Susan Reinhardt, RN, BSN, CBN, recalls an incident when a patients bariatric bed did not fit through the OR doors. No one had considered that the bed may have been too wide for the OR suite, she said. Yet not having the appropriate equipment, training, knowledge and protocols to care for obese surgical patients can threaten the well-being and safety of both patients and staff.
There is significant complexity of care for obese patients, and I dont think we (U.S. hospitals) are as well-prepared as we should be, said David G. Hunt, RN, MSN, director of nursing, cardiac care and radiology at the University of Maryland Medical Center in Baltimore. Hunt previously served as a perioperative safety officer at Johns Hopkins Hospital in Baltimore.
Thirty-four percent of the adult U.S. population and 18% of adolescents 12 to 19 years old are now considered obese, according to the U.S. Centers for Disease Control and Prevention. These individuals are being seen more frequently in all healthcare settings. Providing the same quality of care to patients who are obese as to thinner individuals requires consistent and thorough planning.
A perioperative plan
In the perioperative setting, planning for the care of bariatric patients is vital and requires anticipation, communication and preparation, said Bonnie Denholm, RN, MSN, CNOR, perioperative nursing specialist for the Association of periOperative Registered Nurses. Ideally, planning starts before the patient enters the hospital and continues postoperatively through discharge, she said.
Standardized education and training about the care of patients who are obese for healthcare workers is scant, Hunt said. Yet appropriate interdisciplinary team training and education is essential to provide respectful and quality care to this population.
The additional weight that patients who are obese carry profoundly affects their anatomy and physiology and thus their physiological responses to traditional medications, treatments and procedures, according to experts interviewed for this article. For example, obesity makes patients more prone to chronic diseases such as diabetes, high blood pressure, and cardiac and respiratory conditions, as well as complications from surgery, such as deep vein thrombosis and pulmonary emboli.
The extra adipose tissue affects the metabolism of anesthetic agents, pain medications and drugs for chronic conditions. Just having the patient in a supine position causes shifts in their organs and pressure on the stomach, heart and lungs, Denholm said.
The large folds of skin on their bodies and the extra tissue on their organs make them more prone to postoperative respiratory distress, injuries to their joints and limbs and wound infections, said the nurse experts.
And patient and staff safety can be compromised during a patients transfer between a bed and an OR table if the right equipment is not available or the staff is not properly trained in its use.
When preparing for patients who are obese, the perioperative team should consider the following:
Does the hospital have the appropriate-sized equipment for the patient, including large enough blood pressure cuffs, beds, chairs, OR tables, retractors, arm boards, stirrups, safety belts, etc.?
Are there lifting and transfer devices to protect the patient and staffs physical safety in the OR and on various units in which the patient will receive care?
Has a thorough patient history been done, including any comorbidities diabetes, cardiac disease, high blood pressure, respiratory problems, gastroesophageal reflux disorder that will need to be considered during surgery and postoperatively?
Has the patients skin been carefully assessed, including examining beneath skin folds and looking for excess moisture, rashes or other abnormalities?
Is there adequate staffing to safely transfer the patient, and has the operative team anticipated appropriate positioning of the patient for the procedure?
Nurse leaders should routinely evaluate [needed]supplies … transportation, lifting and handling equipment and evacuation strategies to ensure these also meet the best practice standards, according to the September 2011 article Preparing the Hospital Environment for Patients with Obesity, by Carmel A. McComiskey, David Hunt and Jennifer Servary published in the journal Bariatric Nursing and Surgical Patient Care.
If a facility does not have a designated OR for bariatric patients, then the OR team must anticipate everything a patient needs before he or she comes through the door, said Hunt.
Denholm, who helped develop AORNs recommended practices for positioning patients, said OR teams should plan well in advance how they will position an obese patient during surgery. You need to figure out how to get the patient in and out of surgery and how many people will be needed to position him or her correctly, she said.
Specific guidelines for positioning patients with morbid obesity can be found in Recommendation VIII.m.1 of AORNs Recommended Practices for Positioning the Patient in the Perioperative Practice Setting.
According to the article Perioperative Care of the Morbidly Obese Patient in the Lithotomy Position, by Geraldine Bennicoff, RN, CNOR, published in the September 2010 AORN Journal, nursing interventions can include ensuring that sequential compression stockings fit to prevent constriction and monitoring the patients clothing and bed linen to prevent constriction. …Drapes must be large enough to cover the patient and provide a sterile field. Instruments must be large enough to provide adequate exposure and allow the surgeon to perform.
Obesity also increases the risk of postoperative surgical site infections and the development of pressure sores and other skin and tissue complications, such as opening of the surgical wound (dehiscence). The results of a Johns Hopkins study released this year found patients with obesity undergoing colectomies have a 60% increased risk for developing surgical site infections.
Whenever we care for an obese patient, we are concerned about their airway and oxygenation, said Lisa Thiemann, CRNA, MNA, senior director of the American Association of Nurse Anesthetists, Professional Practice Division. The larger structures and extra tissue in a patients neck and chest may make traditional induction using a masked airway difficult or impossible, requiring the use of fiber-optic intubation during which the patient is awake, she said.
The patients extra weight also can affect the metabolism of anesthetics and pain medications. The pharmacokinetics of most general anesthetic drugs are affected by the mass of adipose tissue, producing a prolonged, less predictable effect, according the article Anaesthesia and Morbid Obesity: Pharmacokinetics of Anaesthetic Agents, published in the journal Continuing Education in Anaesthesia, Critical Care & Pain.
Short- and rapid-acting anesthetics, such as propofol, are usually preferred for obese patients because they are metabolized and eliminated more quickly, Thiemann said. Our inhalation drugs are also fast on and fast off, she said.
Nurse anesthetists also need to consider comorbities such as GERD. When a patient with obesity is supine, increased abdominal tissue can push on his or her stomach, causing the contents to come up from the stomach and then enter the lungs, resulting in aspiration of gastric contents, Thiemann said. These patients may need to be treated prophylactically with medication, she said.
Nurse anesthetists also are concerned about patients oxygenation postoperatively because obstructive sleep apnea is prevalent in obese individuals, leading to lower levels of oxygenation and rapid desaturation. Thiemann wants patients to have good oxygen exchange before extubating and prefers patients to be in a sitting position after surgery so they can breathe more easily.
We want to make sure they are safe and well-oxygenated after surgery, Thiemann said.
Eliminating nurse bias toward morbid obesity
Even if a perioperative team has all the necessary equipment and training, care of patients with obesity will be substandard if nurses and physicians treat them poorly. A patient who was obese once thanked Reinhardt for looking her directly in the eyes before surgery. It was a powerful statement, she said. Ive had patients tell me they felt invisible because they are obese and that people avoid them.
American society is still wedded to thinness as a sign of desirability and success in life, Reinhardt said. Too many people, including nurses, consider obesity a character flaw rather than a chronic disease, according to nurse experts. Research has documented that there is much intolerance and bias against obese individuals, Hunt said. We dont talk enough about teamwork that promotes respect and dignity.
Often the jargon that hospitals use when referring to the medical care surrounding obese patients is not respectful. For example, referring to a bariatric bed as a big boy bed, is not very respectful, Hunt said.
Despite the improvements still needed in the care of patients with obesity, progress is being made. Hunt said federal legislation regarding safe handling and lifting is being improved and that new guidelines and algorithms, such as those used by the Veterans Administration, are being developed. Im hopeful that new laws and algorithms will help to increase the awareness of a new generation [of healthcare workers], bringing improvements in the care of these high-risk patients, Hunt said.