Transcript Management of the Obese Population

C-3 Management of the Obese Population
A Person Centered Care Approach
Presented by:
Carolyn Brown, M.Ed, RN, ARM, FCCWS
National Director of Clinical Services
Learner Objectives
After attending this program the participant will be able to:
1. Define obesity and calculate Body Mass Index (BMI).
2. Discuss prevalence of obesity.
3. Identify unique and predictable clinical issues resulting
from obesity and discuss assessment techniques for
each.
4. Identify community resources to support bariatric care.
5. Review case study and identify appropriate supply and
equipment needs.
Obesity
A life-long, progressive, life threatening, costly,
genetically-related, multi-factorial disease of
excess fat storage.
Bariatric (Greek)
The practice of health care related
to the treatment of obesity and
associated conditions.
Resource: American Society of Bariatric Surgery
Who Is Obese
Obese
• Body Mass Index (BMI) of 30 or greater
Morbid Obesity
• 100 lbs. greater than ideal body weight
• BMI of 40 or greater
• BMI of 35 with 2 or more co-morbidities
Resource: American Society of Bariatric Surgery
Body Mass Index (BMI)
Central Obesity
Waist circumference is now considered a useful tool in
predicting high risk, high cost comorbidities such as diabetes,
high cholesterol , hypertension and coronary artery disease.
Central Obesity identifies a risk category above that defined
by BMI and may allow the clinical team to better predict cost
of care and length of stay.
• Men
> 40 inches
• Women
> 35 inches
Would waist circumference support the customer’s decision
to rent or purchase!!!
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends* Among U.S. Adults
BRFSS, 1991, 1995, 2000 and 2005
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
1995
1991
2000
No Data
<10%
2005
10%-14%
15-19%
20-24%
25%
A Changing Society
Supersized Americans are forcing a re-examination of
out of date weight limits. In 1960 the average
passenger weight was established at 140lbs.
• Elevator manufacturers now display
weight limits; no longer identify
number of people.
• Airline industry is accommodating
additional passenger width.
- The added weight cost airlines an extra
$300 million in fuel in 2005
A Changing Society
• 2003 Charlotte – plane crash kills 21.
FAA raised average passenger weight
to 174lbs
• 2004 Baltimore – 36ft water taxi
capsizes, 5 out of 25 people drowned.
Boat was 700 lbs over 3500lb capacity
• 2005 NY – 47 elderly tourists
capsized on Lake George. The US
Park Service increased passenger
weight capacity to 175lbs
Obesity Update
The year 2006 was important for obesity according to a
report published by the Center for Disease Control and
Prevention (CDC).
• America’s number one health threat.
• Leading cause of preventable death, surpassing tobacco.
• $320 billion is spent annually on obesity.
Healthcare is fast becoming one
of the most dangerous jobs in
the U.S.
Musculoskeletal Disorders
Work-related musculoskeletal
Disorders (MSDs) result when
there is a mismatch between
the physical capacity of
workers and the physical
demands of their job
U.S. Dept. of Labor, Occupational Safety and Health Administration
Cumulative Trauma Disorder
Most work related
musculoskeletal injuries
occur from repetitive injuries.
Overexerting the spine
causes painless micro tears
in the spinal discs creating
cumulative damage.
Cumulative Trauma Disorder
A serious injury may seem to be caused by a
single incident, however the real cause is often
the specific injury coupled with years of
progressive internal weakening and damage.
Safe Patient Handling
Overexerting the spine may result from:
• Lifting improperly
• Lifting weight beyond a
safe lifting capacity
• Working in a “bent over”
position
Safe Patient Handling
Benefits include and increase in patient satisfaction
and mobility and a decrease in:
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Workers comp costs
Staff/patient injury
Lost time claims
Staff turnover
New employee training costs
Scenario
Barb S., Director of Safety Services at
Kaiser Permanente Hospital in
Fresno, CA reported 12 employee
injuries over a 2 week period from
routine care of a nearly 500 pound
patient.
Sten+Barr Medical Inc.
Risk Factors
• Aging Workforce
Degenerative and arthritic
discs, out of shape,
overweight, poor posture
• Obese patients have
increased in number and
are sicker.
The Unique Challenge
Medical community is challenged to:
• Provide quality care
• Prevent injury to patient and staff
• Minimize costs
Stereotyping
Most Americans have little sympathy for the overweight
individual. Obesity is associated with
• Lack of self discipline
• Self indulgence, low intelligence
• Laziness and non compliance
Surveys identify that staff felt overwhelmed by the care
needs of the obese and were concerned about injury to
themselves and the patient
Resource: National Institute of Health
Scenario
Todd, a 240 pound, 6’3”
physical therapist in
Indianapolis had surgery on a
shoulder muscle that tore when
he was moving a 450-pound
patient ”who decided to hang
on to my right arm when he
lost his balance”
Sten+Barr Medical Inc.
Bariatric Geriatric
As the baby boomer generation
ages, they are likely to carry
their weight problems into their
senior years. Never before has
the healthcare community
experienced the aging obese.
General Management Tips
Plan ahead
• Provide staff training on policies, procedures and
clinical assessment.
• Provide staff with appropriate size supplies.
• Know the weight limitations of your equipment.
• Collect proper size supplies and adequate
assistance.
• Plan the transfer or transport. Be certain the
receiving area is prepared for the patient
Sensitivity and Respect
All patients deserve competent, professional care. Negative
perceptions about obesity can affect the caregivers
approach to caring for the bariatric patient.
• Make eye contact, call patient by name
• Ask the patient how to best assist them
• Provide adequate privacy and space
Bariatric Assessment
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Vital Signs
Weight
Respiratory
Circulation
Skin
Gastrointestinal, Urinary
Nutrition
Mobility
Pharmacology
Medication Administration
Vital Signs
Pulse
• Carotid may be difficult to palpate
• Use radial site
A radial pulse may be
the easiest way to
palpate pulses if the
bariatric patient has a
short, thick neck
Vital Signs
Respirations
• May be unable to tolerate
lying flat or deep breathing
as the chest and abdomen
exerts pressure on the
diaphragm.
• Will have changes in mental status, lab values when
experiencing respiratory difficulty.
• Reverse Trendelenburg position may facilitate lung
expansion.
Vital Signs
Respirations
• When listening for breath sounds
displace skin folds, place the
diaphragm of the stethoscope
firmly over the exposed area.
• Listen over dependent areas
where the lung tissue is closest to
the chest wall and where fluid is
most likely to collect.
• Ask the patient to inhale deeply
– Observe cough and changes of mental status
during assessment
Vital Signs
Blood Pressure Equipment
• A standard-sized blood pressure cuff should not be used on
an upper arm circumference of more than 13 inches.
• The width of the cuff must be
40% to 50% of the arm’s
circumference to obtain an
accurate reading.
• A variety of cuff sizes should be
available.
– too small = false high
Vital Signs
Management Tips
• Consistently utilize bariatric BP cuff
• Secure cuff with tape if needed
• Use a cuff on the forearm and feel for the radial pulse
to determine the systolic pressure
• Validate hypotension manually “ by ear” with doppler
stethoscope
– modify care plan
• Elevating the limb may make the first systolic “click”
more audible
Weight
Equipment
• Weigh only if pertinent to care
• Obtaining an accurate weight can be a
challenge due to size and mobility
• Stand-up or sling scales are only
accurate up to 350 lbs.
Weight
Management Tips
• Evaluate the weight capacity of your scale
• Utilize a bariatric bed with a scale for
mobility challenged
• Protect the patients dignity when
recording weight
Respiratory
Clinical Issues
• Lung capacity does not increase with weight gain
• Weight on abdomen and chest restricts
inspiration and expiration
- Obesity Hypoventilation Syndrome (OHS)
- Obstructive Sleep Apnea (OSA)
• Fat deposits in the diaphragm and intercostal muscles
limit breathing
• Increased soft tissue of head, neck and tongue creates
a challenge in positioning and intubation
• High risk for rapid desaturation
Respiratory
Management Tips
• Identify a rescue/alternative airway management plan
• Identify and maintain extra size supplies
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masks, longer endotracheal tubes
HOB 30 degrees
CPAP or BiPAP for sleep apnea
Monitor O2 saturation frequently
Position shoulders and neck as needed
Maintain bed in reverse Trendelenburg’s position to
facilitate lung expansion
• Provide specific Heimlich training
Circulation
Clinical Issues
• Hypertension, Hypotension
• Congestive Heart Failure
• Cellulitis
Management Tips
• Turn patient to left side to evaluate heart sounds on
the left lateral chest wall
• Use aortic or pulmonic areas to right and left of
sternal border of the chest for best results
Skin
Clinical Issues
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Turning and positioning is difficult
Moist conditions foster the growth of yeast and fungus
Increased pressure and friction within the skin
Surgical wounds are prone to dehiscence
Blood supply to adipose tissue is poor
Tubes and catheters cause areas of pressure
Improper size equipment causes areas of pressure
Poor thermoregulation
- Potential dehydration resulting from increased perspiration
Skin
Management Tips
• Exposing the entire body is required to identify skin
breakdown, bleeding, rashes or source of odor
• Carefully assess areas of skin on skin under
breasts, abdominal fold, back fold and
perineal area
• Keep skin folds clean and dry, use powders,
talc, cornstarch or skin fold management
product to reduce friction and moisture
(Interdry)
• Sprinkle antifungal products as needed
• Change linen/gowns frequently.
Skin
Management Tips
• Provide proper size equipment which allows for
turning, repositioning and pressure redistribution
• Reposition panniculus with side lying position
• Apply a binder to minimize
pressure on abdominal incisions
• Add extension tubing
• Utilize tube and catheter holders
• Float heels on appropriate device
Gastro Intestinal
Clinical Issues
• Chronic constipation and/or incontinence
may result from a reluctance to ambulate
• Increased insulin resistance
• Increased abdominal pressure may cause
– Gastroesophageal reflux (GERD)
– Hiatal hernia
– Risk for aspiration
Gastro Intestinal
Management Tips
Provide proper equipment and opportunity
• Bowel sounds take longer to distinguish.
- Mark the location to maintain consistency among staff.
Document location and how long you listened.
• Girth measurement.
- Mark abdomen, leave cloth tape in place
• Colostomy care may require vendor support
• Provide right-size commode, incontinence
products and hygiene assistance
Urinary
Clinical Issues
• Functional incontinence and UTI
may result from a reluctance to
ambulate or lack of bariatric
equipment
• Stress incontinence is caused by
the large abdomen increasing
intraabdominal pressure
Urinary
Management Tips
• Encourage self toileting
• Ask about usual bowel and bladder routine
• Provide appropriate size commode chair,
incontinence products and hygiene assistance
including cleansers, barriers, hair dryer on cool
Catheter Insertion
Management Tips
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Gather appropriate supplies and adequate assistance
Lateral recumbent or supine position (female)
Drop one leg to side of bed or use lift to elevate leg
Approach from foot of bed
Add extension tubing and secure
Hang bag from foot board
Gynecological
Clinical Issues
• Most ignored assessment
– Most common diagnosis = deferred
– Embarrassing
– Limited hygiene
• Increased endometrial cancer in
obese women
Management Tips
• Gather appropriate supplies and adequate help
– Longer speculum
– Sit on metal bedpan
• Recommend pelvic floor relaxation
Nutrition
Clinical Issues
• Malnutrition, undernourished
• Lack essential nutrients necessary for healing
Management Tips
• Complete a comprehensive assessment of
nutritional status
– Diet history
– Evaluate lab data including serum albumin,
pre-albumin, lymphocyte
– Clinical examination
– Anthropometric measurement
Mobility
Clinical Issues
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Chronic back pain
Flattening of the arches of the feet
Abdominal girth may obstruct the patients view of their
feet, gait may be wide-based to accommodate a topheavy mass, thighs may position legs further apart
Transient parasthesias of the extremities may result
from positioning or bunched clothing
Sensory neuropathy and amputations
Mobility
Management Tips
• Good body mechanics is essential for staff safety
however it is no longer enough
• Interview patients about their normal level of activity
– Tolerance for standing and walking
– When was last time he or she walked
– Ambulation aids and toileting routines
• Assess strength, movement and
endurance of all extremities prior
to activity
Mobility
Note:
• Common and predictable complications related to
obesity may result from caregivers inability to transfer
and mobilize patients.
• An inadequately trained staff
results in patient isolation
Mobility
Management Tips
• Provide the proper size bed and mattress
– Lock wheels, position bed against the wall
– Raise bed to the highest setting to push
– Trapeze allows the resident to assist
– Trendelenburg facilitates boosting
– Reverse Trendelenburg facilitates breathing
– Scale weighs immobile patient
• Emergency preparedness plan must include evacuation
of extended capacity equipment
Mobility
Management Tips
• Provide the proper size and type of
lift and sling
• Lifting requires a unique approach
to protect the patient and reduce
worker injury
Key
Bed
Lift
Commode
Transfer Devices
Pharmacology
Clinical Issues
• Altered absorption of medication
• Drug levels may be subtherapeutic or toxic
Management Tips
• Obtain accurate weight on admission
• Consult with pharmacist to verify dosing and
administration routes are safe and effective
• Calculate dosage by :
– Actual Body Weight for meds highly soluble in fat
(opiates, analgesics)
– Ideal Body Weight for meds distributed in lean tissue
(acetaminophen, digoxin)
Medication Administration
Clinical Issues
• Oral meds rely on normal pH for proper absorption,
obesity encourages lower gastric pH
• Topical meds-cutaneous tissue is not well vascularized
• Subcutaneous injection may be inappropriate due to
low vascularization
• Skin patches-cutaneous tissue is not well perfused
• IM administration may be difficult to access
– delayed onset
– accumulation causes overdose
• IV access may be difficult as veins are deep
Medication Administration
Management Tips
• Assess dosages and administration routes
• Monitor effectiveness of weight calculated
dosages to ensure therapeutic effect
• Oral/topical meds doses may need to be
increased or given more frequently
• IM – use longer needles and whatever
muscle is closest to surface.
• Peripherally inserted central catheter (PICC) if peripheral
access is limited / long term
• Epidural drug absorption is uniform
Glucose
All obese patients have some degree of glucose
intolerance which predisposes them to hyperglycemia
• Check glucose on all ill or dehydrated obese patients
or any who report “thirst”, “fatigue”, “weakness”,
increased urination”
Motion Related Incidents
Every preventive effort should be made to avoid falling or
taking a position on the floor. If an incident should occur,
getting up must be done without injury to the staff and patient.
• Bring a footstool or solid chair close
at hand as a balance point or resting
spot for the patient
• Use a strong chair behind the
shoulders to tilt into a sitting position
• Use a mechanical lift or blankets and
adequate help to lift
- Continue nursing care
• Call Emergency Services as needed
• Implement your Performance Improvement Process
Restraints
Obese patients suffer more pain and disability from positions
of restraint
• Adjust knee gatch to lessen
strain on knees and prevent
sliding downward
• Maintain high Fowlers
Position to maximize
respiratory efficiency
• Offer Range of Motion
exercise
• Facilitate early restraint release
A Model for Success
How do you increase bariatric census while cost effectively
providing safe, quality care for this population of size?
Your facility must become the Community Bariatric resource
including solutions for:
- Transport and transfer
- Emergency assistance for unplanned transfer
- Radiology services (Xray, CT, MRI, Ultrasound)
- Funeral Services
- Support and advocacy groups
Transport and Transfer
Features of an ambulance specially designed to safely
transport bariatric residents include:
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EC box type resident compartment
1000 # capacity
Gurney with hydraulic lift
Aluminum rear loading ramps
Winch system
Contacts:
American Medical Response www.amr-inc.com
“Build Your Own Bariatric Unit” www.swambulance.com
Emergency Assistance
Firefighters are perceived as “specially trained in rescue”
Specialized lifting teams
have been implemented in
emergency rescue.
Radiology Services
Standard imaging methods (X-rays, Ultrasound, CT Scan, MRI)
cannot penetrate excessive fat, inhibiting diagnosis and
treatment of the “technically difficult resident”.
Proper diagnosis may be
inconclusive and treatment
is compromised because
of obesity
New York – Bronx Zoo receives
dozens of calls requesting use of
their large animal MRI
Resource: www.usa.siemens.com
Funeral Services
“ 300lb plus bodies are becoming common and moving
them is a danger to employees. A funeral director recently
incurred a back injury and was out of work for a month after
an abortive attempt to move an obese corpse”.
Science Daily Oct 2005
“Morticians are forced to
purchase wider work tables, plus
size caskets and vaults to place
into larger cemetery plots.”
Standard weight capacity for
caskets is 300 lbs.
Resources
• Goliathcaskets.com
• HillRom/Dimensions.com End of Life Solutions
Goliath Caskets specializes in up to
1000lb capacity (52 inches in width)
Funeral Services
Body Size and levels of body fat have considerable
effects on the operation of cremation equipment.
Standard weight capacity is 300lbs. Cremation of
heavy human remains requires:
• Larger capacity chamber with an adequate opening.
• Special positioning.
• Additional monitoring.
• Longer processing.
Resources: www.cremationassociation.org
Facility Preparation
Facility Preparation
Facility Preparation
Facility Preparation
Facility Preparation
Facility Preparation
Case Study
A case study is used to illustrate the unique challenges of
bariatric care and encourage discussion about predicting and
planning for the admission of an obese patient.
Sonia is an alert 54 year old female who
lived at home with her husband until she
fell and fractured her left hip. Hip surgery
(ORIF) was performed; during her hospital
stay she developed a urinary track
infection UTI) and 2 pressure ulcers; a
Stage IV on her coccyx and Stage II on
right heel.
Case Study
Sonia’s diabetes, COPD and diabetics are controlled by
oral medications however her respiratory symptoms have
worsened as a result of her immobility. Her left hip incision
is infected.
Height: 4 ft 10 in
Weight: 295 lbs
BMI: 61
Waist Circumference: 56
Vital Signs
Temperature 99.3
Pulse 98
Respirations 80
BP 188/130
Admitting Diagnosis
Admitting Diagnosis:
- Post Left Hip Fracture
- Respiratory Disease(COPD)
- Diabetes
- Pressure Ulcers
- Urinary Track Infection(UTI)
- Dehydration
- Pressure Ulcers
- Hypertension
- Arthritis
Admission Assessment
Respiratory: Breath sounds diminished, dyspnea
Skin:
Moist and diaphoretic
Non healing pressure ulcers Stage IV coccyx, Stage II R heel
Infected L hip incision open and draining
Edema: R and L feet and lower legs
Elimination:
Urge and Stress Incontinence, painful urination
Constipation, last BM 12 days ago
Abdomen distended
Pain:
L hip and L knee
Back
All major joints
Pain scale 8-9
Pain scale 6
Pain scale 6
Comments
Sonia is uncooperative with
transferring and repositioning
due to her pain. Her long
hospital stay and immobility
have left her very weak and
fearful of falling. The Stage IV
pressure ulcer on her coccyx
has heavy drainage and
undermining.
Physician’s Orders
- Maintain hip precautions
- Full weight bearing status
- Out of bed
- Turn and reposition q2h
- Mattress per protocol
- No concentrated sweets
- Encourage fluids
- Weigh weekly
- BP and pulse qd
- Pulse Oximetry q week and prn,
-O2 to maintain SAT 90%
- Obtain BS qd, notify physician if
- DiaBeta 1.25mg po qd
- Cover L hip incision c border gauze and
monitor for s/s of infection. Change qd/pm
- Initiate Negative Pressure Wound Therapy
(NPWT) to coccyx wound per protocol
- Apply Hydrocolloid to R heel pressure ulcers,
change q4d/prn
- Generic antibiotic 500mg po qd
- Lasix 40mg qd po
- Benicar 20mg qd po
- Demerol 100mg IM q 6h
- Tylenol #3 po q6h prn for pain
- Prednisone 10mg po qd
- Ducolax (1) po hs prn
BS is >160
Identify unique supplies, equipment and staff training necessary for
Sonia’s care
Pre-Admission Assessment
On-line Education Programs
RecoverCare offers
continuing education
(CEU’s) from the
convenience of your
own computer.
Visit us at:
www.stenbarr.com/sbu.asp
Practical Aspects of
Bariatric Care
Thank You
Please complete your Program Evaluation
Carolyn Brown M.Ed., RN, ARM,FCCWS
National Director of Clinical Services - RecoverCare
[email protected]
14350 Carlson Circle Tampa, Florida 33626