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Care of the Critically Ill Bariatric Patient - 4 Nursing CEs
Care of the Critically Ill Bariatric Patient - 4 Nursing CEs
Author: Brooke Baldwin-Rodriguez, RN, MSN, WCC

Course Description
The epidemic of obesity in the United States creates the need for critical care nurses to understand the physiologic needs and the psychosocial needs of this patient population. This course will define and describe obesity so that students will have the background to identify and treat the consequences of obesity in the critically ill patient. The second part of this course will focus on how obesity affects the care and management of the critically ill patient by reviewing the effects of obesity on the body systems. The top reasons patients with obesity are admitted to the critical care area will be highlighted. The last part of this course will focus on the issues that affect the critical care nurses who care for the obese patient as well as safety for the obese patient while in the intensive care unit.
 
Course Objectives
  • Define obesity
  • Identify body mass index and the correspondence to obesity
  • Define common terms associated with obesity
  • State the prevalence of obesity in the United States
  • Identify the most 3 common reasons patients who are obese are admitted to the Intensive Care Unit
  • Identify the physiologic changes associated with obesity
  • List the consequences of physiologic changes when caring for the critically ill obese patient
  • Describe concerns for caregivers caring for obese patients
  • Identify equipment that may help in caring for the critically ill obese patient
  • Identify safety concerns for the obese patient in the intensive care unit
Definition and Description of Obesity
Obesity is a complex and multifaceted disease that involves interactions between social, behavioral, cultural, physiological, metabolic, and genetic factors. Obesity is defined as an excess in body fat stores. Generally, obesity is treated in the physician’s office. Obesity compromises health and leads to early death. Many patients who are obese are admitted to the critical care unit due to the comorbidities associated with obesity. When a patient is admitted to the critical care unit, obesity affects both patient outcomes and how nurses care for the patient.
 
Body mass index is the most common and accepted method of determining the degree of excess weight or obesity. Body Mass Index is calculated by multiplying the individual’s weight (in pounds) by 703, then, dividing by the height (in inches) squared. This calculation approximates BMI in kilograms per meter squared (kg/m2). There are also BMI charts to help determine a patient’s BMI.
 
Classifications for BMI, adopted by the Expert Panel on Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, are as follows:
BMI
Underweight < 18.5 kg/m2
Normal weight 18.5-24.9 kg/m2
Overweight 25-29.9 kg/m2
Obesity (Class 1) 30-34.9 kg/m2
Obesity (Class 2) 35-39.9 kg/m2
Extreme obesity (Class 3) > 40 kg/m2

Body mass index is strongly correlated with total body fat content and should be used to monitor changes in body weight. However, caution should be taken when calculating BMI in children, adults with edema, ascites, pregnancy, or individuals with a high ratio of muscle mass because the calculation may not accurately represent the true amount of excess fat tissue. Body circumference indices may also be used to assess for central pattern of obesity versus peripheral distribution of body fat. Central pattern obesity and a waist circumference to hip circumference ratio of > 0.9 in women and > 1.0 in men and is associated with higher risk of morbidity and mortality due to cardiovascular disease, diabetes, breast cancer, and stroke than peripheral pattern of fat distribution.
 
Some diseases or risk factors associated with obesity place patients at a higher risk for mortality in general. Diseases and conditions that reflect a high risk of mortality include established coronary artery disease, other atherosclerotic diseases, type 2 diabetes, and sleep apnea. Three or more of the following risk factors also reflect a high absolute risk of mortality: hypertension, cigarette smoking, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, impaired fasting glucose, family history of early cardiovascular disease, and age (male > 45 years, female > 55 years).
Definitions associated with care of the obese patient include: overweight, obesity, morbid obesity, and bariatrics.
 
Overweight
Excess body weight compared to established standards, such as BMI > 25-29.9 kg/m2. Excess weight may come from muscle, bone, fat, and/or water.

Obesity
Abnormal proportion of body fat. It is possible to be overweight without being obese (i.e. body builder), but many people are both.

Morbid obesity
Lifelong, progressive, life-threatening, genetics-related, multifactorial disease of excess fat storage with multiple comorbidities

Bariatrics
From the Greek baros for “weight”. Bariatrics includes health care related to the treatment of obesity and associated conditions.
 
Prevalence of Obesity
With an estimated 97 million adults that are overweight or obese, obesity is an epidemic. Healthcare providers must understand the potential consequences and realities of caring for this population since 10% to 25% of people between the ages of 26 years and 75 years are obese and more than 3% to 10% in this age range are morbidly obese. In the last decade the percentage of adults, ages 20 yeas or older, who are in the categories of overweight and obese has increased to 54.9 percent.
 
Many obese patients may seek treatment late due to impaired mobility, limited transportation options, and embarrassment and, thus, end up being admitted to the critical care units.
 
Why Care of the Obese Patient is Important for the Critical Care Nurse
Patients who are obese enter critical care units for various reasons. Three common reasons for admission are: acute complications associated with gastric restrictive surgery, factors of the consequences of obesity (i.e. cardiac, vascular, respiratory, endocrine, and immunologic sequelae), and as a result of trauma injury that requires admission to a critical care unit. Due the size and weight of the patient this becomes an important consideration for nurses because the patient may not be able to participate in care because of mobility and ambulation difficulties. Additionally, most hospital equipment is not designed for patients over 350 pounds. Prolonged lengths of stay may also lead to complications and co-morbidities. Co-morbidities associated with obesity include: pressure ulcers, wound infections, respiratory problems, and urinary incontinence. Nursing care must focus on the prevention of the potential complications. Physical assessments, turning, transferring, ambulating, physical care, and pharmacology are aspects of nursing care that are affected, and of special concern, for this patient population.
 
Review of physiological system effects of obesity
An increase in caloric intake and decrease in physical activity leads to obesity. Excess fat accumulation and the increased size of normal structures and fat deposits interfere with the mechanics of numerous body functions. Obesity is characterized by inflammation, hypercoagulability, and insulin resistance and is considered to be a chronic inflammatory state that diminishes immune and metabolic reserves.

Pathophysiology of Obesity
System Major Pathophysiology
Pulmonary
  • Decreased functional reserve capacity
  • Decreased total lung capacity
  • Decreased vital capacity
  • Decreased expiratory reserve volume
  • Obstructive sleep apnea syndrome
  • Alveolar collapse
  • Increased work of breathing
Cardiovascular
  • Chronic hypoxemia
  • Increased total blood volume
  • Increased vascular tone
  • Decreased ventricular contractility
  • Cardiac de-conditioning
Renal
  • Increased clearance of drug excretion
  • Increased intra-abdominal pressure
Metabolic / Endocrine
  • Increased resting expenditure level
  • Insulin resistance
  • Increased proteolysis
  • Stress of critical illness may deplete protein rather than glucose stores
Hematologic / Immune
  • Increased fibrinogen
  • Decreased antithrombin-III
  • Increased tumor necrosis factor
  • Increased interleukin-6
  • Impaired neutrophil function
Gastrointestinal / Nutritional
  • Hiatal hernia
  • Increased gastric secretion volume
  • Decreased gastric pH
  • Increased intra-abdominal pressure
  • Increased nutritional requirements
  • Hypermetabolism
Musculoskeletal
  • Increased joint trauma
  • Increased pain with movement
  • Increased disuse atrophy of musculature

Pulmonary Considerations
Both structural and physiological changes affect the pulmonary system of the obese patient. Structural changes lead to restrictive lung patterns and physiologic changes lead to increased work of breathing.  Functionally, there is a decrease in functional residual capacity, vital capacity, total lung capacity, inspiratory capacity, minute ventilation volumes, and expiratory reserve volumes due to the increase in intraabdominal pressure and the diaphragm pushing up on the lungs. Physiologically, increased pulmonary blood volume and increases in carbon dioxide production lead to an increased work of breathing. These structural and physiological changes lead to what is called “obesity hypoventilation.” Sleep apnea is very common in the obese patient due to airway narrowing from fat distribution in the upper airway and tongue.  Obstruction is commonly due to relaxation of throat structures; the base of the tongue falls against the posterior wall, occluding the pharynx and upper airway and leads to hypoxia.
 
The end result of sleep apnea for the obese patient may be the failure to breath. As breathing becomes more difficult in general for the patient, the respiratory rate will increase and there is a ventilation/perfusion mismatch. Hypoxemia and respiratory acidosis are the usual results of the ventilation/perfusion mismatch. A large body requires increased oxygen in order to maintain adequate tissue perfusion. Alveolar hypoventilation and sleep apnea may be the main reasons that the obese patient is hospitalized.
 
Continuous positive airway pressure (CPAP) may be used to treat the obstructive sleep apnea. With CPAP the air flows through a nasal mask against the airway resistance. The air enters the nasal pharynx and pushes the tongue forward, preventing the recurrent obstructive events. Body position will also influence respiratory status. Lying flat or in the Trendelenburg position will increase respiratory problems. Maintaining 30 to 45 degree semi-recumbent position is preferred. Atelectasis and pneumonia may result in shallow respirations. Adequate pain control will result in deeper respirations and more effective coughing, especially if the patient has had surgery.
 
Regular tracheostomy tubes may be too short to fit the obese patient. Using an extra long tracheostomy tube may be required. Tracheostomy ties may cause skin irritation and burrow into the skin. Tissue erosion can occur if ties are applied too tightly, so foam tracheostomy ties may provide better protection against tissue erosion.
 
When an obese patient has respiratory failure and requires a mechanical ventilator the delivered tidal volume should be calculated based on ideal body weight (IBW) rather than actual body weight (ABW) to avoid high airway pressures, alveolar over-distention, and barotraumas. The obese patient may have higher peak and static airway pressures than are usually recommended, but these may be necessary in order to oxygenate and have adequate alveolar ventilation. Positive End Expiratory Pressure (PEEP) may be needed to prevent closure of the alveoli and cause atelectasis.
Ventilatory discontinuance may become more difficult. Increased time on the ventilator leads to an increased risk of ventilator associated pneumonia and aspiration pneumonia. The reverse trendelenberg position at 45 degrees may facilitate discontinuing the ventilator in these patients.
 
Cardiovascular Considerations
Approximately 3 milliliters of blood volume are need per 100 grams of adipose tissue to maintain perfusion. Due to the increase in adipose tissue with obesity, circulating blood volume increases, preload increases, stroke volume increases, cardiac output increases, and myocardial workload increases in order to meet the perfusion demands. In order to increase circulating blood volume there is increased red blood cell production which causes increased blood viscosity. Increased blood viscosity leads to an increased risk for thrombophlebitis and thromboembolism.
 
Hyperinsulinemia in the obese patient can lead to sodium retention and, as a result, the obese patient develops hypertension. Other body processes that contribute to heart disease include increased triglyceride levels and reduced high-density-lipoprotein (HDL) cholesterol. Elevated circulating concentrations of catecholamines, mineralocorticoids, renin, and aldosterone usually lead to increased afterload, further contributing to heart disease. Cardiac disease associated with obesity eventually causes myocardial hypertrophy and decreased myocardial compliance. Diastolic dysfunction and ventricular failure can lead to sudden cardiac death.
 
When admitted to critical care units, pulmonary artery catheters may be need in the obese patient due to poor fluid tolerance that occurs with diastolic dysfunction to closely monitor hemodynamic status.
 
Beta-blockers should be used cautiously in obese patients due to the impaired ventricular contractility as a result of decreased beta adrenergic receptors.
 
Renal Considerations
Urinary and fecal incontinence are more common in the obese patient due to increased intra-abdominal pressure from excess abdominal weight. Limited mobility may contribute to incontinence because the patient is unable to ambulate or urinate independently.
 
Metabolic/Endocrine Considerations
Weight gain is associated with an increased demand for insulin and may result in pancreatic failure. Increased food intake may also be associated with an increase in T3 (triiodothyronine) produced from T4 (thyroxin), and lead to an increase in metabolic rate, causing an increase in cardiac output.
 
Metabolic X syndrome is common in the obese population. This syndrome is a culmination of insulin resistance, hyperinsulinemia, hyperglycemia, coronary artery disease, hypertension, and hyperlipidemia. Increased metabolic rate, accelerated net protein breakdown, and alterations in lipid and carbohydrate metabolism of critical illness exacerbate the preexisting metabolic problems for the obese.
 
Hemotalogic/Immune Considerations
One source of tumor necrosis factor and interleukin-6 is adipose tissue. As a patient becomes obese, the adipose tissue produces more of these inflammatory mediators. Another immune consideration is that neutrophils have impaired chemotaxis and activation, causing alteration is response to infection.
 
Gastrointestinal/Nutritional Considerations
Obese patients have an increase resting energy expenditure secondary to increased BMI.
Altered gastric pH and fluid volume have been found in obese surgical patients.
Aspiration risk is increased in the obese patient due to the higher volume of gastric fluid, a lower than normal pH of gastric fluid in fasting obese patients, increased intra-abdominal pressure, a higher incidence of gastroesophageal reflux, and a higher incidence of hiatal hernia.
 
Obese patients in intensive care units are likely to develop protein energy malnutrition due to metabolic stress. Traumatized obese patients mobilize more protein and less fat, compared with nonobese patients. In part, this is due to the fact that central adipose tissue is more metabolically active than peripheral adipose tissue, lipolysis and fat oxidation may be blocked. The preferred use of carbohydrates for energy may accelerate the body protein breakdown. The increased carbohydrate use for fuel increases the respiratory complication and increase in CO2 production. Increased incidence of diabetes mellitus in the obese population will often result in hyperglycemia and should, therefore, be monitored carefully. Insulin infusions may be necessary due to the difficulty in controlling blood sugars with a sliding scale.
 
Calories for nutrition in the intensive care unit should be given primarily as carbohydrates with fats to prevent essential fatty acid deficiency. Nutrition should not be withheld due to the belief that losing weight during critical illness will be beneficial to the patient. Enteral nutrition is the preferred route of feeding and is only contraindicated in patients with bowel obstruction.
 
Musculoskeletal/Integumentary Considerations
Obese patients have increased concentrations of fibrinogen and plasminogen activator inhibitor-1 and decreased concentrations of antithrombin-III and decreased fibrinolysis. The result is an increased risk of developing deep vein thromboses due to increased blood viscosity. Prevention of deep vein thrombosis should be a priority. Low-molecular weight heparin (LMWH), oral anticoagulation or the combination of pneumatic compression and LMWH should be considered for prophylaxis.
 
Obese patients often have chronic dermatitis in skin folds. Perineal skin breakdown can occur as a result of immobility, the inability to get to the bathroom, and the inability of the patient to adequately clean the perineal area. For men, it may be difficult to use the urinal due to problems of either sitting on the side of the bed or standing at the side of the bed. Catheterization of the obese patient may be difficult for the nurse and assistance if often needed for correct insertion technique. When an obese patient develops a wound the healing of the wound may occur more slowly due to the increase in adipose tissue which is less well vascularized. Wounds that develop in skin fold areas may be more prone to infection due to the moisture build up and the accumulation of bacteria.
 
Pharmacology
Obese patients react differently to medications due to a high percentage of adipose tissue and lower percentage of water and lean body mass. Medications are absorbed differently due to body composition. Drug levels may become sub-therapeutic or toxic.
 
Drugs that are highly soluble in fat and distribute mostly in adipose tissue include:
  • Carbaniazepine
  • Diazepam
  • Propofol
  • Opiate analgesics
 
Drugs that are highly soluble in adipose tissue should be calculated using the patient’s actual body weight. Drugs that are lipophilic need an increase in dose, but the half-life and the elimination rate is prolonged.
Drugs that are mainly distributed in lean tissue include:
  • Acetaminophen
  • Dioxin
Drugs that are mainly distributed in lean tissue should be dosed according to ideal body weight to avoid toxicity.
Longer needles may need to be used.

Drugs that rely on normal gastric pH absorption may be altered due to the lower pH.
Cutaneous tissue is not as well perfused in bariatric patients because absorption rates are based on the tissue perfusion of persons of average weight. Dosing and administration schedules may need to be adjusted.
 
Monitoring of clinical endpoints, signs of toxicity, clinical response, and serum drug levels, when appropriate, are essential components of care.
 
Issues for caregivers caring for the bariatric patient
When caring for an obese, or morbidly obese patient, the care for the patient becomes ever more intensive. Often patient’s may be unable to participate in their own care. Safety of both the patient and the caregiver is a major concern.
 
Equipment Considerations
Weight limits of the hospital bed, including the bed frame and side rails should be assessed. It is also important to know if the mattress will provide pressure relief versus pressure reduction for the weight of the patient. Specialty beds may be needed to provide the appropriate support for the weight of the patient. The pressure-relieving capabilities and whether the width of the bed is appropriate are two points for concern. All patients who are bed-ridden are at risk for skin breakdown, but those who are obese are at especially high risk. Poor blood supply to fatty tissue reduces the nutrients needed for healing. Also, pressure of skin folds may be enough to cause skin breakdown. Many bed companies have beds that support 800 to 1,000 pounds. Adequate nutritional assessment should be completed by the dietitian in any patient who is obese with a wound.
 
Wheelchairs and bedside commodes/shower chairs must be able to accommodate the patient’s size and weight. Door frame sizes, toilets, and sinks must be assessed prior to patient transfers and use of equipment.
 
Supplies of large gowns, adequate walkers, and bedside chairs must be in place. Tests and treatments may also be difficult due to the need to transfer patients, use the x-ray, or place the patient on the OR table. MRI weight capabilities should also be checked.
 
Over the bed trapezes may help the patient move in bed and reduce the risk of back strain to the health care provider. When the patient is immobile specialty beds and specialty lift and transfer equipment must be used for the safety of the nurse and patient.  Cardiac chairs that support the size and weight of the patient should be in place. Proper use of body mechanics is essential.
 
Routine Assessments
Routine assessments of weight, respiratory status, and blood pressure of the patient who is obese may be difficult. Auscultation of breath sound may be impossible and pulse oximetery may not penetrate the layer of fat requiring assessment of the respiratory status via arterial blood gases measurement and the appearance of sputum. Measuring blood pressure of a patient with a cuff that is too small for the upper arm will cause a falsely high reading, as well as possibly cause tissue injury to the patient’s arm. The width of the cuff bladder must be 40% to 50% of the arm’s circumference, and the length of the bladder must be 80% of the circumference to obtain an accurate reading. A cuff created especially for the bariatric patient will help provide the most accurate reading. When listening for breath sounds, displace all skin folds over the area, and then place the diaphragm 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. Listening for heart sounds either over the left lateral chest wall while the patient is turned toward the left side, or over the aortic or pulmonic areas to the left or right of the sternal border at the second intercostal space is optimal for the obese patient. Bowel sounds will take longer to distinguish than usual. Marking the location where bowel sounds were most easily heard will help with the consistency amongst the healthcare team. Obese patient are at special high risk for developing pressure ulcers. Skin inspection must include all skin folds – especially under breasts, abdominal folds, back skin folds, and perineal areas.
 
Nutritional assessment should be completed. Overweight patients are not always well nourished. They may be protein deficient and lack essential nutrients necessary for healing. Comprehensive assessment of nutritional status should include an assessment of laboratory values. Many obese patients may have obstructive sleep apnea. Apneic episodes occur largely during rapid eye movement sleep. If a patient has had surgery, the obstructive sleep apnea may not return until the 3rd to 5th night, which means the nurse must be aware of this possibility.
 
Central line placement on an obese patient is difficult due to the stubby neck, loss of physical landmarks, and greater skin-blood vessel distance. Catheters may be malpositioned more often with increased attempts at line placement. Obese patients also have poor peripheral venous sites. Central line should be vigilantly surveyed as central catheters are usually kept in longer, because they are difficult to insert, and the skin folds predispose the patient to infection.
 
Mobility
Ambulation, mobilization, and physical and occupational therapy should be initiated early in the hospital stay to prevent muscle atrophy and weakness. Proper body mechanics for both the patient and caregiver are essential to prevent injury for both. Prior to mobilizing patient ensure that the appropriate equipment is available.
 
Care of the skin
Topical antifungal agents are frequently needed to treat fungal rashes in skin folds. Powder should be avoided because it usually cakes under skin folds, which can lead to skin breakdown due to friction. Lubricants and ointments are better for treating superficial skin irritations and wicking away moisture from the skin.  Consideration of adequate pressure relieving surfaces should be evaluated in order to decrease the risk of the obese patient developing pressure ulcers. No-rinse perineal cleansers are useful for perineal care. The area should be thoroughly dried to maintain skin integrity. Moisture-barrier ointments are great adjuncts to prevent irritation of the skin from urine and feces.
 
When an obese patient has a wound, frequent dressing changes can place the patient at greater risk for skin tears due to tape application and removal. Consider using dressing that is changed less frequently to avoid such problems. Common complications that are found with wounds in obese patients include: infection, dehiscence, and hematoma and seroma formation. Infection becomes a greater risk with insufficient oxygen to the tissue to bring neutrophils and phagocytizing bacteria. Dehiscence may be due to increased tissue pressure and lack of oxygen to the area of the wound for healing. Hematomas and seromas may also create increased pressure and add tension to the incision.
 
Psychosocial Issues of Care
Weight control is essential for this patient population, but may not be the optimal topic of discussion during and acute care health crisis. The effect of excess weight on health can be discussed with the patient and family. Consultation to nutritional services should be included and offered to the patient and family as appropriate in the acute care setting. Including family members in the discussion is essential to avoid sabotage of the patient attempts to control weight and nutrition. Health care providers must also be mindful of facial expressions and body language and the types of messages sent.
 
Policy issues
As critical care units are seeing more and more patients who are overweight, obese, and morbidly obese. Critical care nurses must not only be aware of how to care for these patients, but must be proactive in creating guidelines and protocols that influence how patients are cared for. Proactive guidelines and protocols will not only help patients, but will help nurses in the resources needed to decrease the risk of complications, such as pressure ulcers, that may result from consequences of critical illness and the ability of the patient to participate in self care. Protocols and guideline help bring awareness of safety concerns for the obese patient population.
 
References
Marini, J., J. MD. Wheeler, A., P. (2009). Critical care medicine: the essentials. (4th ed.). Lippincott, Williams & Wilkins. Philadelphia

Hargrove-Huttel, R., A. (2008). Lippincott’s review series: medical-surgical nursing. (2nd ed.). Lippincott, Williams & Wilkens. Philadelphia

Alspach, J.G. (editor) (2006). Core Curriculum for Critical Care Nursing (6th edition). Saunders Elsevier: St. Louis, MO.

Barr, J. & Cunneen, J. (2001). Understanding the Bariatric Client and Providing a Safe Hospital Environment. Clinical Nurse Specialist, 15(5): 219-223.

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 of Critical Care Nursing, 23(2): 76-83.

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

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, 26(2), 139-149.

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).

Wilson, J.A. & Clark, J.J. (2003). Obesity: Impediment to Wound Healing. Critical Care Nurse Quarterly, 26(2), 119-132.

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