies any
PMH and take no medications. You see that
the Blood pressure documented in 152/96.
The most appropriate action would be to
A.
B.
C.
Recheck the blood pressure using an appropriate
sized cuff.
Ask the patient what is his usual blood pressure
Recognize that the elevated blood pressure as an
effect of his obesity.
2. Mrs. Jones, 54 year old, weight 368 lbs,
needs to go to radiology for an X-ray. You
see the transported with a standard
wheelchair. The most appropriate action
would be to
A.
B.
C.
Tell the transporter to be carful
Instruct the transported to obtain an
extended capacity wheelchair
Cancel the x-ray
3. To avoid a delay in transporting Mrs. Jones,
the best course of action would be to
A.
B.
C.
Notify the radiology department of Mrs.
Jones equipment needs
Schedule a portable x-ray to avoid
transporting Mrs. Jones
Insist the patient be transported in the bed.
4. Mr. White, 35 year old, BMI 43 is in a
hospital gown that is pulling across his
abdomen and you can see he is
uncomfortable. The most appropriate action
would be to
A.
A.
B.
Remove the gown and just leave a sheet over
Mr. White
Obtain a bariatric gown and inform Mr. White that
you have a more comfortable gown for him
Using the intercom system, instruct the
receptionist to order a larger gown for Mr. White.
1. A – a double check of the patient’s blood pressure is
warranted to ensure that the right cuff was used and the
reading is accurate.
2. B – To avoid any injury to the patient and transporter the
appropriate bariatric wheelchair is necessary to transport
Mrs. Jones.
3. A – Effective communication between departments is
necessary to avoid delay in treatment or any
embarrassment to the patient.
4. B – Changing the patient’s gown to a bariatric gown will
ultimately make him more comfortable without any need to
identify that it is a larger gown.
VISN 8 Patient Safety Center of Inquiry. Safe Bariatric Patient Handling Toolkit;
2007. Available at www.visn8.va.gov/patientsafetycenter
Iredell County Health Department, Iredell County Community Health Assessment
2011. Available www.co.iredell.nc.us/departments/health/health.asp
Center for Disease control and Prevention. Behavioral Risk Factor Surveillance
System Survey Data. Atlanta, Georgia: US Department of Health and Human
Services, CDC 2009-2010
Baldwin-Rodriguez, B. Dynamic Nursing Education. Care of the Critically Ill
Bariatric Patient. 9/11/2009. Available at
http://dynamicnursingeducation.com/class.php?class_id=134&pid=18
57th AORN Congress. Bariatric Surgery Updates Clinical Study Guide # 8245,
March 2010