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  1. 1. Focus on Obesity (Relates to Chapter 41, “Nursing Management: Obesity,” in the textbook)
  2. 2. Obesity and Overweight <ul><li>Imbalance between energy expenditure and energy intake from a long-term sedentary lifestyle and/or excessive calorie intake </li></ul><ul><li>Obesity is an abnormal increase in the proportion of fat cells </li></ul>
  3. 3. Obesity and Overweight <ul><li>Primarily occurs in the visceral and subcutaneous tissues of the body </li></ul>
  4. 4. Obesity and Overweight <ul><li>Weight gain in adulthood is characterized predominantly by adipocyte hypertrophy </li></ul><ul><ul><li>Adipocyte hypertrophy is a process by which adipocytes can increase their volume several thousandfold to accommodate large increase in lipid storage </li></ul></ul>
  5. 5. Obesity <ul><li>Has reached epidemic proportions in developed and nondeveloped countries </li></ul><ul><li>In the United States </li></ul><ul><ul><li>Most common nutritional problem </li></ul></ul><ul><ul><li>Affects one third of the population </li></ul></ul>
  6. 6. Obesity <ul><li>Second leading cause of preventable death </li></ul><ul><li>Third leading reason for liver transplantation </li></ul>
  7. 7. Etiology and Pathophysiology <ul><li>Energy intake exceeds energy output </li></ul><ul><li>Processes leading to obesity are much more complex and still undergoing investigation </li></ul>
  8. 8. Etiology and Pathophysiology <ul><li>Cause involves significant genetic/biologic susceptibility factors that are ↑ influenced by environment and psychosocial factors </li></ul><ul><li>Caloric consumption must exceed energy expenditure for condition to continue </li></ul>
  9. 9. Genetic/Biologic Basis <ul><li>Strong evidence of genetic predisposition </li></ul>
  10. 10. Genetic/Biologic Basis <ul><li>Most common form considered to be polygenic, arising from the interaction of multiple genetic and environmental factors </li></ul><ul><ul><li>Identifying these genes will lead to a better understanding of the pathogenesis </li></ul></ul>
  11. 11. Genetic/Biologic Basis <ul><li>Appetite is influenced by many factors that are integrated by the brain </li></ul><ul><ul><li>Most importantly, the hypothalamus </li></ul></ul><ul><li>Input to the hypothalamus is received from the periphery from many different hormones and peptides </li></ul>
  12. 12. Hormones & Peptides that Interact with Hypothalamus to Effect Obesity <ul><li>Fig. 41-3 </li></ul>
  13. 13. Genetic/Biologic Basis <ul><li>Associated with ↑ circulating plasma levels of leptin, insulin, and ghrelin, and ↓ levels of peptide YY </li></ul><ul><li>Adipocytes secrete a number of hormones and cytokines known as adipokines </li></ul>
  14. 14. Environmental Factors <ul><li>Greater access to food </li></ul><ul><ul><li>Prepackaged food </li></ul></ul><ul><ul><li>Fast food </li></ul></ul><ul><ul><li>Soft drinks </li></ul></ul><ul><ul><li>Increased portion sizes </li></ul></ul><ul><li>Obese individuals tend to underestimate food and caloric intake </li></ul>
  15. 15. Environmental Factors <ul><li>Lack of physical exercise </li></ul><ul><ul><li>Decreased at home and work </li></ul></ul><ul><ul><li>Advances in technology and labor-saving devices </li></ul></ul><ul><ul><li>Increased time watching television and playing video games </li></ul></ul>
  16. 16. Psychosocial Factors <ul><li>Emotional component to overeat is powerful </li></ul><ul><li>People use food for many reasons </li></ul><ul><li>Social component of eating is developed early in life </li></ul><ul><ul><li>Birthday parties, holidays </li></ul></ul>
  17. 17. Classification of Body Weight and Obesity <ul><li>Primary obesity ( majority of obese ) </li></ul><ul><ul><li>Excess caloric intake for the body’s metabolic demands </li></ul></ul><ul><li>Secondary obesity </li></ul><ul><ul><li>Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders </li></ul></ul>
  18. 18. Classification of Body Weight and Obesity <ul><li>Body mass index </li></ul><ul><ul><li>Degree to which a patient is classified as underweight, healthy (normal) weight, overweight, or obese </li></ul></ul><ul><ul><li>Common clinical index of obesity or altered body fat distribution </li></ul></ul><ul><ul><li>Uses weight-to-height ratios </li></ul></ul>
  19. 19. Body Mass Index <ul><li>Fig. 41-4 </li></ul>
  20. 20. Classification of Body Weight and Obesity <ul><li>Waist-to-hip ratio (WHR) </li></ul><ul><ul><li>Weight circumference is another way to assess and classify weight </li></ul></ul><ul><ul><li>Method of describing distribution of subcutaneous and visceral adipose tissue </li></ul></ul><ul><ul><li>Waist measurement/hip measurement = ratio </li></ul></ul><ul><ul><li>WHR <0.80 is optimal </li></ul></ul>
  21. 21. Classification of Body Weight and Obesity <ul><li>Waist-to-hip ratio (WHR) (cont’d) </li></ul><ul><ul><li>WHR >0.80 indicates greater risk for health complications </li></ul></ul><ul><ul><li>People with more visceral fat are at an increased risk for cardiovascular disease and metabolic syndrome </li></ul></ul><ul><ul><li>Preferred tool when patient is predominantly muscular </li></ul></ul>
  22. 22. Classification of Body Weight and Obesity <ul><li>By body shape or fat distribution </li></ul><ul><ul><li>Apple-shaped body </li></ul></ul><ul><ul><ul><li>Fat located primarily in the abdominal area </li></ul></ul></ul><ul><ul><ul><li>At greater risk for obesity-related complications </li></ul></ul></ul><ul><ul><ul><li>Android obesity </li></ul></ul></ul><ul><ul><li>Pear-shaped body </li></ul></ul><ul><ul><ul><li>Fat located primarily in upper legs </li></ul></ul></ul><ul><ul><ul><li>Gynoid obesity </li></ul></ul></ul>
  23. 23. Classification of Body Shapes <ul><li>Fig. 41-5 </li></ul>
  24. 24. Common Fat Distribution <ul><li>Fig. 41-1 </li></ul>
  25. 25. Health Risks Associated with Obesity <ul><li>Problems occur at higher rates for obese patients </li></ul><ul><li>Mortality rate rises as obesity increases </li></ul><ul><ul><li>Especially with increased visceral fat </li></ul></ul><ul><li>Obese patients have a decreased quality of life </li></ul><ul><li>Most conditions improve with weight loss </li></ul>
  26. 26. Health Risks Associated with Obesity <ul><li>Fig. 41-6 </li></ul>
  27. 27. Cardiovascular Problems <ul><li>Obesity is a significant risk factor for predicting cardiovascular disease </li></ul><ul><li>WHR is best predictor of risk </li></ul><ul><ul><li>Android obesity patients at greater risk </li></ul></ul>
  28. 28. Cardiovascular Problems <ul><li>Risks </li></ul><ul><ul><li>↑ Low-density lipoproteins (LDLs) </li></ul></ul><ul><ul><li>↑ Triglycerides </li></ul></ul><ul><ul><li>↓ High-density lipoproteins (HDLs) </li></ul></ul>
  29. 29. Cardiovascular Problems <ul><li>Risks (cont’d) </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><ul><li>↑ Circulating blood volume </li></ul></ul></ul><ul><ul><ul><li>Abnormal vasoconstriction </li></ul></ul></ul><ul><ul><ul><li>↓ Vascular relaxation </li></ul></ul></ul><ul><ul><ul><li>↑ Cardiac output </li></ul></ul></ul>
  30. 30. Cardiovascular Problems <ul><li>Larger cuff to avoid artifactual ↑ may be needed when taking blood pressure </li></ul>
  31. 31. Respiratory Problems <ul><li>Severe obesity may be associated with </li></ul><ul><ul><li>Sleep apnea </li></ul></ul><ul><ul><li>Obesity hypoventilation syndrome </li></ul></ul><ul><ul><li>↓ Chest wall compliance </li></ul></ul><ul><ul><li>↑ Work of breathing </li></ul></ul><ul><ul><li>↓ Total lung capacity and functional residual capacity </li></ul></ul>
  32. 32. Diabetes Mellitus <ul><li>Hyperinsulinemia </li></ul><ul><li>Insulin resistance </li></ul><ul><li>Type 2 diabetes </li></ul><ul><ul><li>80% of patients with type 2 diabetes are obese </li></ul></ul><ul><li>Weight loss and exercise improve glucose control </li></ul>
  33. 33. Musculoskeletal Problems <ul><li>Osteoarthritis </li></ul><ul><ul><li>Trauma to weight-bearing joints </li></ul></ul><ul><li>Hyperuricemia </li></ul><ul><li>Gout </li></ul>
  34. 34. Gastrointestinal and Liver Problems <ul><li>Gastroesophageal reflux disease (GERD) </li></ul><ul><li>Gallstones </li></ul><ul><li>Nonalcoholic steatohepatitis (NASH) </li></ul><ul><ul><li>Can eventually lead to cirrhosis </li></ul></ul><ul><ul><li>Weight loss can improve NASH </li></ul></ul>
  35. 35. Cancer <ul><li>Obesity is one of the most important known preventable causes of cancer </li></ul><ul><ul><li>Women </li></ul></ul><ul><ul><ul><li>Breast, endometrial, ovarian, cervical </li></ul></ul></ul><ul><ul><ul><li>Possibly from ↑ estrogen postmenopause </li></ul></ul></ul><ul><ul><li>Men </li></ul></ul><ul><ul><ul><li>Prostate </li></ul></ul></ul><ul><ul><li>Both genders: Colon </li></ul></ul>
  36. 36. Nursing Assessment <ul><li>Patient may withhold information out of embarrassment or shyness </li></ul><ul><li>Provide acceptable reasons for personally intrusive questions </li></ul><ul><li>Respond to concerns about diagnostic tests </li></ul><ul><li>Interpret outcomes </li></ul>
  37. 37. Nursing Assessment <ul><li>Health history </li></ul><ul><ul><li>Time of obesity onset </li></ul></ul><ul><ul><li>Diseases related to metabolism and obesity </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Objective </li></ul></ul><ul><ul><ul><li>Height, weight, BMI, skinfold thickness, waist circumference </li></ul></ul></ul>
  38. 38. Nursing Assessment <ul><li>Health history (cont’d) </li></ul><ul><ul><li>History with weight gain/weight loss </li></ul></ul><ul><ul><li>Interested in losing weight </li></ul></ul><ul><ul><li>Contributors to weight gain </li></ul></ul><ul><ul><li>What impedes weight loss </li></ul></ul>
  39. 39. Nursing Assessment <ul><li>Health history (cont’d) </li></ul><ul><ul><li>How patient uses food (e.g., to relieve stress, provide comfort) </li></ul></ul><ul><ul><li>Other overweight family members </li></ul></ul><ul><ul><li>Environmental or genetic factors influencing weight gain </li></ul></ul>
  40. 40. Nursing Diagnoses <ul><li>Imbalanced nutrition: More than body requirements </li></ul><ul><li>Impaired skin integrity </li></ul><ul><li>Ineffective breathing pattern </li></ul><ul><li>Chronic low self-esteem </li></ul><ul><li>Health-seeking behaviors </li></ul>
  41. 41. Planning <ul><li>Modify eating patterns </li></ul><ul><li>Participate in a regular physical activity program </li></ul><ul><li>Achieve weight loss to a specified level </li></ul><ul><li>Maintain weight loss at a specified level </li></ul><ul><li>Minimize or prevent health problems related to obesity </li></ul>
  42. 42. Nursing Implementation <ul><li>When no organic cause can be found for obesity, it should be considered a chronic, complex disease </li></ul><ul><li>Supervise a plan </li></ul><ul><ul><li>Successful weight loss, requiring a short-term energy deficit </li></ul></ul><ul><ul><li>Successful weight control, requiring long-term behavior changes </li></ul></ul>
  43. 43. Nursing Implementation <ul><li>Multipronged approach ought to be used with attention to multiple factors </li></ul><ul><ul><li>Dietary intake, physical activity, behavior modification, and/or drug therapy </li></ul></ul><ul><li>All opportunities for patient education should stress healthy eating and exercise </li></ul>
  44. 44. Nursing Implementation <ul><li>Motivation is essential to weight loss </li></ul><ul><li>Set a realistic and healthy goal for weight loss </li></ul><ul><li>1 to 2 pounds per week </li></ul><ul><li>Slower weight loss offers better cosmetic results </li></ul>
  45. 45. Nursing Implementation <ul><li>Plateaus can last from several days to several weeks </li></ul><ul><li>Daily weighing is not recommended </li></ul><ul><li>Weigh once a week with similar clothing, at the same time of day </li></ul>
  46. 46. Nutritional Therapy <ul><li>Restricted food intake is a cornerstone </li></ul><ul><li>A good weight loss plan contains food from the basic food groups </li></ul><ul><li>Diet classifications </li></ul><ul><ul><li>800 to 1200 calories: Low calorie </li></ul></ul><ul><ul><li><800 calories: Very low calorie </li></ul></ul>
  47. 47. Nutritional Therapy <ul><li>Adequate amounts of </li></ul><ul><ul><li>Fruits and vegetables </li></ul></ul><ul><ul><li>Lean meat, fish, and eggs </li></ul></ul><ul><li>Fad diets should be discouraged </li></ul><ul><ul><li>Often body water is lost and not fat </li></ul></ul>
  48. 48. Nutritional Therapy <ul><li>Need to consider the proportion of calories from animal sources and calories from fruits, grains, and vegetables </li></ul><ul><ul><li>American Institute for Cancer Research </li></ul></ul><ul><ul><ul><li>2/3 of the diet should be plant-source </li></ul></ul></ul><ul><ul><ul><li>1/3 or less from animal protein </li></ul></ul></ul>
  49. 49. Nutritional Therapy Table 41-8
  50. 50. Nutritional Therapy <ul><li>Food portion sizes </li></ul><ul><ul><li>Serving of fruit and vegetables </li></ul></ul><ul><ul><ul><li>Size of woman’s fist or baseball </li></ul></ul></ul><ul><ul><li>Serving of meat </li></ul></ul><ul><ul><ul><li>Human’s palm or a deck or cards </li></ul></ul></ul><ul><ul><li>Serving of cheese </li></ul></ul><ul><ul><ul><li>Size of a thumb or six dice </li></ul></ul></ul>
  51. 51. Exercise <ul><li>An essential part of a weight control program </li></ul><ul><li>Should be done daily for 30 minutes to an hour </li></ul><ul><li>Sensible forms of exercise should be encouraged </li></ul><ul><ul><li>Walking, swimming, cycling </li></ul></ul>
  52. 52. Behavior Modification <ul><li>Assumption behind behavior modification </li></ul><ul><ul><li>Learned disorder </li></ul></ul><ul><ul><li>Critical difference between an obese person and a nonobese person are cues that regulate eating behavior </li></ul></ul><ul><li>Goal is to deemphasize diet and focus of how and when a person eats </li></ul>
  53. 53. Behavior Modification <ul><li>Has been successful helping people maintain weight loss </li></ul><ul><li>Useful basic techniques </li></ul><ul><ul><li>Self-monitoring: Show what and when foods are eaten </li></ul></ul><ul><ul><li>Stimulus control: Separate events that trigger eating from the act of eating </li></ul></ul><ul><ul><li>Rewards: Incentives for weight loss </li></ul></ul>
  54. 54. Support Groups <ul><li>Encouragement can be offered to join a group of other obese persons who are receiving professional counseling to help modify eating habits </li></ul><ul><li>Many self-help groups are available </li></ul><ul><ul><li>Take Off Pounds Sensibly (TOPS) </li></ul></ul><ul><ul><li>Weight Watchers </li></ul></ul>
  55. 55. Drug Therapy <ul><li>Classified into two categories </li></ul><ul><ul><li>↓ Food intake by reducing appetite or increasing satiety </li></ul></ul><ul><ul><li>↓ Nutrient absorption </li></ul></ul><ul><li>Drugs that ↑ energy expenditure are not approved by the FDA </li></ul>
  56. 56. Drug Therapy <ul><li>Appetite-suppressing drugs </li></ul><ul><ul><li>Decrease food intake through nonadrenergic or serotonergic mechanisms in the central nervous system (CNS) </li></ul></ul><ul><ul><ul><li>Phentermine </li></ul></ul></ul><ul><ul><ul><li>Diethylpropion </li></ul></ul></ul><ul><ul><ul><li>Phendimetrazine </li></ul></ul></ul><ul><ul><li>Recommended for short-term use </li></ul></ul>
  57. 57. Drug Therapy <ul><li>Appetite-suppressing drugs (cont’d) </li></ul><ul><ul><li>Serotonergic drugs ↑ release of serotonin or ↓ its uptake thus ↓ metabolism </li></ul></ul><ul><ul><ul><li>fenfluramine (Pondimin) </li></ul></ul></ul><ul><ul><ul><li>dexfenfluramine (Redux) </li></ul></ul></ul><ul><ul><ul><li>Removed from market in 1997 </li></ul></ul></ul>
  58. 58. Drug Therapy <ul><li>Appetite-suppressing drugs (cont’d) </li></ul><ul><ul><li>Mixed nonadrenergic–serotonergic agents </li></ul></ul><ul><ul><ul><li>Do not stimulate release of serotonin </li></ul></ul></ul><ul><ul><ul><li>Sibutramine (Meridia) </li></ul></ul></ul>
  59. 59. Drug Therapy <ul><li>Nutrient absorption-blocking drugs </li></ul><ul><ul><li>Work by blocking fat breakdown and absorption in intestine </li></ul></ul><ul><ul><li>Inhibits action of intestinal lipases </li></ul></ul><ul><ul><li>Undigested fat is excreted in feces </li></ul></ul><ul><ul><ul><li>Orlistat (Xenical) </li></ul></ul></ul><ul><li>Purchasing over-the-counter drugs should be discouraged </li></ul>
  60. 60. Bariatric Surgery <ul><li>Used to treat morbid obesity </li></ul><ul><li>Currently the only treatment found to have a successful and lasting impact for sustained weight loss </li></ul>
  61. 61. Bariatric Surgery <ul><li>Must meet all of the following criteria to be considered an ideal candidate </li></ul><ul><ul><li>BMI ≥40 kg/m 2 with one or more obesity-related complication </li></ul></ul><ul><ul><li>18 years or older </li></ul></ul><ul><ul><li>Understands the risks and benefits </li></ul></ul><ul><ul><li>Has been obese for >5 years </li></ul></ul><ul><ul><li>Has tried and failed to lose weight </li></ul></ul>
  62. 62. Bariatric Surgery <ul><li>Criteria to be considered an ideal candidate (cont’d) </li></ul><ul><ul><li>Has no serious endocrine problems </li></ul></ul><ul><ul><li>Has psychiatric and social stability </li></ul></ul><ul><ul><li>Availability of a team of health care providers </li></ul></ul><ul><ul><li>Surgery would ↓ or eradicate high-risk conditions </li></ul></ul>
  63. 63. Bariatric Surgery <ul><li>Three broad categories </li></ul><ul><ul><li>Restrictive </li></ul></ul><ul><ul><li>Malabsorptive </li></ul></ul><ul><ul><li>Combination of restrictive and malabsorptive </li></ul></ul>
  64. 64. Restrictive Surgery <ul><li>Reduces the size of a stomach to 30 ml or less </li></ul><ul><li>Causes patient to feel full quicker </li></ul><ul><li>Normal stomach digestion and intestinal absorption of food </li></ul><ul><ul><li>↓ Risk of anemia and cobalamin deficiency </li></ul></ul>
  65. 65. Restrictive Surgery <ul><li>Vertical banded gastroplasty </li></ul><ul><ul><li>Partitions stomach into a small pouch in upper portion </li></ul></ul><ul><ul><li>Small pouch drastically limits capacity </li></ul></ul><ul><ul><li>Stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch </li></ul></ul>
  66. 66. Restrictive Surgery <ul><li>Fig. 41-7A </li></ul>
  67. 67. Restrictive Surgery <ul><li>Adjustable gastric banding (AGB) </li></ul><ul><ul><li>Also referred to as the LapBand </li></ul></ul><ul><ul><li>Stomach size is limited by an inflated band placed around fundus of stomach </li></ul></ul><ul><ul><li>Band is connected to a subcutaneous port </li></ul></ul><ul><ul><li>Can be inflated or deflated to change stoma size </li></ul></ul>
  68. 68. Restrictive Surgery <ul><li>AGB (cont’d) </li></ul><ul><ul><li>Can be done laparoscopically and can be modified or reversed </li></ul></ul><ul><ul><li>Better choice for patients who are surgical risks </li></ul></ul><ul><ul><li>Weight loss is slower than in other procedures </li></ul></ul>
  69. 69. Restrictive Surgery <ul><li>Fig. 41-7B </li></ul>
  70. 70. Malabsorptive Surgeries <ul><li>Biliopancreatic diversion (BPD) </li></ul><ul><ul><li>Removes ~3/4 of stomach to ↓ food intake and ↓ acid output </li></ul></ul><ul><ul><li>Remaining 1/4 of stomach is connected to lower portion of small intestine </li></ul></ul><ul><ul><li>Pancreatic enzymes and bile enter final segment of intestine </li></ul></ul><ul><ul><li>Nutrients pass without being digested </li></ul></ul>
  71. 71. Malabsorptive Surgeries <ul><li>Biliopancreatic diversion with duodenal switch </li></ul><ul><ul><li>Variation of BPD </li></ul></ul><ul><ul><li>By including duodenal switch, surgeons leave a larger portion of the stomach intact </li></ul></ul><ul><ul><li>Helps prevent dumping syndrome </li></ul></ul>
  72. 72. Restrictive Surgery <ul><li>Fig. 41-7C </li></ul>
  73. 73. Combination of Restrictive and Malabsorptive Surgery <ul><li>Roux-en- Y surgical procedure </li></ul><ul><ul><li>Has low complication rates </li></ul></ul><ul><ul><li>Excellent patient tolerance </li></ul></ul><ul><ul><li>Stomach size is ↓ with a gastric pouch anastomosis that empties directly into jejunum </li></ul></ul>
  74. 74. Combination of Restrictive and Malabsorptive Surgery <ul><li>Roux-en- Y surgery (cont’d) </li></ul><ul><ul><li>Variations </li></ul></ul><ul><ul><ul><li>Stapling stomach without transection to create a small 20- to 30-ml gastric pouch </li></ul></ul></ul><ul><ul><ul><li>Creating an upper and lower gastric pouch and totally disconnecting the pouches </li></ul></ul></ul><ul><ul><ul><li>Creating an upper gastric pouch and completely removing the lower pouch </li></ul></ul></ul>
  75. 75. Restrictive Surgery <ul><li>Fig. 41-7D </li></ul>
  76. 76. Cosmetic Surgeries <ul><li>Ideal candidates have </li></ul><ul><ul><li>Achieved weight reduction </li></ul></ul><ul><ul><li>Excess skinfolds or fat </li></ul></ul><ul><li>Chooses surgery for cosmetic reasons </li></ul><ul><ul><li>Lipectomy </li></ul></ul><ul><ul><li>Liposuction </li></ul></ul>
  77. 77. Preoperative Care <ul><li>Patients who are obese are likely to suffer other comorbidities, such as </li></ul><ul><ul><li>Diabetes, altered cardiorespiratory function, abnormal metabolic function, atherosclerosis </li></ul></ul><ul><li>A team approach may be necessary </li></ul><ul><ul><li>Cardiologist, pulmonologist, gynecologist, gastroenterologist, or other specialist </li></ul></ul>
  78. 78. Preoperative Care <ul><li>Have room ready for patient prior to arrival </li></ul><ul><ul><li>Larger size blood pressure cuff </li></ul></ul><ul><ul><li>Larger gown </li></ul></ul><ul><ul><li>Bariatric wheelchair </li></ul></ul><ul><ul><ul><li>Or a wheelchair with removable arms </li></ul></ul></ul><ul><ul><li>Strongly reinforced trapeze bar over bed for movement and positioning </li></ul></ul>
  79. 79. Preoperative Care <ul><li>Have room ready for patient prior to arrival (cont’d) </li></ul><ul><ul><li>It may be necessary to put beds together or specially construct a chair </li></ul></ul><ul><ul><li>Have proper amount of staff on hand for ambulating, bathing, and turning patient </li></ul></ul>
  80. 80. Preoperative Care <ul><li>Wound infection is one of the most common complications because of the many layers of flabby skinfolds, especially in the abdominal area </li></ul><ul><li>Skin preparation is important </li></ul><ul><li>May be necessary to ask patient to bathe or shower frequently for a few days before admission to hospital </li></ul>
  81. 81. Preoperative Care <ul><li>Obesity can make breathing shallow and rapid </li></ul><ul><li>Instruct patient in proper </li></ul><ul><ul><li>Coughing techniques </li></ul></ul><ul><ul><li>Deep, diaphragmatic breathing </li></ul></ul><ul><ul><li>Methods of turning and positioning to prevent pulmonary complications </li></ul></ul>
  82. 82. Preoperative Care <ul><li>Obtaining venous access may be complicated </li></ul><ul><ul><li>Assistance may be needed </li></ul></ul><ul><ul><li>Mark the spot of injection with a sterile skin marker once a vein has been found </li></ul></ul><ul><ul><li>If patient has excess fat, or pitting edema, hold a firm finger over the spot with pressure </li></ul></ul>
  83. 83. Preoperative Care <ul><li>Obtaining venous access (cont’d) </li></ul><ul><ul><li>Multiple tourniquets can be used to distend veins and hold back excess tissue </li></ul></ul><ul><ul><li>Tourniquet should be removed as soon as it is no longer needed to avoid edema </li></ul></ul><ul><ul><li>Edema can worsen if catheter is anchored with tape to arm </li></ul></ul><ul><ul><ul><li>Further impeding venous return </li></ul></ul></ul>
  84. 84. Preoperative Care <ul><li>Obtaining venous access (cont’d) </li></ul><ul><ul><li>May need a longer catheter to traverse overlying tissue </li></ul></ul><ul><ul><ul><li>Longer than 1 inch </li></ul></ul></ul><ul><ul><li>Important that cannula is far enough into vein so that it is not dislodged or infiltrated </li></ul></ul>
  85. 85. Preoperative Care <ul><li>Patients undergoing anesthesia have an increased risk of failing to wean from mechanical vent ilation </li></ul>
  86. 86. Postoperative Care <ul><li>Trained staff should assist transfer of unconscious patient </li></ul><ul><li>During transfer ensure that patient’s </li></ul><ul><ul><li>Airway is stabilized </li></ul></ul><ul><ul><li>Pain is managed </li></ul></ul><ul><li>In severely obese patients it is essential to monitor for rapid oxygen desaturation </li></ul>
  87. 87. Postoperative Care <ul><li>Early ambulation is essential </li></ul><ul><li>Frequently ↑ ambulation after initial move </li></ul><ul><ul><li>Generally 3 to 4 times a day </li></ul></ul><ul><li>Pneumatic compression devices, elastic compression stockings, or elastic wraps will be used </li></ul>
  88. 88. Postoperative Care <ul><li>Patients undergoing bariatric surgery are often in considerable abdominal pain </li></ul><ul><li>Pain medications should be given as frequently as necessary during immediate postoperative period </li></ul>
  89. 89. Ambulatory and Home Care <ul><li>Patients who have just had bariatric surgery have been unsuccessful in the past maintaining a prescribed diet </li></ul><ul><li>Patient is now reduced intake due to anatomic changes </li></ul><ul><li>Must learn to adjust intake sufficiently with regard to nutrition and maintaining a stable weight </li></ul>
  90. 90. Ambulatory and Home Care <ul><li>Diet prescribed is generally </li></ul><ul><ul><li>High protein </li></ul></ul><ul><ul><li>Low carbohydrates </li></ul></ul><ul><ul><li>Low fats </li></ul></ul><ul><ul><li>Low roughage </li></ul></ul><ul><ul><li>6 small feedings </li></ul></ul><ul><ul><li>Fluids not to be ingested with meals </li></ul></ul><ul><ul><ul><li><1000 ml/day </li></ul></ul></ul>
  91. 91. Ambulatory and Home Care <ul><li>Possible complications from bariatric surgery </li></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Vitamin deficiencies </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Psychiatric problems </li></ul></ul>
  92. 92. Ambulatory and Home Care <ul><li>Possible complications from bariatric surgery (cont’d) </li></ul><ul><ul><li>Peptic ulcer formation </li></ul></ul><ul><ul><li>Dumping syndrome </li></ul></ul><ul><ul><li>Small bowel obstruction </li></ul></ul>
  93. 93. Evaluation <ul><li>Expected outcomes </li></ul><ul><ul><li>Long-term weight loss </li></ul></ul><ul><ul><li>Improvement in obesity-related comorbidities </li></ul></ul><ul><ul><li>Integration of healthy practices into lifestyle </li></ul></ul><ul><ul><li>Monitoring possible adverse side effects </li></ul></ul><ul><ul><li>Improved self-image </li></ul></ul>
  94. 94. Gerontologic Considerations <ul><li>Number of older obese persons has risen </li></ul><ul><li>More common in women than men </li></ul><ul><li>Decreased energy expenditure and loss of muscle mass are important contributors </li></ul><ul><li>Exacerbates age-related problems </li></ul>
  95. 95. Metabolic Syndrome <ul><li>Also known as </li></ul><ul><ul><li>Syndrome X, insulin resistance syndrome, dysmetabolic syndrome </li></ul></ul><ul><li>Collection of risk factors that increase an individual’s chance of developing cardiovascular disease and diabetes mellitus </li></ul>
  96. 96. Metabolic Syndrome <ul><li>Diagnosed if an individual has three or more of the conditions listed </li></ul><ul><ul><ul><li>Waist circumference ≥40 inches (men) or ≥35 inches (women) </li></ul></ul></ul><ul><ul><ul><li>Triglycerides >150 mg/dl or being treated </li></ul></ul></ul><ul><ul><ul><li>High-density lipoprotein (HDL) cholesterol <40 men, <50 women or being treated </li></ul></ul></ul><ul><ul><ul><li>Blood pressure ≥130 mm Hg systolic or ≥85 mm Hg diastolic or being treated </li></ul></ul></ul><ul><ul><ul><li>Fasting glucose is ≥100 mg/dl or being treated </li></ul></ul></ul>
  97. 97. Metabolic Syndrome Etiology and Pathophysiology <ul><li>Main underlying risk factors </li></ul><ul><ul><li>Abdominal obesity </li></ul></ul><ul><ul><li>Insulin resistance </li></ul></ul>
  98. 98. Metabolic Syndrome Etiology and Pathophysiology <ul><li>Other risk factors </li></ul><ul><ul><li>Physical inactivity </li></ul></ul><ul><ul><li>Presence of inflammatory markers </li></ul></ul><ul><ul><li>Prothrombotic tendencies </li></ul></ul><ul><ul><li>Hormonal imbalances </li></ul></ul><ul><ul><li>Aging </li></ul></ul><ul><ul><li>Genetic or ethnic predisposition </li></ul></ul>
  99. 99. Metabolic Syndrome Etiology and Pathophysiology <ul><li>No symptoms </li></ul><ul><li>Medical problems develop if syndrome is not addressed </li></ul><ul><ul><li>Heart disease </li></ul></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Renal disease </li></ul></ul>
  100. 100. Metabolic Syndrome Nursing and Collaborative Management <ul><li>Lifestyle therapy is first line of intervention </li></ul><ul><ul><li>Manage cholesterol </li></ul></ul><ul><ul><li>Stop smoking </li></ul></ul><ul><ul><li>Lower blood pressure </li></ul></ul><ul><ul><li>Reduce glucose levels </li></ul></ul>
  101. 101. Metabolic Syndrome Nursing and Collaborative Management <ul><li>Lifestyle therapy is first line of intervention (cont’d) </li></ul><ul><ul><li>Lose weight </li></ul></ul><ul><ul><li>Increase physical activity </li></ul></ul><ul><ul><li>Healthy dietary habits </li></ul></ul>
  102. 102. Metabolic Syndrome Nursing and Collaborative Management <ul><li>Because there is only management, the nurse can assist patients by providing information </li></ul>