OBESITY: Caring for the Patient of Size

2. OBESITY: Caring for the Patient of Size Denise Rivera, MSN, RN-BC, CBN

3. Definitions 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)

5. Obesity Trends* Among U.S. AdultsBRFSS,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%

6. Obesity Trends In 2009-2010: • 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

7. Iredell County

8. Causes of Obesity Multifactoral • Biological/Genetic • Environmental • Socioeconomic • Behavioral • Cultural background

9. Consequences of Obesity

10. Bariatric Sensitivity • Language • Avoid identifications that indicate obesity to others • Equipment / Furniture • Sturdiness • Weight limits • Width • Space • Temperature • Accommodation

11. Nursing Care Consideration Mobility/Transfer • Assess patients functional status • Appropriate equipment • Weight limits • Width dimensions • Know how to use • Appropriate assistance • Always use the appropriate number of people • Door Frames Proper body mechanics for both patient and caregiver essential to avoid injury.

12. Nursing Care Consideration Medications • 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.

13. Medications • 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

14. Nursing Care Consideration 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 • Skin at a higher risk for breakdown due to moisture, friction, decrease perfusion.

15. Nursing Care Consideration Nutrition • Overweight does not mean well nourished • Comprehensive assessment • Lab values • Food preferences • Food diaries • Supplements Psychological • Coping mechanisms

16. Nursing Care Consideration 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.

17. The Hospitalized Patient 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

18. The Hospitalized Patient Increase risk • Respiratory complications • Structural and functional change • Length of time under anesthesia • Narcotic use Treatment • Incentive Spirometer • Coughing & deep breathing • Supplemental oxygen • CPAP

19. The Hospitalized Patient Increased risk • Skin Breakdown/Wound Healing • Moisture • Friction • Cormorbidities • Treatment • Thorough skin assessments every shift • Meticulous skin care/wound care • Pressure relief • Maintain glucose control

20. Weight Loss Surgery • 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

21. Commonalities of all WLS • 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 • 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

22. Nursing Care Consideration after WLS 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

23. Summary • Obesity is a chronic disease • You will care for a patient of size • Nurses should be sensitive to the unique needs of the bariatric population • All patients deserve nondiscriminatory, appropriate treatment and care

24. Critical Thinking 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 • 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.

25. Critical Thinking 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 • Tell the transporter to be carful • Instruct the transported to obtain an extended capacity wheelchair • Cancel the x-ray

26. Critical Thinking 3. To avoid a delay in transporting Mrs. Jones, the best course of action would be to • 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.

27. Critical Thinking 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 • 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.

28. Answers 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.

29. Resources 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