Obesity

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Focus on Focus on ObesityObesity(Relates to Chapter 41, (Relates to Chapter 41, “Nursing Management: Obesity,” “Nursing Management: Obesity,” in the textbook)in the textbook)


Obesity and OverweightObesity and Overweight

• Imbalance between energy expenditure Imbalance between energy expenditure and energy intake from a long-term and energy intake from a long-term sedentary lifestyle and/or excessive sedentary lifestyle and/or excessive calorie intakecalorie intake

• Obesity is an abnormal Obesity is an abnormal increase in the increase in the proportion of fat cellsproportion of fat cells



• Primarily occurs in the visceral and Primarily occurs in the visceral and subcutaneous tissues of the body subcutaneous tissues of the body



• Weight gain in adulthood is Weight gain in adulthood is characterized predominantly by characterized predominantly by adipocyte hypertrophy adipocyte hypertrophy Adipocyte hypertrophyAdipocyte hypertrophy is a process by is a process by

which adipocytes can increase their which adipocytes can increase their volume several thousandfold to volume several thousandfold to accommodate large increase in lipid accommodate large increase in lipid storagestorage


ObesityObesity

• Has reached epidemic proportions in Has reached epidemic proportions in developed and nondeveloped countriesdeveloped and nondeveloped countries

• In the United StatesIn the United States Most common nutritional problemMost common nutritional problem Affects one third of the populationAffects one third of the population


ObesityObesity

• Second leading cause of preventable Second leading cause of preventable deathdeath

• Third leading reason for liver Third leading reason for liver transplantationtransplantation


Etiology and PathophysiologyEtiology and Pathophysiology

• Energy intake exceeds energy outputEnergy intake exceeds energy output

• Processes leading to obesity are much Processes leading to obesity are much more complex and still undergoing more complex and still undergoing investigationinvestigation


Etiology and PathophysiologyEtiology and Pathophysiology

• Cause involves significant Cause involves significant genetic/biologic susceptibility factors genetic/biologic susceptibility factors that are that are ↑ influenced by environment ↑ influenced by environment and psychosocial factorsand psychosocial factors

• Caloric consumption must exceed Caloric consumption must exceed energy expenditure for condition to energy expenditure for condition to continuecontinue


Genetic/Biologic BasisGenetic/Biologic Basis

• Strong evidence of genetic Strong evidence of genetic predispositionpredisposition



• Most common form considered to be Most common form considered to be polygenic, arising from the interaction polygenic, arising from the interaction of multiple genetic and environmental of multiple genetic and environmental factorsfactors Identifying these genes will lead to a Identifying these genes will lead to a

better understanding of the pathogenesis better understanding of the pathogenesis



• Appetite is influenced by many factors Appetite is influenced by many factors that are integrated by the brain that are integrated by the brain Most importantly, the hypothalamus Most importantly, the hypothalamus

• Input to the hypothalamus is received Input to the hypothalamus is received from the periphery from many from the periphery from many different hormones and peptidesdifferent hormones and peptides


Hormones & Peptides that Interact Hormones & Peptides that Interact with Hypothalamus to Effect Obesitywith Hypothalamus to Effect Obesity

Fig. 41-3Fig. 41-3



• Associated with Associated with ↑ circulating plasma ↑ circulating plasma levels of leptin, insulin, and ghrelin, levels of leptin, insulin, and ghrelin, and ↓ levels of peptide YYand ↓ levels of peptide YY

• Adipocytes secrete a number of Adipocytes secrete a number of hormones and cytokines known as hormones and cytokines known as adipokines adipokines


Environmental FactorsEnvironmental Factors

• Greater access to foodGreater access to food Prepackaged foodPrepackaged food Fast foodFast food Soft drinksSoft drinks Increased portion sizesIncreased portion sizes

• Obese individuals tend to Obese individuals tend to underestimate food and caloric intakeunderestimate food and caloric intake


Environmental FactorsEnvironmental Factors

• Lack of physical exerciseLack of physical exercise Decreased at home and workDecreased at home and work Advances in technology and labor-saving Advances in technology and labor-saving

devicesdevices Increased time watching television and Increased time watching television and

playing video gamesplaying video games


Psychosocial FactorsPsychosocial Factors

• Emotional component to overeat is Emotional component to overeat is powerfulpowerful

• People use food for many reasonsPeople use food for many reasons

• Social component of eating is Social component of eating is developed early in lifedeveloped early in life Birthday parties, holidaysBirthday parties, holidays


Classification of Body Weight Classification of Body Weight and Obesityand Obesity• Primary obesity (Primary obesity (majority of obesemajority of obese))

Excess caloric intake for the body’s Excess caloric intake for the body’s metabolic demandsmetabolic demands

• Secondary obesitySecondary obesity Results from various congenital Results from various congenital

anomalies, chromosomal anomalies, anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and metabolic problems, or CNS lesions and disordersdisorders


Classification of Body Weight Classification of Body Weight and Obesityand Obesity• Body mass indexBody mass index

Degree to which a patient is classified as Degree to which a patient is classified as underweight, healthy (normal) weight, underweight, healthy (normal) weight, overweight, or obeseoverweight, or obese

Common clinical index of obesity or Common clinical index of obesity or altered body fat distributionaltered body fat distribution

Uses weight-to-height ratiosUses weight-to-height ratios


Body Mass IndexBody Mass Index

Fig. 41-4Fig. 41-4


Classification of Body Weight Classification of Body Weight and Obesityand Obesity• Waist-to-hip ratio (WHR)Waist-to-hip ratio (WHR)

Weight circumference is another way to Weight circumference is another way to assess and classify weightassess and classify weight

Method of describing distribution of Method of describing distribution of subcutaneous and visceral adipose tissuesubcutaneous and visceral adipose tissue

Waist measurement/hip measurement = Waist measurement/hip measurement = ratioratio

WHR <0.80 is optimal WHR <0.80 is optimal


Classification of Body Weight Classification of Body Weight and Obesityand Obesity• Waist-to-hip ratio (WHR) (cont’d)Waist-to-hip ratio (WHR) (cont’d)

WHR >0.80 indicates WHR >0.80 indicates greater risk for greater risk for health complicationshealth complications

People with People with more more visceral fat are at an visceral fat are at an increased risk for cardiovascular disease increased risk for cardiovascular disease and metabolic syndromeand metabolic syndrome

Preferred tool when patient is Preferred tool when patient is predominantly muscularpredominantly muscular


Classification of Body Weight Classification of Body Weight and Obesityand Obesity• By body shape or fat distributionBy body shape or fat distribution

Apple-shaped bodyApple-shaped body Fat located primarily in the abdominal areaFat located primarily in the abdominal area At greater risk for obesity-related complicationsAt greater risk for obesity-related complications Android obesityAndroid obesity

Pear-shaped bodyPear-shaped body Fat located primarily in upper legsFat located primarily in upper legs Gynoid obesityGynoid obesity


Classification of Body ShapesClassification of Body Shapes

Fig. 41-5Fig. 41-5


Common Fat DistributionCommon Fat Distribution

Fig. 41-1Fig. 41-1


Health Risks Associated with Health Risks Associated with ObesityObesity• Problems occur at Problems occur at higherhigher rates for obese rates for obese

patientspatients

• Mortality rate rises as obesity increasesMortality rate rises as obesity increases Especially with Especially with increased increased visceral fatvisceral fat

• Obese patients have a Obese patients have a decreaseddecreased quality quality of lifeof life

• Most conditions improve with weight lossMost conditions improve with weight loss


Health Risks Associated with Health Risks Associated with ObesityObesity

Fig. 41-6Fig. 41-6


Cardiovascular ProblemsCardiovascular Problems

• Obesity is a significant risk factor for Obesity is a significant risk factor for predicting cardiovascular diseasepredicting cardiovascular disease

• WHR is best predictor of riskWHR is best predictor of risk Android obesity patients at Android obesity patients at greater riskgreater risk



• RisksRisks ↑ ↑ Low-density lipoproteins (LDLs)Low-density lipoproteins (LDLs) ↑ ↑ Triglycerides Triglycerides ↓ ↓ High-density lipoproteins (HDLs)High-density lipoproteins (HDLs)



• Risks (cont’d)Risks (cont’d) HypertensionHypertension

↑ ↑ Circulating blood volumeCirculating blood volume Abnormal vasoconstrictionAbnormal vasoconstriction ↓ ↓ Vascular relaxationVascular relaxation ↑ ↑ Cardiac outputCardiac output



• Larger cuff to avoid artifactual ↑ may Larger cuff to avoid artifactual ↑ may be needed when taking blood pressurebe needed when taking blood pressure


Respiratory ProblemsRespiratory Problems

• Severe obesity may be associated withSevere obesity may be associated with Sleep apneaSleep apnea Obesity hypoventilation syndromeObesity hypoventilation syndrome ↓ ↓ Chest wall complianceChest wall compliance ↑ ↑ Work of breathingWork of breathing ↓ ↓ Total lung capacity and functional Total lung capacity and functional

residual capacity residual capacity


Diabetes MellitusDiabetes Mellitus

• HyperinsulinemiaHyperinsulinemia

• Insulin resistanceInsulin resistance

• Type 2 diabetesType 2 diabetes 80% of patients with type 2 diabetes are 80% of patients with type 2 diabetes are

obeseobese

• Weight loss and exercise improve Weight loss and exercise improve glucose controlglucose control


Musculoskeletal ProblemsMusculoskeletal Problems

• Osteoarthritis Osteoarthritis Trauma to weight-bearing joints Trauma to weight-bearing joints

• Hyperuricemia Hyperuricemia

• GoutGout


Gastrointestinal and Liver Gastrointestinal and Liver ProblemsProblems• Gastroesophageal reflux disease Gastroesophageal reflux disease

(GERD)(GERD)

• GallstonesGallstones

• Nonalcoholic steatohepatitis (NASH)Nonalcoholic steatohepatitis (NASH) Can eventually lead to cirrhosis Can eventually lead to cirrhosis Weight loss can improve NASHWeight loss can improve NASH


CancerCancer

• Obesity is one of the most important Obesity is one of the most important known preventable causes of cancer known preventable causes of cancer WomenWomen

Breast, endometrial, ovarian, cervical Breast, endometrial, ovarian, cervical Possibly from Possibly from ↑ estrogen postmenopause↑ estrogen postmenopause

MenMen Prostate Prostate

Both genders: Colon Both genders: Colon


Nursing AssessmentNursing Assessment

• Patient may withhold information out Patient may withhold information out of embarrassment or shynessof embarrassment or shyness

• Provide acceptable reasons for Provide acceptable reasons for personally intrusive questionspersonally intrusive questions

• Respond to concerns about diagnostic Respond to concerns about diagnostic teststests

• Interpret outcomesInterpret outcomes



• Health historyHealth history Time of obesity onsetTime of obesity onset Diseases related to metabolism and Diseases related to metabolism and

obesityobesity MedicationsMedications ObjectiveObjective

Height, weight, BMI, skinfold thickness, Height, weight, BMI, skinfold thickness, waist circumference waist circumference



• Health history (cont’d)Health history (cont’d) History with weight gain/weight lossHistory with weight gain/weight loss Interested in losing weight Interested in losing weight Contributors to weight gainContributors to weight gain What impedes weight lossWhat impedes weight loss



• Health history (cont’d)Health history (cont’d) How patient uses food (e.g., to relieve How patient uses food (e.g., to relieve

stress, provide comfort)stress, provide comfort) Other overweight family membersOther overweight family members Environmental or genetic factors Environmental or genetic factors

influencing weight gaininfluencing weight gain


Nursing Diagnoses Nursing Diagnoses

• Imbalanced nutrition: More than body Imbalanced nutrition: More than body requirementsrequirements

• Impaired skin integrityImpaired skin integrity

• Ineffective breathing patternIneffective breathing pattern

• Chronic low self-esteemChronic low self-esteem

• Health-seeking behaviorsHealth-seeking behaviors


PlanningPlanning

• Modify eating patternsModify eating patterns• Participate in a regular physical Participate in a regular physical

activity programactivity program• Achieve weight loss to a specified levelAchieve weight loss to a specified level• Maintain weight loss at a specified levelMaintain weight loss at a specified level• Minimize or prevent health problems Minimize or prevent health problems

related to obesityrelated to obesity


Nursing ImplementationNursing Implementation

• When no organic cause can be found When no organic cause can be found for obesity, it should be considered a for obesity, it should be considered a chronic, complex diseasechronic, complex disease

• Supervise a planSupervise a plan Successful weight loss, requiring a Successful weight loss, requiring a

short-term energy deficitshort-term energy deficit Successful weight control, requiring Successful weight control, requiring

long-term behavior changeslong-term behavior changes



• Multipronged approach ought to be Multipronged approach ought to be used with attention to multiple factors used with attention to multiple factors Dietary intake, physical activity, behavior Dietary intake, physical activity, behavior

modification, and/or drug therapymodification, and/or drug therapy

• All opportunities for patient education All opportunities for patient education should stress healthy eating and should stress healthy eating and exerciseexercise



• Motivation is essential to weight lossMotivation is essential to weight loss

• Set a realistic and healthy goal for Set a realistic and healthy goal for weight lossweight loss

• 1 to 2 pounds per week1 to 2 pounds per week

• Slower weight loss offers better Slower weight loss offers better cosmetic resultscosmetic results



• Plateaus can last from several days to Plateaus can last from several days to several weeksseveral weeks

• Daily weighing is not recommendedDaily weighing is not recommended

• Weigh once a week with similar Weigh once a week with similar clothing, at the same time of dayclothing, at the same time of day


Nutritional TherapyNutritional Therapy

• Restricted food intake is a cornerstoneRestricted food intake is a cornerstone

• A good weight loss plan contains food A good weight loss plan contains food from the basic food groupsfrom the basic food groups

• Diet classificationsDiet classifications 800 to 1200 calories: Low calorie800 to 1200 calories: Low calorie <800 calories: Very low calorie <800 calories: Very low calorie



• Adequate amounts of Adequate amounts of Fruits and vegetablesFruits and vegetables Lean meat, fish, and eggsLean meat, fish, and eggs

• Fad diets should be discouraged Fad diets should be discouraged Often body water is lost and not fatOften body water is lost and not fat



• Need to consider the proportion of Need to consider the proportion of calories from animal sources and calories from animal sources and calories from fruits, grains, and calories from fruits, grains, and vegetablesvegetables American Institute for Cancer ResearchAmerican Institute for Cancer Research

2/3 of the diet should be plant-source2/3 of the diet should be plant-source 1/3 or less from animal protein1/3 or less from animal protein



Table 41-8Table 41-8



• Food portion sizesFood portion sizes Serving of fruit and vegetablesServing of fruit and vegetables

Size of woman’s fist or baseballSize of woman’s fist or baseball Serving of meatServing of meat

Human’s palm or a deck or cardsHuman’s palm or a deck or cards Serving of cheeseServing of cheese

Size of a thumb or six dice Size of a thumb or six dice


ExerciseExercise

• An essential part of a weight control An essential part of a weight control programprogram

• Should be done daily for 30 minutes to Should be done daily for 30 minutes to an houran hour

• Sensible forms of exercise should be Sensible forms of exercise should be encouragedencouraged Walking, swimming, cycling Walking, swimming, cycling


Behavior ModificationBehavior Modification

• Assumption behind behavior Assumption behind behavior modificationmodification Learned disorderLearned disorder Critical difference between an obese Critical difference between an obese

person and a nonobese person are cues person and a nonobese person are cues that regulate eating behaviorthat regulate eating behavior

• Goal is to deemphasize diet and focus Goal is to deemphasize diet and focus of how and when a person eatsof how and when a person eats


Behavior ModificationBehavior Modification

• Has been successful helping people Has been successful helping people maintain weight loss maintain weight loss

• Useful basic techniquesUseful basic techniques Self-monitoring: Show what and when Self-monitoring: Show what and when

foods are eatenfoods are eaten Stimulus control: Separate events that Stimulus control: Separate events that

trigger eating from the act of eatingtrigger eating from the act of eating Rewards: Incentives for weight lossRewards: Incentives for weight loss


Support GroupsSupport Groups

• Encouragement can be offered to join a Encouragement can be offered to join a group of other obese persons who are group of other obese persons who are receiving professional counseling to receiving professional counseling to help modify eating habits help modify eating habits

• Many self-help groups are available Many self-help groups are available Take Off Pounds Sensibly (TOPS)Take Off Pounds Sensibly (TOPS) Weight Watchers Weight Watchers


Drug TherapyDrug Therapy

• Classified into two categoriesClassified into two categories ↓ ↓ Food intake by reducing appetite or Food intake by reducing appetite or

increasing satiety increasing satiety ↓ ↓ Nutrient absorption Nutrient absorption

• Drugs that ↑ energy expenditure are Drugs that ↑ energy expenditure are not approved by the FDAnot approved by the FDA



• Appetite-suppressing drugsAppetite-suppressing drugs Decrease food intake through nonadrenergic or Decrease food intake through nonadrenergic or

serotonergic mechanisms in the central nervous serotonergic mechanisms in the central nervous system (CNS)system (CNS)

PhenterminePhentermine DiethylpropionDiethylpropion PhendimetrazinePhendimetrazine

Recommended for short-term useRecommended for short-term use



• Appetite-suppressing drugs (cont’d)Appetite-suppressing drugs (cont’d) Serotonergic drugs ↑ release of serotonin Serotonergic drugs ↑ release of serotonin

or ↓ its uptake thus ↓ metabolismor ↓ its uptake thus ↓ metabolism fenfluramine (Pondimin)fenfluramine (Pondimin) dexfenfluramine (Redux)dexfenfluramine (Redux) Removed from market in 1997Removed from market in 1997



• Appetite-suppressing drugs (cont’d)Appetite-suppressing drugs (cont’d) Mixed nonadrenergic–serotonergic Mixed nonadrenergic–serotonergic

agentsagents Do not stimulate release of serotonin Do not stimulate release of serotonin Sibutramine (Meridia)Sibutramine (Meridia)



• Nutrient absorption-blocking drugsNutrient absorption-blocking drugs Work by blocking fat breakdown and Work by blocking fat breakdown and

absorption in intestine absorption in intestine Inhibits action of intestinal lipases Inhibits action of intestinal lipases Undigested fat is excreted in fecesUndigested fat is excreted in feces

Orlistat (Xenical) Orlistat (Xenical)

• Purchasing over-the-counter drugs Purchasing over-the-counter drugs should be discouraged should be discouraged


Bariatric SurgeryBariatric Surgery

• Used to treat morbid obesityUsed to treat morbid obesity

• Currently the only treatment found to Currently the only treatment found to have a successful and lasting impact have a successful and lasting impact for sustained weight lossfor sustained weight loss



• Must meet all of the following criteria Must meet all of the following criteria to be considered an ideal candidateto be considered an ideal candidate BMI BMI ≥40 kg/m≥40 kg/m2 2 with one or more with one or more

obesity-related complicationobesity-related complication 18 years or older18 years or older Understands the risks and benefits Understands the risks and benefits Has been obese for >5 yearsHas been obese for >5 years Has tried and failed to lose weightHas tried and failed to lose weight



• Criteria to be considered an ideal Criteria to be considered an ideal candidate (cont’d)candidate (cont’d) Has no serious endocrine problemsHas no serious endocrine problems Has psychiatric and social stability Has psychiatric and social stability Availability of a team of health care Availability of a team of health care

providersproviders Surgery would Surgery would ↓ or eradicate high-risk ↓ or eradicate high-risk

conditionsconditions



• Three broad categoriesThree broad categories RestrictiveRestrictive Malabsorptive Malabsorptive Combination of restrictive and Combination of restrictive and

malabsorptive malabsorptive


Restrictive SurgeryRestrictive Surgery

• Reduces the size of a stomach to 30 ml Reduces the size of a stomach to 30 ml or lessor less

• Causes patient to feel full quickerCauses patient to feel full quicker

• Normal stomach digestion and Normal stomach digestion and intestinal absorption of foodintestinal absorption of food ↓ ↓ Risk of anemia and cobalamin Risk of anemia and cobalamin

deficiencydeficiency



• Vertical banded gastroplastyVertical banded gastroplasty Partitions stomach into a small pouch in Partitions stomach into a small pouch in

upper portion upper portion Small pouch drastically limits capacitySmall pouch drastically limits capacity Stoma opening to rest of stomach is Stoma opening to rest of stomach is

banded to delay emptying of solid food banded to delay emptying of solid food from proximal pouchfrom proximal pouch



Fig. 41-7AFig. 41-7A



• Adjustable gastric banding (AGB)Adjustable gastric banding (AGB) Also referred to as the LapBandAlso referred to as the LapBand Stomach size is limited by an inflated Stomach size is limited by an inflated

band placed around fundus of stomachband placed around fundus of stomach Band is connected to a subcutaneous portBand is connected to a subcutaneous port Can be inflated or deflated to change Can be inflated or deflated to change

stoma size stoma size



• AGB (cont’d)AGB (cont’d) Can be done laparoscopically and can be Can be done laparoscopically and can be

modified or reversed modified or reversed Better choice for patients who are Better choice for patients who are

surgical riskssurgical risks Weight loss is slower than in other Weight loss is slower than in other

proceduresprocedures



Fig. 41-7BFig. 41-7B


Malabsorptive Surgeries Malabsorptive Surgeries

• Biliopancreatic diversion (BPD)Biliopancreatic diversion (BPD) Removes ~3/4 of stomach to Removes ~3/4 of stomach to ↓↓ food intake food intake

and and ↓ acid output↓ acid output Remaining 1/4 of stomach is connected to Remaining 1/4 of stomach is connected to

lower portion of small intestine lower portion of small intestine Pancreatic enzymes and bile enter final Pancreatic enzymes and bile enter final

segment of intestinesegment of intestine Nutrients pass without being digestedNutrients pass without being digested


Malabsorptive Surgeries Malabsorptive Surgeries

• Biliopancreatic diversion with Biliopancreatic diversion with duodenal switchduodenal switch Variation of BPDVariation of BPD By including duodenal switch, surgeons By including duodenal switch, surgeons

leave a larger portion of the stomach leave a larger portion of the stomach intactintact

Helps prevent dumping syndromeHelps prevent dumping syndrome



Fig. 41-7CFig. 41-7C


Combination of Restrictive and Combination of Restrictive and Malabsorptive SurgeryMalabsorptive Surgery• Roux-en-Roux-en-YY surgical procedure surgical procedure

Has low complication ratesHas low complication rates Excellent patient toleranceExcellent patient tolerance Stomach size is Stomach size is ↓ with a gastric pouch ↓ with a gastric pouch

anastomosis that empties directly into anastomosis that empties directly into jejunumjejunum


Combination of Restrictive and Combination of Restrictive and Malabsorptive SurgeryMalabsorptive Surgery• Roux-en-Roux-en-YY surgery (cont’d) surgery (cont’d)

VariationsVariations Stapling stomach without transection to Stapling stomach without transection to

create a small 20- to 30-ml gastric pouchcreate a small 20- to 30-ml gastric pouch Creating an upper and lower gastric pouch Creating an upper and lower gastric pouch

and totally disconnecting the pouchesand totally disconnecting the pouches Creating an upper gastric pouch and Creating an upper gastric pouch and

completely removing the lower pouchcompletely removing the lower pouch



Fig. 41-7DFig. 41-7D


Cosmetic SurgeriesCosmetic Surgeries

• Ideal candidates have Ideal candidates have Achieved weight reduction Achieved weight reduction Excess skinfolds or fatExcess skinfolds or fat

• Chooses surgery for cosmetic reasonsChooses surgery for cosmetic reasons LipectomyLipectomy LiposuctionLiposuction


Preoperative CarePreoperative Care

• Patients who are obese are likely to Patients who are obese are likely to suffer other comorbidities, such as suffer other comorbidities, such as Diabetes, altered cardiorespiratory Diabetes, altered cardiorespiratory

function, abnormal metabolic function, function, abnormal metabolic function, atherosclerosis atherosclerosis

• A team approach may be necessaryA team approach may be necessary Cardiologist, pulmonologist, gynecologist, Cardiologist, pulmonologist, gynecologist,

gastroenterologist, or other specialistgastroenterologist, or other specialist



• Have room ready for patient prior to Have room ready for patient prior to arrivalarrival Larger size blood pressure cuffLarger size blood pressure cuff Larger gown Larger gown Bariatric wheelchairBariatric wheelchair

Or a wheelchair with removable arms Or a wheelchair with removable arms Strongly reinforced trapeze bar over bed Strongly reinforced trapeze bar over bed

for movement and positioningfor movement and positioning



• Have room ready for patient prior to Have room ready for patient prior to arrival (cont’d)arrival (cont’d) It may be necessary to put beds together It may be necessary to put beds together

or specially construct a chairor specially construct a chair Have proper amount of staff on hand for Have proper amount of staff on hand for

ambulating, bathing, and turning patientambulating, bathing, and turning patient



• Wound infection is one of the most Wound infection is one of the most common complications because of the common complications because of the many layers of flabby skinfolds, many layers of flabby skinfolds, especially in the abdominal areaespecially in the abdominal area

• Skin preparation is important Skin preparation is important • May be necessary to ask patient to May be necessary to ask patient to

bathe or shower frequently for a few bathe or shower frequently for a few days before admission to hospital days before admission to hospital



• Obesity can make breathing shallow Obesity can make breathing shallow and rapidand rapid

• Instruct patient in proper Instruct patient in proper Coughing techniques Coughing techniques Deep, diaphragmatic breathingDeep, diaphragmatic breathing Methods of turning and positioning to Methods of turning and positioning to

prevent pulmonary complications prevent pulmonary complications



• Obtaining venous access may be Obtaining venous access may be complicatedcomplicated Assistance may be neededAssistance may be needed Mark the spot of injection with a sterile Mark the spot of injection with a sterile

skin marker once a vein has been found skin marker once a vein has been found If patient has excess fat, or pitting edema, If patient has excess fat, or pitting edema,

hold a firm finger over the spot with hold a firm finger over the spot with pressurepressure



• Obtaining venous access (cont’d)Obtaining venous access (cont’d) Multiple tourniquets can be used to Multiple tourniquets can be used to

distend veins and hold back excess tissuedistend veins and hold back excess tissue Tourniquet should be removed as soon as Tourniquet should be removed as soon as

it is no longer needed to avoid edema it is no longer needed to avoid edema Edema can worsen if catheter is anchored Edema can worsen if catheter is anchored

with tape to armwith tape to arm Further impeding venous returnFurther impeding venous return



• Obtaining venous access (cont’d)Obtaining venous access (cont’d) May need a longer catheter to traverse May need a longer catheter to traverse

overlying tissueoverlying tissue Longer than 1 inch Longer than 1 inch

Important that cannula is far enough into Important that cannula is far enough into vein so that it is not dislodged or vein so that it is not dislodged or infiltrated infiltrated



• Patients undergoing anesthesia have an Patients undergoing anesthesia have an increased risk of failing to wean from increased risk of failing to wean from mechanical ventmechanical ventilation ilation


Postoperative CarePostoperative Care

• Trained staff should assist transfer of Trained staff should assist transfer of unconscious patient unconscious patient

• During transfer ensure that patient’sDuring transfer ensure that patient’s Airway is stabilized Airway is stabilized Pain is managedPain is managed

• In severely obese patients it is essential to In severely obese patients it is essential to monitor for rapid oxygen desaturation monitor for rapid oxygen desaturation



• Early ambulation is essential Early ambulation is essential

• Frequently Frequently ↑ ambulation after initial ↑ ambulation after initial movemove Generally 3 to 4 times a dayGenerally 3 to 4 times a day

• Pneumatic compression devices, elastic Pneumatic compression devices, elastic compression stockings, or elastic wraps compression stockings, or elastic wraps will be used will be used



• Patients undergoing bariatric surgery Patients undergoing bariatric surgery are often in considerable abdominal are often in considerable abdominal painpain

• Pain medications should be given as Pain medications should be given as frequently as necessary during frequently as necessary during immediate postoperative period immediate postoperative period


Ambulatory and Home CareAmbulatory and Home Care

• Patients who have just had bariatric Patients who have just had bariatric surgery have been unsuccessful in the surgery have been unsuccessful in the past maintaining a prescribed dietpast maintaining a prescribed diet

• Patient is now Patient is now reduced intake due to reduced intake due to anatomic changes anatomic changes

• Must learn to adjust intake sufficiently Must learn to adjust intake sufficiently with regard to nutrition and with regard to nutrition and maintaining a stable weightmaintaining a stable weight



• Diet prescribed is generally Diet prescribed is generally High protein High protein Low carbohydrates Low carbohydrates Low fatsLow fats Low roughage Low roughage 6 small feedings6 small feedings Fluids not to be ingested with mealsFluids not to be ingested with meals

<1000 ml/day <1000 ml/day



• Possible complications from bariatric Possible complications from bariatric surgerysurgery Anemia Anemia Vitamin deficiencies Vitamin deficiencies Diarrhea Diarrhea Psychiatric problemsPsychiatric problems



• Possible complications from bariatric Possible complications from bariatric surgery (cont’d)surgery (cont’d) Peptic ulcer formationPeptic ulcer formation Dumping syndromeDumping syndrome Small bowel obstruction Small bowel obstruction


EvaluationEvaluation

• Expected outcomesExpected outcomes Long-term weight lossLong-term weight loss Improvement in obesity-related Improvement in obesity-related

comorbiditiescomorbidities Integration of healthy practices into Integration of healthy practices into

lifestylelifestyle Monitoring possible adverse side effects Monitoring possible adverse side effects Improved self-image Improved self-image


Gerontologic ConsiderationsGerontologic Considerations

• Number of older obese persons has Number of older obese persons has risen risen

• More common in women than menMore common in women than men

• Decreased energy expenditure and loss Decreased energy expenditure and loss of muscle mass are important of muscle mass are important contributorscontributors

• Exacerbates age-related problemsExacerbates age-related problems


Metabolic SyndromeMetabolic Syndrome

• Also known as Also known as Syndrome X, insulin resistance syndrome, Syndrome X, insulin resistance syndrome,

dysmetabolic syndrome dysmetabolic syndrome

• Collection of risk factors that Collection of risk factors that increase increase an individual’s chance of developing an individual’s chance of developing cardiovascular disease and diabetes cardiovascular disease and diabetes mellitus mellitus


Metabolic SyndromeMetabolic Syndrome

• Diagnosed if an individual has three or Diagnosed if an individual has three or more of the conditions listed more of the conditions listed

Waist circumference ≥40 inches (men) or ≥35 inches Waist circumference ≥40 inches (men) or ≥35 inches (women)(women)

Triglycerides >150 mg/dl or being treatedTriglycerides >150 mg/dl or being treated High-density lipoprotein (HDL) cholesterol <40 men, High-density lipoprotein (HDL) cholesterol <40 men,

<50 women or being treated<50 women or being treated Blood pressure ≥130 mm Hg systolic or ≥85 mm Hg Blood pressure ≥130 mm Hg systolic or ≥85 mm Hg

diastolic or being treateddiastolic or being treated Fasting glucose is ≥100 mg/dl or being treated Fasting glucose is ≥100 mg/dl or being treated


Metabolic SyndromeMetabolic SyndromeEtiology and PathophysiologyEtiology and Pathophysiology• Main underlying risk factorsMain underlying risk factors

Abdominal obesityAbdominal obesity Insulin resistanceInsulin resistance


Metabolic SyndromeMetabolic SyndromeEtiology and PathophysiologyEtiology and Pathophysiology• Other risk factors Other risk factors

Physical inactivityPhysical inactivity Presence of inflammatory markersPresence of inflammatory markers Prothrombotic tendencies Prothrombotic tendencies Hormonal imbalances Hormonal imbalances Aging Aging Genetic or ethnic predisposition Genetic or ethnic predisposition


Metabolic SyndromeMetabolic SyndromeEtiology and PathophysiologyEtiology and Pathophysiology• No symptomsNo symptoms

• Medical problems develop if syndrome Medical problems develop if syndrome is not addressedis not addressed Heart diseaseHeart disease StrokeStroke DiabetesDiabetes Renal diseaseRenal disease


Metabolic SyndromeMetabolic SyndromeNursing and Collaborative ManagementNursing and Collaborative Management

• Lifestyle therapy is first line of Lifestyle therapy is first line of interventionintervention Manage cholesterolManage cholesterol Stop smokingStop smoking Lower blood pressureLower blood pressure Reduce glucose levelsReduce glucose levels



• Lifestyle therapy is first line of Lifestyle therapy is first line of intervention (cont’d)intervention (cont’d) Lose weightLose weight Increase physical activity Increase physical activity Healthy dietary habits Healthy dietary habits



• Because there is only management, the Because there is only management, the nurse can assist patients by providing nurse can assist patients by providing information information

Obesity

Documents

obesity problems

obesity waist

effect obesity

classification of body

obesity body mass index

upper legs gynoid obesity

altered body fat distribution

classification of body