The challenges in caring for morbidly obese patients in Intensive Care: A focused ethnographic study.

BACKGROUND: Critically ill morbidly obese patients pose considerable healthcare delivery and resource utilisation challenges. However little is known about the care of these patients in intensive care. OBJECTIVE: To explore medical and nursing practices and attitudes in intensive care when caring for critically ill morbidly obese patients. METHODS: A focused ethnographic approach was adopted. Participant observation of care practices and interviews with intensive care doctors and nurses were undertaken over a four month period. Qualitative analysis was conducted using constant comparison. SETTING: An 18 bedded tertiary intensive care unit in New Zealand. PARTICIPANTS: Sixty-seven intensive care nurses and 13 intensive care doctors involved with the care and management of seven critically ill patients with a body mass index ≥40kg/m2. FINDINGS: Morbidly obese patients present significant physical and language challenges for intensive care practice. The physical shape of morbidly obese patients did not appropriately fit the different equipment used. Staff used specific knowledge of the patient's body size and shape to adapt care practices and keep patients safe and comfortable. There were also specific language challenges where staff expressed concern about what words were most appropriate to use to describe body mass when in the presence of morbidly obese patients. CONCLUSIONS: Bariatric care pathways need to be developed that use more suitable body measurements to inform the use of bariatric equipment. Intensive care staff need to engage in debate about what is acceptable, respectful, and appropriate language in the delivery of bariatric patient care.

Fistula Isolation and the Use of Negative Pressure to Promote Wound Healing: A Case Study.

BACKGROUND: A 54-year-old morbidly obese woman with a small bowel obstruction and large ventral hernia was admitted to hospital. She underwent an exploratory laparotomy, lysis of adhesions, and ventral hernia repair with mesh placement. She subsequently developed an enteroatmospheric fistula; several months of hospital care was required to effectively manage the wound and contain effluent from the fistula. METHODS: Several approaches were used to manage output from the fistula during her hospital course. She was initially discharged to a skilled nursing facility where a fistula management pouch was used for several months to encompass the wound and contain effluent, but this method ultimately proved ineffective. The fistula was then isolated using a collapsible enteroatmospheric fistula isolation device and an ostomy appliance to contain effluent. CONCLUSION: The application of the collapsible enteroatmospheric fistula isolation and effluent containment devices in conjunction with negative-pressure wound therapy produced positive patient outcomes; it improved patient satisfaction with fistula management, promoted wound healing, and diminished cost.

The impact of a lifestyle change program on the mental health of obese under-served African American women.

BACKGROUND: Obesity is a critical social and health issue, adversely impacting life expectancy, quality of life, and mental health. Minorities are disproportionately impacted by obesity with African Americans experiencing the highest prevalence among minority groups. PURPOSE: The aim of this study was to determine if a lifestyle program that integrated chair exercises, nutrition and educational counseling, and scripture readings would help under-served obese African American women make lifestyle changes that would positively impact their quality of life, especially mental health. METHODS: A repeated measures intervention study was conducted (24-weeks). Weeks 1-12 involved meeting twice a week for a total of 4h with participants engaged in chair exercises, educational counseling, and scripture readings. During weeks 13-24, the participants were "on their own" but were encouraged to exercise and eat healthy. Focus groups were held at 12 and 24-weeks. Participants were recruited from a nurse managed center and a primary care clinic for the uninsured. Mental health data were collected at baseline, 12, and 24-weeks. The Medical Outcomes Study Short Form Version 2 (SF-36v2) was used to measure changes in mental health. Higher scores indicate better perceived health status. Group scores less than 47 indicate impaired functioning. FINDINGS: 55 women had complete data for all three data collection points, with a mean age of 50 and a mean BMI of 41.2. Repeated ANOVAs detected significant differences on the mental component summary of the SF-36v2: this score improved from baseline (M=44.1) to 12-weeks (M=50.7) but decreased at 24-weeks (M=47.9) (p=.000). The four domains (vitality, social functioning, role emotional, mental health) were also significantly different over the three data collection points. IMPLICATIONS: The findings have significant implications for psychiatric nurses in terms of education, clinical practice, and future research. The study contributed to the participants' mental health through the various group activities including scripture readings, socialization with "like minded" women and structured exercises. These findings offer psychiatric nurses additional tools for effective care.

Nursing care of the super bariatric patient: challenges and lessons learned.

PURPOSE: The purpose of this article is to describe the care of a "super bariatric" patient. DESIGN AND METHODS: We used a case study approach to describe the complex interdisciplinary care challenges posed in the care of a super bariatric patient at a Veterans Administration Hospital in the Midwest. FINDINGS: Nurses and other healthcare providers discovered ways to provide high-quality patient-centered care under challenging conditions and also ensure the safety and well-being of nursing staff and other providers. CONCLUSIONS/CLINICAL RELEVANCE: An interdisciplinary, patient-centered approach with advance planning and coordination is necessary to ensure the delivery of safe, high-quality nursing care to veterans with complex health problems who are "super bariatric."

Patients' perception of the nursing contribution to gastric band surgery.

Gastric banding is an established and effective form of weight-loss surgery. However, the nursing contribution to it remains largely unexplored. Using semi-structured interviews, this study explored the experiences and opinions of 20 purposively recruited patients about their nurses' contribution to weight-loss surgery. The data were analysed using thematic analysis. Three themes emerged. First, the provision of knowledge and fostering of understanding, both before and after surgery, focusing on information that addresses patients'needs. Second, staying in touch throughout the treatment period,being available whenever problems arise and advice or interventions are needed. The third theme concerned qualities demonstrated by the nurses. Open-minded patient engagement combined with person centered care fostered confidence in patients and promoted a close therapeutic relationship. Nurses make a substantial contribution to weight-loss surgery, caring for their patients' physical, surgical and,most importantly, psychosocial needs. Their role descriptions should emphasise the psychological, supportive aspects of this role.

Self-care predictors for success post-bariatric surgery: a literature review.

The prevalence of obesity in the United States has more than doubled from 1980 to 2008. Obesity leads to a multitude of comorbidities, most notably diabetes and cardiovascular diseases, resulting in more than $147 billion annually in healthcare costs. Bariatric surgery is becoming a common weight loss option for morbidly obese individuals. Studies in this review examine patients who have undergone laparoscopic adjustable gastric banding or Roux-en-Y gastric bypass surgery. Patients initially lose large amounts of weight postoperatively; unfortunately, around 30% of these individuals begin to regain weight 18-24 months after surgery. The purpose of this article is to analyze the current literature to ascertain which self-care variables are predictors of successful long-term weight loss after bariatric surgery. The studies analyzed in this review found that patients who undergo a surgical weight loss intervention lose more weight faster than patients who do not have a surgical weight loss intervention. However, patients reported feeling unprepared for the extreme psychosocial and lifestyle changes after bariatric surgery. Findings from these studies point to the need for future research in the area of postsurgical psychosocial support for successful long-term weight loss maintenance.

Caring for persons with bariatric health care issues: a primer for the WOC nurse.

The prevalence of obesity has nearly doubled in the last 3 decades. Nurses practicing in all care settings are looking for creative strategies to achieve safe, effective care for this patient population. Understanding skin injury events and the resulting complications is essential in the development of protocols for care, educational approaches, and interventions providing the best outcomes of care. Areas of concern for the WOC nurse with regard to bariatric patients include bathing, toileting, skin fold management, odor and genital care.

Nutritional management after Roux-en-Y gastric bypass.

Changes in the anatomy and function of the gastrointestinal tract after bariatric surgery markedly change patients' eating patterns. Malnutrition is a significant risk associated with all bariatric procedures, which can lead to dangerous nutritional deficiencies. However, if correct patient selection is conducted and if patients receive thorough preoperative nutrition education and postoperative nutritional follow-up, these deficiencies are largely preventable. Nurses are important members of the multidisciplinary team; assisting in patient selection, providing hands-on care, and educating the patient on the surgical process and post-operative dietary restrictions. It is critical for nurses to understand immediate and projected nutritional consequences of surgery, in order to monitor the patient for diet tolerance and nutrient deficiency symptoms, to encourage dietary compliance, and to reinforce the long-term dietary restrictions. With appropriate supplementation and patient compliance, all nutritional deficiencies can be avoided or corrected.

Procedure and outcomes of Roux-en-Y gastric bypass.

Bariatric surgery is an effective intervention for weight loss in the morbidly obese patient and can result in resolution of associated comorbidities. However, it is a complex area of practice and care, as these patients suffer a series of comorbidities that can compromise outcomes after surgery. Nurses must be aware of these comorbidities and anticipate the required interventions to ensure timely and effective treatment, and to minimize potential problems. This article reviews the technical procedures of the laparoscopic Roux-en-Y gastric bypass (LRYGBP)--which is considered the gold standard in bariatric surgery--and outlines its complications and outcomes. Other forms of bariatric surgery are briefly discussed in comparison to the LRYGBP. With knowledge in this area, nurses are in a ideal position to educate and prepare patients for life after surgery, and to diminish their anxiety during adaptation to this new phase of life.

Nursing students' attitudes towards obese people, knowledge of obesity risk, and self-disclosure of own health behaviours: An exploratory survey.

BACKGROUND: The rates of people being overweight and obese are recognised as global public health concerns. Negative attitudes towards obese and overweight people are prevalent among health care professionals. Nurses and nursing students have a significant role in health promotion of people who are obese or overweight and can assist people in achieving healthy lifestyles. However, evidence suggests that nurses and nursing students fail to engage in healthy lifestyles themselves and display negative attitudes towards obese and overweight people. Such negative behaviours put nurses and nursing students in a precarious position when advising overweight and obese people to adopt healthy lifestyles. OBJECTIVES: This study aimed to ascertain nursing students' obesity risk knowledge, their attitudes towards obese and overweight people, and their own health promoting lifestyle behaviours. DESIGN: A descriptive correlational study was used. SETTING: One university in the United Kingdom. PARTICIPANTS: A total of 210 nursing students enrolled on a university degree course in Adult or Mental Health Nursing in years 1, 2 and 3. METHODS: Data were collected using three valid and reliable questionnaires: Obesity Risk Knowledge Scale, Attitudes Towards Obese Persons Scale and the Health Promoting Lifestyle Profile. Dependent variables were correlated with independent variables on field of study, year of study, and gender. RESULTS: Results showed that nursing students engage in unhealthy lifestyle behaviours and fail to meet government recommended levels for physical activity. Nursing students had poor knowledge on obesity risk and displayed neutral attitudes towards overweight and obese people. CONCLUSIONS: Educational providers of nursing courses should embrace the need for nursing students to interrogate and enhance their own healthy lifestyle behaviours as an integral component of the pre-registration education course. This may strengthen the credibility and suitability of nursing students as future nurses in health promoting activities of patients who are overweight and obese.

Knowledge and Attitudes Towards Obesity and Bariatric Surgery in Chinese Nurses.

BACKGROUND: Obesity has become a global epidemic. Surgical treatment of obesity and metabolic disorders in China is increasing rapidly, but it is still a new discipline even to health professionals. As an important member of the multidisciplinary team, the knowledge and attitudes of nurses provide crucial health care to the patients and support to surgeons. OBJECTIVES: To study the Chinese nurses' knowledge of obesity and metabolic disorders, and attitudes towards bariatric surgery and to improve their capability of work in this new discipline. METHODS: This is a multicenter study, with the questionnaire distributed to cooperative hospitals in the form of an electronic questionnaire by the First Affiliated Hospital of Jinan University in April 2018. A questionnaire was designed to investigate nurses' demographic, knowledge, and attitude towards obesity, weight loss, and bariatric surgery. RESULTS: A total of 5311 questionnaires were received, with an effective rate of 91.8% (4878 questionnaires); 65.2% of nurses had a normal BMI. Nurses generally had a high knowledge of obesity and related cardiovascular diseases (98.6%) and type 2 diabetes mellitus (90.2%). However, there was a lack of knowledge in other related aspects, for example its relations to carcinoma (49.5%), gastroesophageal reflux disease (40.1%), and psychological disorders (49.1%), which are controversial issues in bariatric surgery. It was found that education (p < 0.05) had an important influence to nurses' knowledge about the comorbidities of obesity. Female nurses had a higher tendency to choose weight loss than males, but male nurses did physical exercise more frequently than females (p < 0.05). Their acceptance of safety (25.1%) and efficacy (22.9%) of bariatric surgery is low, with concerns predominantly about postoperative complications and adverse effects. Surgical nurses had a more optimistic attitude towards surgery (p < 0.05). CONCLUSIONS: Chinese nurses have poor knowledge of obesity-related metabolic disorders and also have poor acceptance of surgical treatment modalities. Our findings suggest that it is crucial to enhance the continuing education of Chinese nurses for obesity, metabolic disorders, and bariatric surgery.

[Five-year comparison of two techniques of bariatric surgery in patients with morbid obesity followed up in a nurse consultation]. / Comparación a 5 años de dos técnicas de cirugía bariátrica en pacientes con obesidad mórbida seguidos en consulta enfermera.

AIMS: To compare the evolution of weight loss and complications in the patients subjected to two techniques of bariatric surgery (RVG: ring vertical gastroplasty and BP: gastric by pass type Capella) carried out in HospitalLa Paz during the years 2000 and 2001. MATERIAL AND METHODS: 51 patients (27 RVG and 24 BP) were operated, and 44 (22 RVG and 22 BP) completed the follow-up at 1 year, 43 (22 RVG and 21 BP) at 2 years, and 28 (10 RVG and 18 BP) at 5 years. The parameters analyzed at 6, 12, 18, 24 months and 5 years were BMI (body mass index), EI (effectiveness index), % LW (percentage of lost weight), % LEW (percentage of lost excess of weight), alimentary intolerances, digestive complications, surgical complications, physical activity and modification of alimentary habits. RESULTS: An important reduction of weight was observed at 6 months with both techniques (% LEW: 45.8% with RVG and 53.4% with BP). After 12 months the loss of weight was significantly higher with BP (% LEW at 2 years: 59.5% with RVG and 83% with BP). However, at 5 years a weight recovery was detected in both groups of patients. At 12 months the patients subjected to RVG tolerated worse the meat and at 18 months the group of BP tolerated worse the rice. There were not significant differences in other parameters. CONCLUSION: The long term results are better with BP than with RVG. There is a reduction of effectiveness at 5 years that could be related with the modification of alimentary habits and with giving up attendance to the nurse consultation.

Competency in obesity management: An educational intervention study with nurse practitioner students.

BACKGROUND: The National Center for Health Statistics reported that obesity is at epidemic levels in the United States, with an estimated 70.7% of adults affected by overweight and obesity. The disease state of obesity affects all generations and is pervasive among all socioeconomic groups. PURPOSE: This study was designed to examine the impact of implementing educational modules to determine if the intervention improved knowledge and comfort levels for Nurse Practitioner students when managing patients with obesity. METHODS: Nurse Practitioner students completed a survey regarding knowledge and comfort level in managing patients with obesity. Students then completed modules designed to train health care providers on the management of obesity. A postmodule assessment was administered to determine if the obesity management modules improved competency and perceived skills when treating patients with overweight and obesity. RESULTS: Participants' mean score on the knowledge test represented a significant improvement following training. Their comfort level in managing patients with obesity increased. IMPLICATIONS FOR PRACTICE: Implementing these modules in graduate education may be a helpful avenue to improve competency in obesity management. Acknowledging that obesity is a disease and requires a multifaceted approach when helping patients improve their health. This change in perception may lead to better goal-setting with the patient, empathetic understanding, and broader patient involvement in the treatment.

Perioperative nursing care of the bariatric surgical patient.

APPROXIMATELY TWO-THIRDS of the US population is overweight or obese. The effects of the comorbidities that accompany obesity often are severe and can be life threatening over time. Currently, the most effective and sustainable method of substantial weight loss is bariatric surgery. Bariatric surgery also has been successful in reversing comorbidities. THE BENEFITS, RISKS, AND COMPLICATIONS of common weight-loss surgical procedures (eg, Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, vertical-banded gastroplasty, biliopancreatic diversion and duodenal switch) are discussed. THE HEALTH CARE FIELD OF BARIATRICS is growing rapidly. More information is needed to support and guide changes in current standards of practice to better meet the needs of this patient population.

The Effects of a Health Partner Program on Alleviating Depressive Symptoms Among Healthy Overweight/Obese Individuals.

Background and Purpose: Although lifestyle interventions have been shown to be effective in losing weight and increasing physical activity in community settings, little is known whether these programs may also ameliorate negative mood states in healthy overweight/obese adults when such programs are delivered in workplace settings. The aim of the study was to determine whether a health partner program may alleviate depressive symptoms among healthy overweight/obese individuals at 1 year. Methods: A secondary data analysis was performed using the Center for Health Discovery and Well Being database at Emory University in the United States. A total of 297 healthy overweight/obese university employees were recruited from the health partner program. Participants worked with health partners to establish an individualized health action plan, which might include changes in diet or exercise, modification of risk-related behaviors (e.g., tobacco use, alcohol use), and stress reduction strategies such as yoga. Depressive symptoms were measured by the Beck Depression Inventory-II at baseline and one-year follow-up. Results: At baseline, 9.7% of participants had depressive symptoms. At one-year follow-up, these participants had a small-to-moderate improvement in depressive symptoms (Cohen's d = 0.423), and the changes in depressive symptoms were statistically significant (p < 0.001). Implications for Practice: Since overweight/obese individuals are more likely to experience depressive symptoms than normal-weight individuals, early interventions to steer these individuals to better mental health are therefore essential. This study has demonstrated the potential benefits of a health partner program on alleviating depressive symptoms among overweight/obese individuals and this should be integrated into clinical practice.

Handling of the bariatric patient in critical care: a case study of lessons learned.

Bariatric admissions across the United States (US) are increasing at an alarming rate. The obesity epidemic costs the US health care system $70 billion per year. Many bariatric surgical and medical patients are admitted to critical care units. The mortality risks for these patients compared with non-bariatric patients is up to 2:1. Managing these patients is a challenge to health care nursing personnel. Patient size, care required, equipment technology, availability, and environmental space can increase risk for injury for nursing personnel and patients. The Health Sciences Center in Winnipeg shares a case study of an admission of a 697-lb patient, reviewing lessons learned, techniques, equipment, and difficulties.

Wound wise: wounds in surgical patients who are obese.

The number of surgical patients who are obese in the United States is rising, a trend that's likely to continue. Such patients are at higher risk than nonobese patients are for surgical site infections and other complications such as dehiscence, pressure ulcers, deep tissue injury, and rhabdomyolysis. This article details the factors that can contribute to such complications, including a high number of comorbidities, and offers practical suggestions for preventing them. Nurses should understand that special equipment, precautions, and protocols may be needed at every stage of care, and that obese patients aren't anomalies but rather a part of a growing population with particular needs.

Hypovitaminosis D and morbid obesity.

There is scarce and flawed data regarding vitamin D status in morbidly obese patients. More often than not, vitamin D deficits have been linked with bariatric surgery, not considering that the deficit may well precede surgery. Moreover, several pathophysiologic mechanism might explain, in part, vitamin D deficits. Conversely, the association between vitamin D deficits and secondary hyperparathyroidism in morbidly obese patients has been reported before and after bariatric surgery. Taking into account the elevated prevalence of vitamin D deficits in morbidly obese patients, its associated comorbidity, and the efficacy and low cost of its treatment to restore normal serum values of 25-OH-vitamin D, it seems advisable to recommend routine monitoring of serum calcium, phosphorus, and 25-OH-vitamin D levels in morbidly obese patients and to implement calcium and vitamin D supplementation whenever necessary.

Quality of life after Roux-en-Y gastric bypass surgery.

The incidence of obesity is rising worldwide, leading to a related increase in obesity-associated comorbidities that directly affect longevity and quality of life. Surgical interventions, including the Roux-en-Y gastric bypass procedure, are available for those who have increased risk for morbidity and mortality as a result of repeatedly failed medical management of obesity. Three months after undergoing gastric bypass surgery, patients were sent a survey based on the Impact of Weight on Quality of Life-Lite instrument. The survey results demonstrated marked improvement in overall quality of life and physical function in this population, as well as the ability to decrease or discontinue medications for obesity-related comorbid conditions.