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Caring for the Obese Patient Magic Valley Residency Program 2011

Caring for the Obese Patient Magic Valley Residency Program 2011. Presenter Jane Hurd RN, CBN. Caring for the Obese Patient -- Objectives 1. Etiology of obesity 2. Comfort and Safety issues 3. Co morbidities of obesity 4. Multi system assessments 5. Bariatric surgeries

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Caring for the Obese Patient Magic Valley Residency Program 2011

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  1. Caring for the Obese PatientMagic Valley Residency Program2011 Presenter Jane Hurd RN, CBN

  2. Caring for the Obese Patient -- Objectives 1. Etiology of obesity 2. Comfort and Safety issues 3. Co morbidities of obesity 4. Multi system assessments 5. Bariatric surgeries 6. Potential post operative complications

  3. Obesity: On the RiseObesity Trends among U.S. Adults Percent of Obese [BMI > 30] Adults in United States BMI Percentage of people BMI > 30 <10% 10-14% 15-19% 20-24% 25-29% >30% Source: Behavioral Risk Factor Surveillance System, CDC

  4. Etiology of Obesity Etiology of Obesity Multiple influencing factors Balance of calories in vs calories burned Appetite Control Genetics Physiological

  5. Physiological Factors-Appetite Control (It is not as simple as willpower) Second Order Neuron EAT POMC CART FULL CCK Liver

  6. Physiological effects caused by the fat cell Obesity is a multi-system disease Visfatin

  7. Multiple influencing factors leads to obesity Cultural Influences Food Choices Portion Distortion Psychological Influences Inactivity Depression

  8. Additives to food chain What are they doing to our metabolism? BPA (synthetic estrogen) added to plastic bottles Growth Hormones fed to cattle

  9. Recognizing obesity as a disease helps us overcome obesity bias • Studies show society has low respect for the morbidly obese. • Society is not tolerant of obese people--especially women • 80% of obese individuals report being treated disrespectfully by the medical community • Our goal, as health care providers, should be • to eliminate this discrimination and treat all patients with respect.

  10. KCI Rental BedsBari Max II 1000# Capacity Comfort and Dignity Appropriate size Gown To widen bed -Turn toggle switch, -Pull out 4 shelves, -Buckle and zip the extender mattresses to sides. Bed needs to be in narrowest position to fit through the doors

  11. Patient and Staff Safety Hoover Use Hover Mats if Available Use Lifts When Needed

  12. Appropriate Safe Seating Comfort, Safety, Dignity Wall Mounted Toilets about 300 lbs capacity

  13. Obesity is a multi-system disease • Pulmonary disease • Abnormal function • Obstructive sleep apnea • Hypoventilation syndrome Idiopathic intracranial hypertension Stroke Cataracts • Nonalcoholic fatty • liver disease • Steatosis • Steatohepatitis • Cirrhosis • Coronary Heart Disease • Diabetes • Dyslipidemia • Hypertension Severe Pancreatitis Gall bladder disease • Cancer • Breast, Uterus, Cervix, • Colon, Esophagus, Pancreas, • Kidney, Prostate • Gynecologic abnormalities • Abnormal menses • Infertility • Polycystic ovarian syndrome Osteoarthritis • Phlebitis • Venous stasis Skin problems Gout 1. Bhoyrul S., Lashock J. The Physical and Fiscal Impact of the Obesity Epidemic: The Impact of Comorbid Conditions on Patients and Payers. .JMCM. 2008 :11(4): 10-17.

  14. Pulmonary Function Expiratory reserve volume ↓ Vital capacity, total lung capacity, functional residual volume are reduced by 30% in severely obese patients.  work of breathing oxygen consumption  CO2 production & retention Ventilation-perfusion mismatch → hypoxia Functional residual capacity falls in supine position → rapid oxygen desaturation • Respiratory Disorders • Reactive airway disease • Obstructive Sleep Apnea • Hypoventilatory Syndrome

  15. Difficult airway - Intubation Ramped position may facilitate intubation Sellick maneuver-cricoid pressure- may facilitate intubation Rapid sequence induction, with a rapid-acting muscle relaxant Fiber optic laryngoscope may be needed Have difficult airway carts available LMA or combi tube may be used if unable to intubate in an emergent situation Trach sizes

  16. CPR in the obese person CPR guidelines require 100 compressions per minute with a ratio of: 30 compressions to 2 breaths. Press hard and fast! It is difficult and requires extra effort to compress the chest 2 inches. CPR will be tiring and those performing it should change staff every 2 minutes. Defibrillation Hands off electrodes are preferred over using paddles, as it may be difficult to reach the paddles across the large chest and keep the operator’s body from touching the body or bed for electrical safety.

  17. Cardiovascular Effects of Obesity ↑total blood volume Left ventricular dilatation & hypertrophy (Related to degree & duration of obesity) ↑ Left ventricular filling pressure (Due to ↑ preload & ↓ ventricular distendibility) ↓Left ventricular contractility & depressed ejection fraction Fluid Boluses may be poorly tolerated However, there may be significant 3rd spacing Hypertension is common Diastolic dysfunction of prolonged relaxation phase & early filling Use appropriate size B/P cuffs to assure accurate pressure readings

  18. Obesity and Diabetes Managing Glucose Level Improves Outcomes Prevent complications Promote healing Decrease length of stay Decrease Mortality

  19. Nutritional Requirements for Obese Patients Total parental nutrition should be initiated An acute illness and hospitalization is not the place or time to go on a “diet” Obese pts have excess body fat but may not be well nourished. Protein malnutrition occurs during metabolic stress Accelerated breakdown of protein due to elevated basal insulin levels suppress lipid mobilization Results in: Rapid ↓ in lean body mass ↑in ureagenesis ↑urinary nitrogen loss

  20. Fat is NOT paddingIt’s added pressure on skin Reposition q 2 hrs Use multiple staff for repositioning Check tubes Keep skin folds clean & dry Bari Maxx II bed is available with low air- loss, rotating surface Skin Care -- Pressure Ulcers Prevention

  21. Some people living with the serious disease of obesity choose surgery as a treatment option

  22. Reasons People Choose Bariatric Surgery To improve their health & quality of life Decrease risk of cancers Lengthen of Life Improve Blood Pressure Reduce need for medications Resolve sleep apnea Decrease risk of stroke & heart attacks Resolve diabetes Improve mobility Improve fertility

  23. y. Co-morbidity Reduction after Bariatric Surgery Migraines 57% resolved 1 Pseudotumor cerebri 96% resolved 2 Dyslipidemia, hypercholesterolmia 63% resolved 1,4,5 Non-alcoholic fatty liver disease 90% improved steatosis 37% resolution of inflammation 20% resolution of fibrosis3 Metabolic syndrome 80% resolved 3 Type II diabetes mellitus 83% resolved 1,4,7 Polycystic ovarian syndrome 79% resolution of hirsutism 100% resolution of menstrual dysfunction 9 Venous stasis disease 95% resolved 8 Depression 55% resolved1,5 Obstructive sleep apnea 74-98% resolved1,5,8 Asthma 82% improved or resolved1,5,7 Cardiovascular disease 82% risk reduction 6 Hypertension 52-92% resolved136 GERD 72-98% resolved1,2,5 Stress urinary incontinence 44-88% resolved 1 Degenerative joint disease 41-76% resolved1,5,6 Gout 72% resolved 1 Risk versus benefits need to be considered when making the decision to undergo bariatric surgery Resolution in co morbidities is a motivating factor Quality of life improved in 95% of patients 1,7 Mortality 30-40% reduction in obesity-related mortality 10,11

  24. Bariatric Surgery Criteria BMI > 40 BMI > 35 with two or more co-morbidities. Attempted & failure of non-surgical weight loss program. No active addictions

  25. Surgical Treatment of Obesity Restrictive MalabsorptiveProcedures Roux-n-Y Gastric Bypass Biliopancreatic Diversion with Duodenal Switch Restrictive Procedures Adjustable Gastric Band Sleeve Gastrectomy

  26. Bariatric Surgery Lifetime Dietary Guide Eat slow Small bites Chew well Stop when you’re full Protein first Low Carb/Low Fat No grazing or nibbling No liquids with meals Sip liquids between meals Vitamins/Minerals

  27. Dumping SyndromePost Roux-n-YExpected side effect-Not a complication

  28. Potential Nutrient Deficiency Vitamins A, D, E & K B12, Thiamine Folic Acid Electrolytes K+ Protein Minerals Calcium, Iron • Most deficiencies can be avoided with good compliance to: • Dietary guidelines • Vitamin and mineral supplements • Yearly blood levels should be evaluated • Adjustments to supplements recommended Chewable supplements

  29. Oral Medications Chewable and liquid more readily adsorbed than pills. Absorption may be altered RnY and DS Avoid NSAIDs for all procedures Large tablets may need to be cut. Capsules may need to be opened. Time release medications may not be crushed (some may be cut) Verify with the pharmacy to assure the integrity of the medication is maintained Small to medium size tablets are usually tolerated The patient may only be able to tolerate a couple pills at a time Pt can NOT tolerate several pills at one time

  30. Anastomotic LeakLeads to Sepsis Rapid pulse >120 Abdominal Pain Shortness of Breath Resp rate  B/P Fever > 101 Change in color of JP drainage Subtle signs: Hiccups, shoulder/chest pain “sense of doom” anxiety

  31. Obese patients at ↑ Risk forDVT /Pulmonary Embolism S/S of PE Dyspnea Tachycardia  O2 Sat,  PO2 Pain-chest/back/shoulder Hemoptysis Arrhythmias Widening pulse pressures These symptoms may be very severe or quite subtle Treatment Anticoagulants Risk Factors BMI>60 Chronic leg edema OSA Prior PE Immobile Prophylaxis : Anticoagulants SDCs Early mobilization

  32. Gastric Remnant Distention Small Bowel Obstruction due to swelling or a kink at thej-j conjunction of bowel can result in gastric distention S/S of Gastric Distention -abdominal pain &/or pressure -abdominal distention (difficult to assess, so listen to your pt’s concerns) -s/s sepsis if gastric sutureline leaks pulse, Resp rate, Temp B/P,  Urine output

  33. Later complications Nausea/Vomiting/Dehydration Stenosis/Band Slippage Adhesions/Bowel obstruction Band device problems Ulcers/GI Bleed Hernias- internal/incisional Intussception Mesenteric Vein Thrombosis Gallstones

  34. Nausea/Vomiting Dehydration

  35. Potential Thiamine deficiency S/S- numbness, weakness, unsteady gait, cognitive difficulties Thiamine is consumed as an enzyme cofactor in carbohydrate metabolism, a concentrated glucose load will rapidly deplete thiamine stores, which can precipitate or worsen encephalopathy in a pt with thiamin deficiency. TX- Give 100mg Thiamine IV Prior to glucose administration

  36. Stenosis Narrowing of the stoma Tx= EGD with dilitation

  37. Band Slippage & Gastric Prolapse Proper placement of band Basically horizontal position Dilated pouch causing band to “slip” to vertical position Gastric Prolapse Signs/Symptoms Dysphagia Nocturnal reflux Night cough Epigastric pain Diagnosis Esophogram Treatment Remove all fluid form band Emergent or Scheduled surgery

  38. Band Adjustment may be too tight, leading to inability to tolerate liquids or food may get “stuck”may cause inflammation leading to fibrosis Band removed due to erosion into stomach. Upper stomach deformity R/T fibrosis

  39. Adhesions & Bowel Obstruction

  40. Nasogastric Tubes Post op NGs are rare Tape securely If dislodged tape & notify MD DO NOT reposition DO NOT irrigate without specific MD order (Know your Pt’s history) NGs are to be placed ONLY under fluoroscopy for all recent or past bariatric surgery pts. Bands should be emptied under fluoroscopy with Huber needle by a radiologist and the NG placed in Medical Imaging

  41. Ulcers Gastrointestinal Bleeding Ulcers Pouch Avoid NSAIDs G-J anastomosis ulcer (most common) Remnant stomach Duodenum ulcers (uncommon) Suture line post op bleeds Gastric lines J-J anastomosis of RnY Duodenal &J-I anastomosis of DS

  42. Internal Hernia Post RnY CT shows mesenteric vessels supplying herniated bowel are crowed, twisted and engorged Upper GI series shows a cluster of dilated bowel in left upper guardant 41 year old women with transmesocolic internal hernia S/S: Vague crampy or acute severe abdominal pain May lead to ischemic/dead bowel

  43. Intusseception The telescoping of the bowel into itself Symptoms Pain Treatment Resolves spontaneously Surgical intervention

  44. Mesentaric vein thrombosis Uncertain etiology (Usually occurs 1-2wks post op) Abdominal pain Diagnosed by CT Treatment Anticoagulants

  45. Adjustable Band Complications 1. Leak at junction of port and connector tube 2. Disconnection of banding system and band erosion into stomach. 3. Port flipped 4. Infected port 5. Gastric band erosion 6. Mis-positioned band with esophageal dilatation 1 2 3 4 5 6

  46. Gallstones Weight loss  cholesterol in the bile  to gallstone formation  Cholecystectomy ERCP is not possible due to changed anatomy Interventional Radiologist may percutaneously evaluate and treat biliary system remove stones dilate strictures place bilary stents

  47. Success is not really a number on the scale.(although it may be a goal) There are potential complications of bariatric surgery For many people the benefits out weigh the risk Freedom of mobility, improved health and enhanced quality of life are the true rewards.

  48. Care of the Obese Patient requiresMultiple system assessmentsEarly recognition and management of complicationsAppropriate interventions in a timely manner

  49. Thank You Questions ?

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