Leading cause of preventable death, surpassing tobacco. ..

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C-3 Management of the Obese PopulationA Person
Centered Care Approach
Presented by
Carolyn Brown, M.Ed, RN, ARM, FCCWS National
Director of Clinical Services
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Learner Objectives

• 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.

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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
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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
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Body Mass Index (BMI)
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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 gt 40 inches
• Women gt 35 inches

Would waist circumference support the customers
decision to rent or purchase!!!
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Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1986
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1987
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1988
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1989
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
25
Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI ? 30, or 30 lbs overweight for 54 woman)
No Data lt10 10-14
15-19 20-24 ?25
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Obesity Trends Among U.S. Adults BRFSS, 1991,
1995, 2000 and 2005
(BMI ? 30, or 30 lbs overweight for 54 woman)
1991
1995
2000
No Data lt10 10-14
15-19 20-24 ?25
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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

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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

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Obesity Update
The year 2006 was important for obesity according
to a report published by the Center for Disease
Control and Prevention (CDC).

• Americas number one health threat.
• Leading cause of preventable death, surpassing
  tobacco.
• 320 billion is spent annually on obesity.

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Healthcare is fast becoming one of the most
dangerous jobs in the U.S.
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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
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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.

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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.

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Safe Patient Handling

• Overexerting the spine may result from

• Lifting improperly
• Lifting weight beyond a safe lifting capacity
• Working in a bent over position

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Safe Patient Handling

• Benefits include and increase in patient
  satisfaction and mobility and a decrease in

• Workers comp costs
• Staff/patient injury
• Lost time claims
• Staff turnover
• New employee training costs

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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.

StenBarr Medical Inc.
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Risk Factors

• Aging Workforce
• Degenerative and arthritic discs, out of
  shape, overweight, poor posture
• Obese patients have increased in number and are
  sicker.

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The Unique Challenge
Medical community is challenged to

• Provide quality care
• Prevent injury to patient and staff
• Minimize costs

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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
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Scenario

• Todd, a 240 pound, 63 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

StenBarr Medical Inc.
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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.
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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

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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

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Bariatric Assessment

• Vital Signs
• Weight
• Respiratory
• Circulation
• Skin
• Gastrointestinal, Urinary
• Nutrition
• Mobility
• Pharmacology
• Medication Administration

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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
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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.

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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

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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
  arms circumference to obtain an accurate
  reading.
• A variety of cuff sizes should be available.

• too small false high

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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

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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.

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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

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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

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Respiratory

• 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 Trendelenburgs position
  to facilitate lung expansion
• Provide specific Heimlich training

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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

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Skin

• 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

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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.

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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

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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

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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

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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

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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

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Catheter Insertion

• 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

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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

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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

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Mobility

• 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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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
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Transport and Transfer

• 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
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Emergency Assistance

• Firefighters are perceived as specially trained
  in rescue

Specialized lifting teams have been implemented
in emergency rescue.
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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
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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.
Goliath Caskets specializes in up to 1000lb
capacity (52 inches in width)

• Resources
• Goliathcaskets.com
• HillRom/Dimensions.com End of Life Solutions

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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
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Facility Preparation
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Facility Preparation
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Facility Preparation
90
Facility Preparation
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Facility Preparation
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Facility Preparation
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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.
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Case Study
Sonias 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
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Admitting Diagnosis
Admitting Diagnosis - Post Left Hip
Fracture - Respiratory Disease(COPD) -
Diabetes - Pressure Ulcers - Urinary Track
Infection(UTI) - Dehydration - Pressure
Ulcers - Hypertension - Arthritis
96
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 Pain scale 8-9 Back Pain scale
6 All major joints Pain scale 6
97
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.
98
Physicians 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 BS is
  gt160

• 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

Identify unique supplies, equipment and staff
training necessary for Sonias care
99
Pre-Admission Assessment
100
On-line Education Programs
RecoverCare offers continuing education (CEUs)
from the convenience of your own computer. Visit
us at
www.stenbarr.com/sbu.asp
Practical Aspects of Bariatric Care
101
Thank You
Please complete your Program Evaluation
Carolyn Brown M.Ed., RN, ARM,FCCWS National
Director of Clinical Services -
RecoverCare Cbrown_at_recovercare.com
14350 Carlson Circle Tampa, Florida 33626