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Presented by:
Carolyn Brown, M.Ed, RN, ARM, FCCWSNational Director of Clinical Services
C-3 Management of the Obese PopulationA Person Centered Care Approach
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.
Learner Objectives
A life-long, progressive, life threatening, costly, genetically-related, multi-factorial disease of excess fat storage.
Resource: American Society of Bariatric Surgery
Obesity
Bariatric (Greek)The practice of health care related to the treatment of obesity and associated conditions.
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
Who Is Obese
Body Mass Index (BMI)
Central ObesityWaist 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.
Would waist circumference support the customer’s decision to rent or purchase!!!
• Men > 40 inches
• Women > 35 inches
Obesity Trends* Among U.S. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 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)
1991
2000
1995
2005
No Data <10% 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
• 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
A Changing Society
The year 2006 was important for obesity according to a report published by the Center for Disease Control and Prevention (CDC).
Obesity Update
• 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.
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
Musculoskeletal Disorders
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.
Cumulative Trauma Disorder
Overexerting the spine may result from:
Safe Patient Handling
• Lifting improperly• Lifting weight beyond a
safe lifting capacity• Working in a “bent over”
position
Benefits include and increase in patient satisfaction and mobility and a decrease in:
Safe Patient Handling
• Workers comp costs• Staff/patient injury• Lost time claims• Staff turnover• New employee training costs
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.
Scenario
• Aging Workforce
Degenerative and arthritic discs, out of shape, overweight, poor posture
• Obese patients have increased in number and are sicker.
Risk Factors
• Provide quality care• Prevent injury to patient and staff• Minimize costs
The Unique Challenge
Medical community is challenged to:
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
Stereotyping
Resource: National Institute of Health
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.
Scenario
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.
Bariatric Geriatric
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
General Management Tips
All patients deserve competent, professional care. Negative perceptions about obesity can affect the caregivers approach to caring for the bariatric patient.
Sensitivity and Respect
• Make eye contact, call patient by name
• Ask the patient how to best assist them
• Provide adequate privacy and space
• Vital Signs• Weight• Respiratory• Circulation• Skin• Gastrointestinal, Urinary• Nutrition• Mobility• Pharmacology• Medication Administration
Bariatric Assessment
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.
Vital Signs
• Will have changes in mental status, lab values when experiencing respiratory difficulty.
• Reverse Trendelenburg position may facilitate lung expansion.
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
Vital Signs
– Observe cough and changes of mental status during assessment
Blood Pressure Equipment• A standard-sized blood pressure cuff should not be used on an
upper arm circumference of more than 13 inches.
Vital Signs
• 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
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
Vital Signs
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
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)
Respiratory
• 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
Management Tips• Identify a rescue/alternative airway management plan• Identify and maintain extra size supplies
– 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
Respiratory
Clinical Issues• Hypertension, Hypotension• Congestive Heart Failure• Cellulitis
Management Tips
Circulation
• 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
Clinical Issues
• 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
Skin
• 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.
Management Tips
Skin
• 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
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
Gastro Intestinal
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
Urinary
Management Tips• 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
Catheter Insertion
Clinical Issues • Most ignored assessment
– Most common diagnosis = deferred– Embarrassing– Limited hygiene
• Increased endometrial cancer in obese women
Gynecological
Management Tips• Gather appropriate supplies and adequate help
– Longer speculum– Sit on metal bedpan
• Recommend pelvic floor relaxation
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
Nutrition
Clinical Issues• 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 top-heavy 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
Mobility
– 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
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
Mobility
• Emergency preparedness plan must include evacuation of extended capacity equipment
MobilityManagement 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
Commode
Lift
Transfer Devices
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)
Pharmacology
Clinical Issues • Oral meds rely on normal pH for proper absorption,
obesity encourages lower gastric pH
Medication Administration
• 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
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.
Medication Administration
• Peripherally inserted central catheter (PICC) if peripheral access is limited / long term
• Epidural drug absorption is uniform
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”
Glucose
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.
Motion Related Incidents
• 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
Obese patients suffer more pain and disability from positions of restraint
Restraints
• 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
- Transport and transfer
- Emergency assistance for unplanned transfer
- Radiology services (Xray, CT, MRI, Ultrasound)
- Funeral Services
- Support and advocacy groups
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:
A Model for Success
Features of an ambulance specially designed to safely transport bariatric residents include:
– 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
Transport and Transfer
Firefighters are perceived as “specially trained in rescue”
Specialized lifting teams have been implemented in emergency rescue.
Emergency Assistance
Standard imaging methods (X-rays, Ultrasound, CT Scan, MRI) cannot penetrate excessive fat, inhibiting diagnosis and treatment of the “technically difficult resident”.
Resource: www.usa.siemens.com
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
Radiology Services
“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.
“ 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
Goliath Caskets specializes in up to 1000lb capacity (52 inches in width)
Resources• Goliathcaskets.com• HillRom/Dimensions.com End of Life Solutions
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:
Resources: www.cremationassociation.org
• Larger capacity chamber with an adequate opening.• Special positioning.• Additional monitoring.• Longer processing.
Funeral Services
Facility Preparation
Facility Preparation
Facility Preparation
Facility Preparation
Facility Preparation
Facility Preparation
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.
Case Study
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.
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.
Case Study
Height: 4 ft 10 in Weight: 295 lbsBMI: 61
Waist Circumference: 56Vital Signs
Temperature 99.3Pulse 98 Respirations 80 BP 188/130
Admitting Diagnosis: - Post Left Hip Fracture- Respiratory Disease(COPD) - Diabetes- Pressure Ulcers - Urinary Track Infection(UTI)- Dehydration- Pressure Ulcers- Hypertension- Arthritis
Admitting Diagnosis
Respiratory: Breath sounds diminished, dyspnea
Skin: Moist and diaphoreticNon healing pressure ulcers Stage IV coccyx, Stage II R heelInfected L hip incision open and drainingEdema: R and L feet and lower legs
Elimination: Urge and Stress Incontinence, painful urinationConstipation, last BM 12 days agoAbdomen distended
Pain: L hip and L knee Pain scale 8-9
Back Pain scale 6All major joints Pain scale 6
Admission Assessment
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.
Comments
- 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 BS is >160
- 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
Physician’s Orders
Identify unique supplies, equipment and staff training necessary for Sonia’s care
Pre-Admission Assessment
RecoverCare offers continuing education (CEU’s) from the convenience of your own computer.
Visit us at:
www.stenbarr.com/sbu.asp
On-line Education Programs
Practical Aspects of Bariatric Care
Please complete your Program Evaluation
Thank You
Carolyn Brown M.Ed., RN, ARM,FCCWSNational Director of Clinical Services - [email protected]
14350 Carlson Circle Tampa, Florida 33626