Care of the Bariatric PatientCare of the Bariatric Patient

22

Objectives Define the classifications of obesity and explain

the impact and costs related to obesity

Explain the considerations in caring for the obese patients due to their pathophysiology

Identify health and safety risks associated with the obese patient

Discuss treatment options for obesity and how to provide weight sensitive care

33

Bariatric comes from the Greek word baros which means weight.

This means the patient of greater size, usually a body mass index of >30.

What do we mean by the bariatric patient?

44

Classifications of Obesity using Body Mass Index (BMI)

Uses Patient’s Height and Weight

Correlates with Total Body Fat Content

Go to http://www.sharp.com/tools/bmi.cfm to calculate your own BMI

55

Morbid Obesity DefinedMorbid Obesity Defined80-100 lbs Overweight80-100 lbs OverweightBody Mass Index=BMIBody Mass Index=BMI

Acceptable Range 18.5 – 24.9

Overweight 25 – 29.9

Obese 30 – 34.9

Severe Obesity 35 – 39.9

Morbid Obesity 40 – 49.9

Super-Morbid Obesity 50 – +++

66

Measures to Assess Health Risks Related to Measures to Assess Health Risks Related to ObesityObesity

Neck circumference: > 16-17 inches is related to greater risk Neck circumference: > 16-17 inches is related to greater risk Obstructive Sleep Apnea (OSA).Obstructive Sleep Apnea (OSA).

Increased waist circumferenceIncreased waist circumference

>40 inches for men or >35 inches for women is related to greater >40 inches for men or >35 inches for women is related to greater metabolic risks.metabolic risks.

77

Impact of Morbid ObesityImpact of Morbid Obesity

Causes 300,000 deaths per year in Causes 300,000 deaths per year in the United Statesthe United States

Smoking and obesity are the leading Smoking and obesity are the leading preventablepreventable causes of death in the causes of death in the United StatesUnited States

Modern worldwide epidemicModern worldwide epidemic

American Obesity Association

88

Prevalence of ObesityPrevalence of ObesityOver 67% of adult Americans are overweightOver 67% of adult Americans are overweight

26% are obese or morbidly obese26% are obese or morbidly obese

In 2010, adult obesity rates increased and In 2010, adult obesity rates increased and reached 30 % in eight states reached 30 % in eight states

High BMI in the U.S. is approximately High BMI in the U.S. is approximately 10 % for infants and toddlers10 % for infants and toddlers

18 % for adolescents and teenagers18 % for adolescents and teenagers

Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008 http://healthyamericans.org/reports/obesity2010/

99

High Cost of ObesityHigh Cost of Obesity Currently, 9 % of all health care dollars are spent for the treatment of obesity and its complications

Some estimate it will climb to 21% of all health care dollars by 2018

Undetermined costs related to hospital worker injury

http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf

1010

Test Your KnowledgeTest Your Knowledge

Currently, approximately 2/3 of Americans are considered overweight or obese

True

False

1313http://win.niddk.nih.gov/statistics/index.htm

What is Morbid Obesity?What is Morbid Obesity?Chronic multi-factorial metabolic

disease

Life-long Progressive Degenerative Life-threatening Genetically related

1414

Morbid Obesity is a Metabolic Disease

As BMI increases, adipose tissue becomes metabolically active and secretes hormones

These hormones influence insulin resistance, hyperlipidemia, inflammation, thrombosis, and hypertension

The mucosa of the stomach of obese persons secretes higher levels of the hormone Ghrelin which increases appetite

1515

Neuropeptides and neurotransmitters in the brain, mainly the hypothalamus, and other hormones affect satiety, appetite and weight regulation

Interestingly, Leptin, a hormone that is secreted by adipose tissue and decreases hunger, is found in higher levels for obese persons but it is believed they are “leptin resistant”

The next two slides will demonstrate the complexity of this disease!

The Disease of Morbid Obesity

1616

Affects satiety Increases energy expenditure

POMC + α MSH Leptin receptors CRH/Urocortin

CNS Vagus nerve activation SerotoninDopamine

CART (Cocaine Associated Receptor Transcript)

Affects hunger Conserves energy

Cannabinoid receptor activation Orexin A

MCH and AGRP Neuropeptide Y

Dynorphin Galanin

Beacon gene activation CNS Sympathetic nerve activation

Anorexic Mediators Orexogenic Mediators

Obesity and Neurohormonal Influences

Located in the brain

1717

Adipose Tissue Secretes:

Tumor Necrosis Factor αInterleukin-6

LeptinLiver

Reduced hepatic glucose

Pancreas

Reduced glucose, Insulin, glucagon and GLIP

Skeletal Muscle

Uncoupling proteins 2 and 3

Adipose Tissue Affects Many Organs

Stomach

CCKEnterostatin

Peptide YY (3-36)

1818

Pathogenesis of Obesity Behavior and lifestyle habits are often determinants

in the development of the disease

But, it is also extremely important to also understand the metabolic mechanisms that influence body weight

For persons who are overweight and mildly obese, dieting and exercise are very effective for weight loss

1919

Challenges for the Morbidly Obese

Changes with hormones and the central nervous system make it VERY CHALLENGING to sustain weight loss long

term by dieting and exercise alone.

At least 85 % regain their weight and more over time

2020

Key Points

• Morbid Obesity is a chronic metabolic disease

• Diet and exercise are very effective for weight loss for those who overweight and mildly obese

• Neurohormonal changes for the morbidly obese

make it very challenging for them to sustain weight loss long term by dieting and exercise alone

2121

Test Your KnowledgeTest Your Knowledge

Ghrelin is a hormone which is secreted by adipose tissue and decreases hunger

True

False

2424

Co-Morbidities of Obesity

Co-morbidities are conditions or diseases caused by or made worse by obesity

For example, asthma, gout, and arthritis may be made worse due to the chronic inflammation associated with obesity

It is important to educate patients about their health risks associated with obesity

2525

Metabolic Syndrome X is linked to ObesityMetabolic Syndrome X is linked to Obesity

Insulin resistanceInsulin resistance

HyperinsulinemiaHyperinsulinemia

HyperglycemiaHyperglycemia

HyperlipidemiaHyperlipidemia

HypertensionHypertension

Heart DiseaseHeart Disease

IR= Insulin ResistanceROS=Reactive Oxygen Species

2626

American Heart Association Definition of Metabolic Syndrome

Increased waist circumference: > 40 inches for men or > 35 inches for women

Elevated triglycerides: Equal or > 150 mg/dL

Reduced HDL (“good”) cholesterol: < 40 mg/dl for men and < 50 mg/dL for women

Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of medication for hypertension

Elevated fasting glucose: Equal to > 100 mg/dL (5.6 mmol/L) or use of medication for hyperglycemia

2727

Stroke Stroke Increased risk for ischemic stroke in both men and women

Ischemic stroke increases progressively and is doubled in those with a BMI > 30 when compared to those having a BMI < 25

Obesity is not proven to be an increased risk for hemorrhagic strokes

J. La State Med Soc. 2005, 156, S42-49.

2828

Cardiovascular Cardiovascular

Considerations Considerations

Increased total blood volume

Left ventricular hypertrophy Left ventricular hypertrophy and decreased ventricular contractility can occur

About 75 % of individuals with hypertension have an About 75 % of individuals with hypertension have an obesity linkobesity link

American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=1818

2929

ECG ConsiderationsECG Considerations Increased fat deposits around the heart may lead to Increased fat deposits around the heart may lead to

degeneration of the conduction system which causes degeneration of the conduction system which causes lethal heart rhythmslethal heart rhythms

Large body mass may cause difficulty with landmarks Large body mass may cause difficulty with landmarks for lead placement and inconsistent or decreased for lead placement and inconsistent or decreased voltagevoltage

Prolonged QT intervalsProlonged QT intervals

Non-specific flat/inverted T waves Non-specific flat/inverted T waves in inferior leadsin inferior leads

Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804.Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804.Zacharias, A. Schwann. T. Riordan, C. et al (2005) Obesity and risk of new-onset of atrial fibrillation after cardiac surgery. Circulation 112 (32), 3247-3255

3030

Diabetes MellitusDiabetes Mellitus Type 2 diabetes mellitus (DM) is strongly associated with

overweight and obesity in both genders and in all ethnic groups

90 % of all patients with type 2 DM are overweight or obese

The risk for type 2 DM also increases in individuals with a more central distribution of body fat (abdominal)

Modest weight loss (medical or surgical weight loss), even 5-10% loss can have significant improvement of type 2 DM

Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales, & James S. Marks, (2003) Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, JAMA, (289),76-79.

3131

Some drugs may impact the renal system in high BMI patients due to high glomerular filtration rates

Increased intra-abdominal pressure may lead to hypertension and insult to the kidney

If BMI is more than 30, nearly twice the risk for kidney failure If BMI of 40 or above, seven times the risk of kidney failure

Renal ImpactRenal Impact

Blackwell Publishing Ltd. (2006, December 26). Obese Kidney Transplant Patients Twice As Likely To Die In The First Year Or Suffer Organ Reference: June Journal of the American Society of Nephrology (2006) http://www.sciencedaily.com/releases/2006/01/060105082226.htm

3232

Nonalcoholic Fatty LiverIf BMI > 40, the prevalence of:

Nonalcoholic fatty liver disease (NAFLD) is more than 95%Nonalcoholic steatohepatitis (NASH) may be as high as 25%.

Sustained liver injury leads to progressive fibrosis and cirrhosis in 10% to 25% of affected individuals.

http://bariatrictimes.com/2010/01/21/nutrition-in-the-management-of-nonalcoholic-fatty-liver/http://www.ccjm.org/content/71/8/657.full.pdf

3333

Obesity Related CancerObesity Related Cancer

Obesity related cancer death rates are 14% for men Obesity related cancer death rates are 14% for men and 20% for womenand 20% for women

Obese women have a 50% increase risk for breast Obese women have a 50% increase risk for breast cancer after menopausecancer after menopause

Obese men are 30-50% more likely as lean men to Obese men are 30-50% more likely as lean men to develop colon cancerdevelop colon cancer

Obesity related cancers include prostate, lymphoma, Obesity related cancers include prostate, lymphoma, liver, pancreas, and gallbladderliver, pancreas, and gallbladder

American Cancer SocietyAmerican Cancer Society

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119

3434

Reproductive ImpactImbalance of the sex hormones especially androgens and

estrogen leads to:

Irregular menstrual cyclesIncreased androgenization and facial hairPolycystic ovarian syndrome (PCOS)Decreased conception rates after fertility treatments

3535

Physiological changes in the obese patientincreases their risk for adverse events and

potential complications

It is extremely important to consider these changes in the way you provide care!

3636

High Risk for Blood ClotsHigh Risk for Blood ClotsObesity is characterized by:Obesity is characterized by:

Chronic inflammationChronic inflammationDecreased immunityDecreased immunityHypercoagulabilityHypercoagulability

This is due to:This is due to:

• Decreased antithrombin-IIIDecreased antithrombin-III• Increased tumor necrosis factor Increased tumor necrosis factor αα and and interleukin-6interleukin-6• Impaired neutrophil functionImpaired neutrophil function• Increased blood volumeIncreased blood volume

Critical Care Medicine 2006 Jun;34(6):1796-804.

3737

Prevent Blood Clots by Early Prevent Blood Clots by Early AmbulationAmbulation

Mobilize patients Mobilize patients earlyearly and and frequentlyfrequently

The efficacy of sequential The efficacy of sequential compression devices and TED hose compression devices and TED hose for obese individuals is unknownfor obese individuals is unknown

Chronic inflammation and Chronic inflammation and hypercoagulation increase the clot hypercoagulation increase the clot riskrisk

There are limited studies about There are limited studies about anticoagulation and the obeseanticoagulation and the obese

The weight of the large pannus The weight of the large pannus (abdominal fold) creates pressure on (abdominal fold) creates pressure on the deep vessels and increases the the deep vessels and increases the riskrisk

Critical Care Medicine 2006 Jun;34(6):1796-804.

3838

Test Your KnowledgeTest Your KnowledgeWhich statement is not true about the increased risk for blood

clots and the obese individual?

A. The weight of the abdomen on deep vessels increases the risk

B. Little is known about the efficacy of SCDs and TED hose

C. Studies on anticoagulation and obesity are limited

D. There is no increased risk

4141

Pulmonary ConsiderationsObese patients desaturate very rapidly due to decreased Obese patients desaturate very rapidly due to decreased

respiratory reserve and lung capacity.respiratory reserve and lung capacity.

Assess reasons oxygen saturation levels are less than 92 %.Assess reasons oxygen saturation levels are less than 92 %.Immediate intervention is critical.Immediate intervention is critical.

The reverse trendelenberg position is the optimal position as The reverse trendelenberg position is the optimal position as it drops the pannus (abdominal fold) from the diaphragm.it drops the pannus (abdominal fold) from the diaphragm.

Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory Rate and Tidal volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal of Critical Care, (3), 102-106.

4242

Pulmonary ConsiderationsPreoxygenate before procedures such as suctioning. It is vital.

Keep upright or semi-recumbent as long as possible before procedures.

Plan rest periods during most activities as dyspnea is common.

4343

Obstructive Sleep Apnea (OSA)Rates of OSA are high, about 71-77% if morbidly obese If also

diabetic, it is about 86% and often undiagnosed

Assess if patient has symptoms of OSA:• Snoring• Patient has been told they stop breathing for periods of time

during sleep• Daytime sleepinessAsk the patient if they use a CPAP machine at home

4444

OSA and ObesityObtain order for Pulmonary Services if patient

uses CPAP at home

Patients may also require:• continuous oxygenation saturation monitoring• planning for difficult airway management

4545

RAMP (Rapid Airway ManagementPosition) for Procedures

Align the top of the ear with the sternal notch

Ramp up or raisethe occipital area using pillows or towels

Form a trapezoid shape beneath the back of the head

Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni

4646

Regional Anesthesia Considerations

Increased abdominal pressure may decrease cerebral spinal fluid volume which may lead to higher

neuroaxial blockade

Monitor patients closely for respiratory compromise

4747

Weight and DrugsWeight and DrugsCaution must be used for drugs highly soluble Caution must be used for drugs highly soluble

in fat, especially with extended time duration, in fat, especially with extended time duration, > 12-24 hours include:> 12-24 hours include:

Opiate analgesics (Morphine, Dilaudid, etc)Opiate analgesics (Morphine, Dilaudid, etc) Carbamazepine (Tegretol)Carbamazepine (Tegretol) PropofolPropofol FentanylFentanyl Midazolam (Versed) Midazolam (Versed)

4848

Pain ManagementPain Management Avoid Intramuscular injectionsAvoid Intramuscular injections

Pain medication in the obese patient is largely Pain medication in the obese patient is largely unknownunknown

Narcotics may lead to “Resedation Phenomenon” Narcotics may lead to “Resedation Phenomenon” Adipose tissue leads to unpredictable absorption Adipose tissue leads to unpredictable absorption

and a delayed response of these drugsand a delayed response of these drugs

Assess sedation levels and for respiratory Assess sedation levels and for respiratory depression very closely especially if patient has depression very closely especially if patient has OSAOSA

4949

Drugs and the Obese PatientDrugs and the Obese Patient Pharmacodynamic and kinetic data are not available for Pharmacodynamic and kinetic data are not available for

many medications such as antibiotics, pain medications, etc. many medications such as antibiotics, pain medications, etc.

Generally, dose to a patient’s ideal body weight plus 40% of Generally, dose to a patient’s ideal body weight plus 40% of the excess body weightthe excess body weight

Start “low and go slow” is the best approachStart “low and go slow” is the best approach

5050

Venous AccessVenous AccessLandmark vessels may be hard to palpate or visualize.Landmark vessels may be hard to palpate or visualize.

Consider Infusion Services to avoid multiple IV sticks. Consider Infusion Services to avoid multiple IV sticks. Midline and PICC catheters may be a better option Midline and PICC catheters may be a better option depending on the length of therapy.depending on the length of therapy.

Assess carefully for signs of phlebitis due to excess skin, Assess carefully for signs of phlebitis due to excess skin, subcutaneous fat and moisture in skin folds.subcutaneous fat and moisture in skin folds.

Assess if standard 1.5-in needles are long enough.Assess if standard 1.5-in needles are long enough.

5151

GI ImpactGI ImpactMonitor for greater aspiration risk due to high:

gastric fluid volume GI reflux incidence of Hiatal Hernia

High Incidence of GallstonesNormally, acids in bile keep cholesterol from

forming into stones

With obesity, cholesterol in the bile increases beyond the ability of acids to maintain the cholesterol in suspension, the cholesterol crystallizes and form stones

5252

Skin Care ConsiderationsSkin Care Considerations Inspect for moisture and irritation in skin folds as this may lead Inspect for moisture and irritation in skin folds as this may lead

to infectionto infection

Ask the patient if they are able to perform their personal Ask the patient if they are able to perform their personal hygiene:hygiene: Obtain adaptive supplies and consult skin team if neededObtain adaptive supplies and consult skin team if needed Offer assistance Offer assistance

Move all lines, tubes, catheters (if possible) and the pannus Move all lines, tubes, catheters (if possible) and the pannus (abdominal fold) every 2 hours to prevent atypical ulcers(abdominal fold) every 2 hours to prevent atypical ulcers

Assess for wound healing since adipose tissue less Assess for wound healing since adipose tissue less vascularizedvascularized

Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA.Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA.

5353

Musculoskeletal Musculoskeletal ConsiderationsConsiderations

Patients have increased:Patients have increased:

joint trauma/painjoint trauma/pain disuse and atrophy of musculaturedisuse and atrophy of musculature

Prevent injury to yourself and the patient by using size Prevent injury to yourself and the patient by using size appropriate equipment. Obtain order for Physical Therapy appropriate equipment. Obtain order for Physical Therapy as needed.as needed.

Look for the weight capacity labels on patient equipment to Look for the weight capacity labels on patient equipment to help select the right equipment (coming soon)help select the right equipment (coming soon)

5454

Test Your Knowledge

Obesity is linked to certain types of cancer

True

False

5757

Treatment of ObesityTreatment of Obesity If BMI is 25-26.9 with co-morbidities:

Advise patient of treatment options for diet, physical activity, and behavioral change

If BMI is 27-29.9 with co-morbidities or 30-34.9 without co-morbidities: Consider pharmacotherapy in addition to diet, physical

activity, and behavioral change

If BMI 35 or greater with two co-morbidities or BMI >40: Consider Bariatric or Weight Loss Surgery in addition

to above noted treatments

5858

Important PointsImportant Points

Morbid obesity is a chronic disease. Conventional Morbid obesity is a chronic disease. Conventional dieting is often not effective long term for the dieting is often not effective long term for the morbidly obese patient.morbidly obese patient.

Currently, medications are successful for about a Currently, medications are successful for about a 5-10% decrease of excess body weight. 5-10% decrease of excess body weight.

Surgical weight loss overall results in a decrease in Surgical weight loss overall results in a decrease in at least 50-60% and more of excess body weight at least 50-60% and more of excess body weight and a profound resolution of serious co-morbidities. and a profound resolution of serious co-morbidities.

Surgery is a “tool” for weight loss success, Surgery is a “tool” for weight loss success, not a not a cure.cure.

5959

Does this make you feel sad?

6060

What do you think?

6161

Weight Bias in Healthcare A recent study reported that only 2% of the

dietitian students had a neutral or positive attitude about obese persons

In one study among nurses:

31% “would prefer not to care for obese patients” 24 % agree that obese patients “repulsed them”

12 % “would prefer not to touch obese patients”

Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society

6262

Physicians and Weight BiasPhysicians and Weight Bias In several anonymous self report surveys, they view obese In several anonymous self report surveys, they view obese

patients as:patients as: “ “Noncompliant, lazy, lacking self control, unsuccessful, Noncompliant, lazy, lacking self control, unsuccessful,

unintelligent, and dishonest” unintelligent, and dishonest”

In a large study, 2,449 overweight and obese women In a large study, 2,449 overweight and obese women reported that 52% had been stigmatized more than once by reported that 52% had been stigmatized more than once by their physiciantheir physician

Overall, physicians: Overall, physicians: spent less time with patientsspent less time with patients assigned more negative symptomsassigned more negative symptoms had reluctance to perform certain screeningshad reluctance to perform certain screenings

Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society

6363

Impact on Patient CareImpact on Patient Care

Patients may delay seeking or cancel Patients may delay seeking or cancel preventative health services and exams preventative health services and exams

Discrimination in every social aspect leads to Discrimination in every social aspect leads to depression, low self esteem, and moredepression, low self esteem, and more

Fear of worker injury and extra time to mobilize Fear of worker injury and extra time to mobilize leads to resentment, impatience, and less leads to resentment, impatience, and less mobilization by providersmobilization by providers

Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society

6464

Providing Weight Sensitive Care

Ask permission from the patient when you: discuss their weight or BMI weigh them

Acknowledge the challenges of losing weight with the patient

Briefly explain why morbid obesity is a disease. Many patients are not aware.

6565

Providing Weight Sensitive Care

Avoid demeaning phrases such as “fluffy”, “fat”, etc

Use the term “bariatric” or “extended capacity equipment” instead of “big boy” equipment

Provide the appropriate sized equipment and supplies

6666

Patient Education If a patient is interested in weight loss options

at Sharp, the patient may attend an out-patient class. These are two options:

Go to www.sharp.com, classes and events then bariatrics-weight loss or

Register at 1-800-82-Sharp, ask for medical or surgical weight loss classes

6767

Test Your Knowledge

Since the topic of obesity is frequently in the news, weight bias is rare among health care providers

True

False

7070

Claims of NegligenceFailure to:

Educate medical providers about risks of obesity

Provide policies about care of the obese patient

Obtain essential bariatric equipment

7171

Claims of NegligenceFailure to:

Provide nonjudgmental, weight sensitive care

Adequately prepare for emergencies of the obese patient

Educate patients about appropriate weight loss resources

7272

How are we providing the best care

at Sharp Healthcare?

7373

System Task Force Safe Care of the Bariatric Patient

Recommended and supported by CNOs and System Safety Steering Committee based on identified risks of this patient population

Comprised of representatives across the system: SMH

Cheryl Holsworth RN, Senior Specialist, Bariatric Surgery Michael Drafz RN, Lead, Vascular Access ServicesJudd Feiler, Lead, Physical Therapy

SGHBethanie Martin RN, Lead 5 East Ron Owen, Manager, Pulmonary Services

SCORBryn Hogan RN, Lead ACC

MBHWNEllen Fleischman RN, RD, Manager MISBernadette Bongato RN, Nursing Specialist OR

SCVMCDeanna White RN, Manager, Acute CareMarquet Johnson RN, CNS, PCU

System Representatives Albert Rizos, PharmD, System Senior Clinical Pharmacy Specialist Cheryl Dailey RN, Director, Patient Safety Francine Parent RN, Senior Specialist, System Supply Chain Services

7474

Focus Areas of Bariatric Task Force Ensure that our clinical staff have ready access to

supplies, products and equipment which are weight and size appropriate

Label weight capacity of equipment using weight sensitive stickers. (Implementation has begun at SMH and planned for all of Sharp Healthcare)

Offer comprehensive programs for medical and surgical weight loss (Surgical programs offered at SMH and SCV)

Implement use of difficult airway kits

7575

Focus Areas Provide education to our staff, patients,

employees, and physicians for the management and care of this patient population

Provide education about ways to provide weight sensitive care

Spread entity best practices across the organization

Provide educational and resource information available to staff via Sharp Intranet and other venues

7676

Bariatric ResourcesBariatric Website (under construction)http://sharpnet/hospitals/memorial/bariatricProgram/index.cfm

www.sharp.com go to classes and events, look for bariatrics

Resource Experts Cheryl Holsworth, RN, MSA, CBN Senior Specialist Bariatric Program Phone 858-939-3083, Cheryl.holsworth@sharp.com

Thomas Hayes Administrative Coordinator Bariatric Program Phone 858-939-3010, Thomas.hayes@sharp.com

7777

Conclusions about Morbid ObesityIt is a metabolic disease

It results in multisystem problems

Care of the patient requires customization of care and thoughtfulness

Refer patients to out-patient resources for medical/surgical weight loss options

7878

Remember how Remember how we think and how we think and how we feel is reflected we feel is reflected in our eyesin our eyes

7979

ReferencesReferences American Society of Metabolic and Bariatric SurgeryAmerican Society of Metabolic and Bariatric Surgery American Cancer SocietyAmerican Cancer Society American Journal of Respiratory and Critical Care Medicine (2004). (169), 557-561.American Journal of Respiratory and Critical Care Medicine (2004). (169), 557-561. Alspach, J.G. (editor) (2006). Core Curriculum for Critical Care Nursing (6Alspach, J.G. (editor) (2006). Core Curriculum for Critical Care Nursing (6thth edition). Saunders Elsevier: St. Louis, MO. edition). Saunders Elsevier: St. Louis, MO. Barr, J. & Cunneen, J. (2001). Understanding the Bariatric Client and Providing a Safe Hospital Environment. Clinical Nurse Barr, J. & Cunneen, J. (2001). Understanding the Bariatric Client and Providing a Safe Hospital Environment. Clinical Nurse

Specialist, 15(5): 219-223.Specialist, 15(5): 219-223. Hahler, B. (2002). Morbid Obesity: A Nursing Care Challenge. Medsurg Nursing, 11(2): 85-90. Hahler, B. (2002). Morbid Obesity: A Nursing Care Challenge. Medsurg Nursing, 11(2): 85-90. Hurst, S., Blanco, K., Boyle, D. Douglass, L. & Wikas, A. (2004). Bariatric Implications of Critical Care Nursing. Dimensions Hurst, S., Blanco, K., Boyle, D. Douglass, L. & Wikas, A. (2004). Bariatric Implications of Critical Care Nursing. Dimensions

of Critical Care Nursing, 23(2): 76-83.of Critical Care Nursing, 23(2): 76-83. Marik, P. & Varon, J. (1998). The Obese Patient in the ICU. Chest, 113, 492-498.Marik, P. & Varon, J. (1998). The Obese Patient in the ICU. Chest, 113, 492-498. National Institutes of Health. (2000). The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity National Institutes of Health. (2000). The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity

in Adults. National Institutes of Health national Heart, Lung, and Blood Institute North American Association for the Study of in Adults. National Institutes of Health national Heart, Lung, and Blood Institute North American Association for the Study of Obesity. Obesity.

Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804.Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804. Reto, C.S. (2003). Psychological Aspects of Delivering Nursing Care to the Bariatric Patient. Critical Care Nurse Quarterly, Reto, C.S. (2003). Psychological Aspects of Delivering Nursing Care to the Bariatric Patient. Critical Care Nurse Quarterly,

26(2), 139-149. 26(2), 139-149. Vachharajani, V. & Vital, S. (2006). Obesity and Sepsis. Journal of Intensive Care Medicine, 21, 287-295.Vachharajani, V. & Vital, S. (2006). Obesity and Sepsis. Journal of Intensive Care Medicine, 21, 287-295. Varon, J. & Marik, P. (2001). Management of the Obese Critically Ill Patient. Critical Care Clinics , 17(1). Varon, J. & Marik, P. (2001). Management of the Obese Critically Ill Patient. Critical Care Clinics , 17(1). Wilson, J.A. & Clark, J.J. (2003). Obesity: Impediment to Wound Healing. Critical Care Nurse Quarterly, 26(2), 119-132.Wilson, J.A. & Clark, J.J. (2003). Obesity: Impediment to Wound Healing. Critical Care Nurse Quarterly, 26(2), 119-132. Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA.Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA.

8080

References ContinuedReferences Continued http://emedicine.medscape.com/article/123702-treatment Bagchi, D. & Preuss, H. (2007) Obesity: Epidemiology, Pathophysiology, and Prevention. (CRC Bagchi, D. & Preuss, H. (2007) Obesity: Epidemiology, Pathophysiology, and Prevention. (CRC

Press, Taylor & Francis Group, LLC). Boca Raton, Fl.Press, Taylor & Francis Group, LLC). Boca Raton, Fl. http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf American Obesity AssociationAmerican Obesity Association http://win.niddk.nih.gov/statistics/index.htmhttp://win.niddk.nih.gov/statistics/index.htm Simoni, R. Brazilian Journal of Anesthesiology (2005). Tracheal Intubation of Morbidly Obese Simoni, R. Brazilian Journal of Anesthesiology (2005). Tracheal Intubation of Morbidly Obese

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(May 2006). Anesthesiology (104) 5, 1081-93.(May 2006). Anesthesiology (104) 5, 1081-93. Bell, R. & Rosenblum, S. (2005). Postoperative Considerations for Patients with Obesity and Bell, R. & Rosenblum, S. (2005). Postoperative Considerations for Patients with Obesity and Sleep Sleep

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Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales, & James S. Marks, (2003) Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, JAMA, (289),76-79.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119

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Author Information

Cheryl Holsworth, RN, MSA, CBNCheryl Holsworth, RN, MSA, CBNSenior Specialist Bariatric ProgramSenior Specialist Bariatric Program

Sharp Memorial HospitalSharp Memorial Hospital

Special thanks to the following SHC specialists for their valuable input:

Rossanne Decastro, RN, PHN, MSNc, Acute Care Specialist, SCVMC Karen Harmon, RNC, MSN, CNS, Perinatal Clinical Nurse Specialist,

SMBHW Steve Leary, RN, MSN, Senior Specialist Acute Care, SMH Susan Moore, RN, MSA, Senior Specialist Acute Care, SMH Paul Neves, RN, BSN, ONC, Acute Care Nursing Specialist, SGH Tanna Thomason, RN, MSN, Clinical Nurse Specialist, SMH

8282

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