Management of the Obese Population - A Person Centered Care ...Presentation Transcript
Presented by: Carolyn Brown, M.Ed, RN, ARM, FCCWS National Director of Clinical Services C-3 Management of the Obese Population A Person Centered Care Approach
After attending this program the participant will be able to:
Define obesity and calculate Body Mass Index (BMI).
Discuss prevalence of obesity.
Identify unique and predictable clinical issues resulting from obesity and discuss assessment techniques for each.
Identify community resources to support bariatric care.
Review case study and identify appropriate supply and equipment needs.
A life-long, progressive, life threatening, costly, genetically-related, multi-factorial disease of excess fat storage.
Obesity Resource: American Society of Bariatric Surgery Bariatric (Greek) The practice of health care related to the treatment of obesity and associated conditions.
Body Mass Index (BMI) of 30 or greater
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 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. Would waist circumference support the customer’s decision to rent or purchase!!!
Men > 40 inches
Women > 35 inches
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) 1991 2000 1995 No Data <10% 10%-14% 15-19% 20-24% 25% 2005
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 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
Lost time claims
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
Degenerative and arthritic discs, out of shape, overweight, poor posture
Obese patients have increased in number and are sicker.
Provide quality care
Prevent injury to patient and staff
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”
Scenario Sten+Barr Medical Inc.
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
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
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
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.
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
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
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
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.
Evaluate the weight capacity of your scale
Utilize a bariatric bed with a scale for mobility challenged
Protect the patients dignity when recording weight
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
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 O 2 saturation frequently
Position shoulders and neck as needed
Maintain bed in reverse Trendelenburg’s position to facilitate lung expansion
Provide specific Heimlich training
Congestive Heart Failure
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
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
- Potential dehydration resulting from increased perspiration
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.
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
Chronic constipation and/or incontinence may result from a reluctance to ambulate
Increased insulin resistance
Increased abdominal pressure may cause
Gastroesophageal reflux (GERD)
Risk for aspiration
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.
- Mark abdomen, leave cloth tape in place
Colostomy care may require vendor support
Provide right-size commode, incontinence products and hygiene assistance
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
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
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
Most ignored assessment
Most common diagnosis = deferred
Increased endometrial cancer in obese women
Gather appropriate supplies and adequate help
Sit on metal bedpan
Recommend pelvic floor relaxation
Lack essential nutrients necessary for healing
Complete a comprehensive assessment of nutritional status
Evaluate lab data including serum albumin, pre-albumin, lymphocyte
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
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
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
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
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
Altered absorption of medication
Drug levels may be subtherapeutic or toxic
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)
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
accumulation causes overdose
IV access may be difficult as veins are deep
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
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”
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
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 - 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:
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
Transport and Transfer Contacts: American Medical Response www.amr-inc.com “ Build Your Own Bariatric Unit” www.swambulance.com
Firefighters are perceived as “specially trained in rescue”
Emergency Assistance Specialized lifting teams have been implemented in emergency rescue.
Standard imaging methods (X-rays, Ultrasound, CT Scan, MRI) cannot penetrate excessive fat, inhibiting diagnosis and treatment of the “technically difficult resident”.
Radiology Services 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
“ Morticians are forced to purchase wider work tables, plus size caskets and vaults to place into larger cemetery plots.”
Funeral Services 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)
HillRom/Dimensions.com End of Life Solutions
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:
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 lbs BMI: 61 Waist Circumference: 56 Vital Signs Temperature 99.3 Pulse 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 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 Pain scale 8-9 Back Pain scale 6 All 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,
O 2 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
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,FCCWS National Director of Clinical Services - RecoverCare [email_address] 14350 Carlson Circle Tampa, Florida 33626