morbidly obese patient - CEConnection for Nursing

MR. MORGAN, 46, is admitted to your unitduring the night for difficulty breathing.His height is 68 inches (170 cm) and heweighs 486 pounds (220.9 kg). He arrivesfrom the emergency department (ED) on astretcher, and it takes six staff members totransfer him to a hospital bed. When youenter his room, Mr. Morgan is supine,breathing deeply, and crying. He has oxy-gen at 4 liters/minute and the tubing is tan-gled in his gown.

After untangling the tubing, you ask himwhy he’s crying. He tells you that he over-heard a nurse in the ED say, “He looks like agorilla and smells like a gorilla.” As you tryto calm him down, you realize that he mustbe uncomfortable, but you’re not sure how

to move him by yourself. You reassure himthat you’ll get help to reposition him.

When you auscultate Mr. Morgan’s lungs,you’re unable to hear any breath sounds,normal or adventitious. You attempt to listento his heart, but his heart sounds are muffledand you can’t differentiate between S1 andS2. Although you’ve made him more com-fortable and less upset, you know there’smore you can be doing to help Mr. Morgan.

Caring for a morbidly obese patient is asignificant challenge for you as a nurse bothphysically and psychologically. And manyof these patients have comorbid conditions,such as diabetes or heart disease, whichcompound their difficulties.

In this article, I’ll detail the issues you may

34 Nursing made Incredibly Easy! May/June 2008

As obesity continues to be a growing epidemic in the UnitedStates, it’s likely you’ll be called on to care for a patient who’smorbidly obese. Although doing so may be challenging, he stillrequires quality care. And we’ll show you how!HELENE HARRIS, RN, MSNInstructor • Temple College • Temple, Tex.

The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to thiseducational activity.

2.0ANCC/AACN

CONTACT HOURS

Nursing care of the

morbidlyobese patient

May/June 2008 Nursing made Incredibly Easy! 35

face while caring for a morbidly obesepatient, as well as nursing interventions youcan perform to give your patient the com-passionate care he deserves.

But before we focus on nursing care, let’stake a quick look at the definition and possi-ble causes of morbid obesity.

Defining morbid obesityAccording to the American Obesity Asso-ciation (AOA), about 9 million adult

Americans are morbidly obese. Any personwhose body mass index (BMI) exceeds 40

kg/m2 is diagnosed as severely, or mor-bidly, obese. This equates to being

about 100 pounds (45.5 kg) over-weight or more than two times theideal body weight (see Calculatingideal body weight). BMI is determined

by dividing a person’s weight by hisheight (see Calculating BMI). In Mr. Mor-gan’s case, his BMI is 73.9.

Morbid obesity is caused by taking inmore calories than expended, such as inovereating. There are numerous reasons

why people overeat: genetic, hormonal,behavioral, environmental, and cultural.That’s why obesity is a multifaceted issue.Genetics may play a role in predisposing aperson to becoming morbidly obese. Ac-cording to a study conducted by the AOA ofpatients undergoing bariatric surgery, 55%of the patients had factors in their historiesthat predisposed them to becoming morbid-ly obese.

Researchers are studying mechanisms ofmetabolism, appetite, and satiety and theirrelation to obesity. Areas of study involvegenetic traits in the way the body expendsenergy, hormones that affect the way calo-ries are processed, and other organ systemsin the body that affect appetite. Eating disor-ders, metabolic syndrome, behavioral issues,and cultural influences about food may alsoaffect the development of obesity.

What can you do to provide the best pos-sible care for these patients? Let’s delve intonursing care next.

The team approachCaring for a morbidly obese patient puts astrain on the nurse physically, so measuresmust be taken to ensure your safety frominjury as well as your patient’s comfort.Your facility may have a no-lift or low-liftpolicy in place, or lifting techniques maybe specified. Follow your facility’s policyregarding the techniques you may use toassist in lifting a morbidly obese patient,such as a trapeze over the bed that allowsthe patient to pull himself up or a mechan-ical lift during linen changes. Assistancefrom other staff nurses may be requiredfor lifting, as well as during tasks such asskin care, wound care, or other procedures.


Calculating ideal bodyweightWomen• Allow 100 pounds for 5 feet of height.• Add 5 pounds for each additional inch over 5feet.• Subtract 10% for small frame; add 10% forlarge frame.

Men• Allow 106 pounds for 5 feet of height.• Add 6 pounds for each additional inch over 5feet.• Subtract 10% for small frame; add 10% forlarge frame.

ExampleThe ideal body weight for a 5-foot, 6-inch adultis:Female:• 5 feet of height: 100 pounds • Per additional inch: 6 inches multiplied by 5pounds/inch = 30 pounds• Ideal body weight: 130 pounds plus/minus 13pounds depending on frame sizeMale: • 5 feet of height: 106 pounds • Per additional inch: 6 inches multiplied by 6pounds/inch = 36 pounds• Ideal body weight: 142 pounds plus/minus 14pounds depending on frame size

A patient isconsidered

morbidly obeseif he’s about100 poundsoverweight.

Follow your facility’s policies and proce-dures outlining the standard of care for themanagement of morbidly obese patients.Don’t let lack of staff deter care of your pa-tient.

Care of the morbidly obese patient in anintensive care unit or ED may also pose achallenge. Staff should proactively discusshow obesity affects the effectiveness of life-saving measures, and alternative courses ofaction should be addressed and a plan putin place (see Critical care and ED challenges).

One system at a timeEach system of a morbidly obese patientmay be affected, so it’s important that youperform a thorough physical exam. How-ever, performing a physical assessment ona morbidly obese patient may be difficultdue to the inability to hear sounds or feelpulses. Let’s take a closer look at the prob-lems you may encounter by system andnursing interventions you can perform foreach system during your assessment.

Cardiovascular Morbidly obese patients are prone tocoronary artery disease, systemic hyper-tension, and hyperlipidemia, all of whichmay lead to heart disease and increase therisk of atherosclerosis, deep vein throm-bosis (DVT), and peripheral vascular dis-ease. Fluid volume overload secondary toimpaired pumping action of the heart is

another problem to watch out for. Fluidbacks up into the lungs, heart, and ve-nous system because of the strain on theheart.

Obtaining accurate vital signs, especiallypulses and blood pressure, may be difficult.Here are some tips to follow:n Assess your patient’s heart sounds byhaving him lie on his left side if possible.This position places the heart closer to thechest wall. Also ensure a quiet environ-ment.n Use a blood pressure cuff that’s largeenough for your patient; otherwise, youmay get a false high reading. Use a thighcuff or place a regular-sized cuff on hisforearm.n Obtain a baseline weight, then weighyour patient daily at the same time eachday to monitor for fluid imbalance. Keep inmind that a standard standing scale maynot be able to accommodate a morbidlyobese patient. n Monitor his calves each day for signs ofDVT, such as redness, tenderness, and heat.n Assess for signs of edema. Note if theedema is pitting or nonpitting and deter-mine the grade if pitting (see Gradingedema). n Note the capillary refill time of his fin-gers and toes.n Monitor his hematocrit and hemoglobinlevels because a decrease in these valuesmay indicate anemia.


Critical care and ED challengesNurses who take care of morbidly obese patients in the intensive care unit and emergency depart-ment (ED) need to consider the following.• Intubation may be difficult if the patient has a short, thick neck.• Two people may be required to perform ventilation by mask: one person holding the mask in placeand the other managing the device.• Performing an emergency tracheotomy may take longer due to increased neck thickness and skinfolds.• Intravenous access may be difficult due to an increased amount of subcutaneous fatty tissue, whichmakes it difficult to see or feel deep veins; central line placement may be required.• Cardiopulmonary resuscitation may also be a challenge because visualization of the larynx may beobstructed due to increased neck thickness.

We’ll helpyou go

system bysystem.

Grading edemaEdema may be pitting or nonpitting. To differentiate between the two, press your finger against theswollen area for 5 seconds, then quickly remove it.

RespiratoryRespiratory failure is common in morbidlyobese patients. The chest wall’s ability toexpand is severely limited due to its en-larged size and the enlarged size of theabdomen. Fat deposits in the diaphragmand intercostal muscles further impairbreathing. Pneumonia or atelectasis mayoccur secondary to hypoventilation. Sleepapnea is also common in morbidly obesepatients. Obesity hypoventilation syn-drome (OHS), or pickwickian syndrome, is another sleep disorder associated withrespiratory insufficiency. The patient be-comes hypoxic and his respiratory drivedecreases, impairing compensation mecha-nisms. A combination of OHS and sleep

apnea is common in morbidly obese pa-tients (see A closer look at pickwickian syn-drome). For more information about sleepapnea, see “A tale of sleep apnea” fromour May/June 2007 issue.

Here’s what you need to do when moni-toring your patient’s respiratory status:n Assess your patient’s respiratory rate anddepth and monitor for signs of accessorymuscle use.n Auscultate his lung sounds at least onceper shift or according to your facility’s pol-icy. Crackles may indicate pneumonia orheart failure; wheezes and rhonchi may in-dicate asthma or chronic obstructive pul-monary disease. Your patient may requirerest periods between auscultation of thevarious areas.n Obtain oxygen saturation levels and lookfor signs of hypoxia, such as restlessnessand a decreasing level of consciousness(LOC). n Monitor his arterial blood gas values, ifordered.


Measuringpitting edema is quite a bit

easier than allthis digging!

Pitting edemaWith pitting edema, pressure forces fluid intothe underlying tissues, causing an indentationthat slowly fills. To determine its severity, esti-mate the indentation’s depth in centimeters: +1,+2, +3, or +4.

Nonpitting edemaWith nonpitting edema, pressure leaves noindentation because fluid has coagulated in thetissues. Typically, the skin feels unusually tightand firm.

n Assess the color of your patient’s skinand nail beds for pallor or cyanosis.n Assess the characteristics of his sputum(color, quantity, and amount); send a speci-men to the lab if required.n Encourage deep breathing and coughinghourly while your patient is awake or ac-cording to your facility’s policy and teachhim how to use an incentive spirometer toprevent pneumonia and expand his lungs.n Maintain the head of the bed at 30 de-grees to facilitate lung expansion and offsetsymptoms of gastroesophageal reflux dis-ease (GERD).n If your patient has OHS or sleep apneaand requires treatment with a bilevel posi-tive airway pressure or continuous positiveairway pressure machine, make sure heuses it.

GenitourinaryMorbidly obese patients may experienceurinary incontinence or have a comorbidityof renal disease. Incontinence is related toseveral factors: the difficulty in sitting on astandard-sized bedpan, bedside commode,or toilet; the time it takes to move the pa-tient onto the bedpan or commode; pres-sure on the bladder from an enlarged ab-domen; and skin folds in the perineal areathat tend to impede the voiding process.You’ll need to assess the characteristics ofhis urine (color, clarity, amount, and odor)and monitor his intake and output, if or-dered.

Here’s how to help your patient with toi-leting:n Offer frequent toileting.n Make sure the bedside commode is ac-cessible. If possible, provide an over-the-toilet commode, which may be easier than abedside commode for your patient to sit on. n It may be easier for some obese men tosit at the edge of the bed or stand when us-ing a urinal.n If catheterization is required, monitor forsigns or symptoms of urinary tract infec-tion.

Gastrointestinal Gallbladder disease and GERD are condi-tions associated with the morbidly obesepatient. Fecal incontinence is also commondue to the pressure of an enlarged ab-domen on the bowel placing pressure onthe sphincter, which can cause stool leak-age. Also, a morbidly obese patient maytend to lie on his back, which places addi-tional pressure on an already weakenedsphincter. Ascites, or fluid in the abdomen,may also be a problem because many mor-bidly obese patients experience portal hy-pertension due to pressure on the bloodvessels in the abdomen.

Here’s what you need to do:n Auscultate your patient’s bowel soundsat least once per shift or according to yourfacility’s policy.n Monitor his bowel status (how often andamount and characteristics of stool).n Listen to patient complaints of signs andsymptoms of GERD such as a burning feel-ing in the esophagus. Administer medica-tions as ordered and consult the dietitian toassist your patient with foods that won’t ex-


A closer look atpickwickian syndromePickwickian syndrome is a group of symp-toms that primarily affects patients withextreme obesity. The major health problemassociated with this syndrome is sleepapnea, which is caused by excessive fattytissue surrounding the chest muscles. Thisstrains the heart, lungs, and diaphragm andcontributes to breathing difficulties.

Besides sleep apnea, symptoms of pick-wickian syndrome include:• excessive daytime sleepiness• shortness of breath• disturbed nighttime sleep• flushed face or bluish tint to the face• hypertension• enlarged liver• elevated red blood cell count.

acerbate his reflux disease.n Monitor for signs of constipation and ad-minister medications as ordered. A dailystool softener may be needed.

Endocrine According to the Centers for Disease Con-trol and Prevention, the incidence of type 2diabetes has tripled in the last 30 years, pri-marily due to an epidemic of obesity; 97%of type 2 diabetes cases are caused by ex-treme weight gain. Because morbidly obesepatients have a high incidence of type 2 dia-betes, you’ll need to monitor for signs of

hypoglycemia (drowsiness, dizziness,pallor, diaphoresis, and decreasing LOC)and hyperglycemia (polyphagia, poly-uria, polydipsia, dry mouth, fatigue, anddry, itchy skin). A morbidly obese patient

can experience an extreme drop in hisblood glucose level despite hav-ing a large amount of adipose

tissue. That’s why it’s important to

check your patient’s blood glu-cose level at least four times a day

or according to your facility’s poli-cy. Dietary management is also

imperative. Teach your patient to eat smallmeals at regular intervals to help maintainhis blood glucose level. Make sure he under-stands how to substitute sugars and carbo-hydrates with other foods. A consult with adietitian can also assist your patient in tryingto change his eating habits. But remember tobe sensitive and understanding—eatinghabits are often difficult to change.

ImmuneMorbid obesity can lead to effects on theimmune system. If your patient has a weak-ened immune system, he may experienceprolonged healing of wounds and incisions.Monitor his white blood cell count, erythro-cyte sedimentation rate, and C-reactive pro-tein level for indications of infection and in-flammation. Assess any wounds for drain-age, odor, redness, and edema.

MusculoskeletalFor the morbidly obese patient, even walk-ing short distances may lead to respiratorydifficulty and fatigue. Simple acts such asbending and lifting may be cumbersome.The disuse of muscles can lead to atrophyand muscle weakness; bones may becomebrittle, making the patient prone to frac-tures.

If your patient is ambulatory, do thesethings:n Encourage him to perform as many ac-tivities of daily living as possible.n Encourage active range-of-motion (ROM)exercises at least three times per shift whileyour patient is awake or according to yourfacility’s policy.n Assist with ambulation. Watch for signsof fatigue and respiratory distress.

If your patient is on bed rest, do the fol-lowing:n Perform passive ROM exercises accord-ing to your facility’s policy to maintain cir-culation and prevent joint stiffness.n If needed, request a physical therapy oroccupational therapy consult.

DermatologicSkin care is a challenge for the morbidlyobese patient because of a large amount ofskin folds that trap perspiration. The risk ishigh for skin breakdown, irritation, andodor. Fungal infections may occur due to ir-ritation and moisture under the skin folds.Morbidly obese patients are also prone tocellulitis (a bacterial infection of the dermisand subcutaneous tissue) due to decreasedcirculation and comorbidities such as dia-betes and a compromised immune system.

To prevent skin breakdown, do the fol-lowing:n If possible, place your patient in a beddesigned specifically for obese patients.These beds are usually padded to preventpressure ulcers and have a larger width.n With the help of additional staff mem-bers, turn him every 2 hours or according toyour facility’s policy.


Remember,many morbidlyobese patientshave diabetes.

n Assess under skin folds, particularly un-der the neck, breasts, abdomen, groin, andperineal area, for fungal infection.n Avoid using tape if possible. Bandagerolls are just as secure and don’t precipitateskin breakdown.

Keep in mind...Other areas of concern when caring for amorbidly obese patient include medicationadministration and psychological issues.Let’s take a closer look.

Obesity can affect the way a drug is ab-sorbed, metabolized, and excreted. Severeobesity, high blood pressure, and diabetes allaffect kidney function and drug eliminationpatterns, which may lead to the effect of thedrug being lessened. And because of a large

kidney mass, the rate of renal elimination inthe morbidly obese patient increases if he’staking several drugs at once.

Morbidly obese patients are associatedwith many negative attributes, includinglaziness, poor hygiene, low intelligence, andpoor social skills. Many of these patients faceinsulting comments from health care work-ers, leading to feelings of embarrassment,guilt, and humiliation. A low self-esteem isthe result of continued negative comments.Always remember to treat your patient withrespect and dignity and encourage andpraise him as needed. (In some states, rude,hurtful comments that cause undue stress ona patient are reportable to the board of nurs-ing.) If your patient is experiencing emotion-al issues, request a consult with a social ser-


Calculating BMIThe body mass index (BMI) is used to determine who’s overweight. The BMI score is at the intersection of height and weight. Ascore of 25 or more is considered overweight; 30 or more, obese; and 40 or more, morbidly obese.

BMI 5703 3 weight in pounds

OR

weight in kilograms

(height in inches)2 (height in meters)2

25 Overweight Limit Overweight

S

Weight 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205Height5 0 20 21 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 405 1 19 20 21 22 23 24 25 26 26 27 28 29 30 31 32 33 34 35 36 37 38 395 2 18 19 20 21 22 23 24 25 26 27 27 28 29 30 31 32 33 34 35 36 37 375 3 18 19 19 20 21 22 23 24 25 26 27 27 28 29 30 31 32 33 34 35 35 365 4 17 18 19 20 21 21 22 23 24 25 26 27 27 28 29 30 31 32 33 33 34 355 5 17 17 18 19 20 21 22 22 23 24 25 26 27 27 28 29 30 31 32 32 33 345 6 16 17 18 19 19 20 21 22 23 23 24 25 26 27 27 28 29 30 31 31 32 335 7 16 16 17 18 19 20 20 21 22 23 23 24 25 26 27 27 28 29 30 31 31 325 8 15 16 17 17 18 19 20 21 21 22 23 24 24 25 26 27 27 28 29 30 30 315 9 15 16 16 17 18 18 19 20 21 21 22 23 24 24 25 26 27 27 28 29 30 305 100 14 15 16 17 17 18 19 19 20 21 22 22 23 24 24 25 26 27 27 28 29 295 110 14 15 15 16 17 17 18 19 20 20 21 22 22 23 24 24 25 26 26 27 28 296 0 14 14 15 16 16 17 18 18 19 20 20 21 22 22 23 24 24 25 26 26 27 286 1 13 14 15 15 16 16 17 18 18 19 20 20 21 22 22 23 24 24 25 26 26 276 2 13 13 14 15 15 16 17 17 18 19 19 20 21 21 22 22 23 24 24 25 26 266 3 12 13 14 14 15 16 16 17 17 18 19 19 20 21 21 22 22 23 24 24 25 266 4 12 13 13 14 15 15 16 16 17 18 18 19 19 20 21 21 22 23 23 24 24 25

vice worker, nurse practitioner, or clinicalnurse specialist who’s certified in the care ofthese patients.

Plans for the futureIs there anything you can do to helpyour patient lose weight? A combi-nation of diet and exercise orsurgery are options. Here’s whatyou need to know. Dietary considerations for the mor-

bidly obese patient focus on cuttingdown the amount of fats and carbohy-

drates he consumes. The dietary regimenmust include an exercise program. If yourpatient has difficulty adhering to a dietplan or has trouble exercising due tofatigue, a medication, such as orlistat(decreases intestinal fat) or sibutramine

(decreases appetite), may be prescribed toassist with weight loss.

If your patient is still having difficultylosing weight, then gastric bypass surgeryor gastric banding may be his only option(see Picturing bariatric surgery). During gas-tric bypass surgery, which may be per-formed by laparoscopy or laparotomy, asmall stomach pouch is created and con-nected to the upper portion of the smallintestine. During the laparoscopic gastricbanding procedure, a silicone band, knownas a lap band, is placed around the stom-ach, creating a smaller pouch. The band isadjustable and can be removed if needed.Adverse effects of these surgeries includedumping syndrome (diarrhea during andright after meals), infection, leaking at thesurgical site, and incisional hernias.


Reducing mysize can helpyour patientlose weight.

Picturing bariatric surgery

Esophagus

Reducedstomach pouch

Band

Inflation anddeflation tube

Stomach

Duodenum

Esophagus

Staples

StomachpouchJejunum

Stomach

Duodenum

Gastric bypass Adjustable gastric bandingIn gastric banding, the surgeon places a band around the top ofthe stomach to create the reduced pouch; the tube attached tothe band is then inflated 4 weeks postoperatively.

In gastric bypass, the surgeon uses sutures and staples with anasto-mosis to the jejunum to create the reduced stomach pouch.

All sizes welcomeCaring for a morbidly obese patient is oftendifficult due to the complexity of perform-ing a thorough head-to-toe exam and theneed for implementing proactive measuresto prevent complications with repositioningand lifting. These patients often have multi-ple comorbidities, including depressionfrom low self-esteem. But with your for-ward thinking, compassion, and respect,you can ensure that patients like Mr. Mor-gan receive the care they need. n

Learn more about itAmerican Obesity Association. AOA Fact Sheets. http://obesity1.tempdomainname.com/subs/fastfacts/aoafactsheets.shtml. Accessed January 29, 2008.

Arzouman J, et al. Developing a comprehensive bariatricprotocol: A template for improving patient care. MedsurgNursing: Official Journal of the Academy of Medical-SurgicalNurses. 15(1):21-26, February 2006.

Davidson JE, et al. Critical care of the morbidly obese. Crit-ical Care Nursing Quarterly. 26(2):105-116, April-June 2003.

Gabriel S, Garguilo H. Bariatric surgery basics. NursingMade Incredibly Easy! 4(1):42-50, January/February 2006.

Grindel ME, Grindel CG. Nursing care of the person hav-ing bariatric surgery. Medsurg Nursing: Official Journal ofthe Academy of Medical-Surgical Nurses. 15(3):129-145, June2006.

Hahler B. Morbid obesity: A nursing care challenge.Medsurg Nursing: Official Journal of the Academy of Medical-Surgical Nurses. 11(2):85-90, April 2002.

Health Assessment Made Incredibly Visual! Philadelphia, Pa.,Lippincott Williams & Wilkins, 2007:106.

Hurst S, et al. Bariatric implications of critical care nurs-ing. Dimensions of Critical Care Nursing. 23(2):76-83,March/April 2004.

Obesity in America. Causes of obesity. http://www.obesityinamerica.org/causes.html. Accessed January 30,2008.

Reto CS. Psychological aspects of delivering nursing careto the bariatric patient. Critical Care Nursing Quarterly.26(2):139-149, April-June 2003.

Smeltzer SC, et al. Brunner and Suddarth’s Textbook ofMedical-Surgical Nursing, 11th edition. Philadelphia, Pa.,Lippincott Williams & Wilkins, 2007:79.

Surgical Care Made Incredibly Visual! Philadelphia, Pa.,Lippincott Williams & Wilkins, 2007:70-71.

Zuzelo P. Bariatric patient care BASICS: Bias, airway,skin, incontinence, chronicity, and safety. The PennsylvaniaNurse. 60(3):18-19, June 2005.


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morbidly obese patient - CEConnection for Nursing