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Outsize Patients --A big nursing challenge! by Tom Trimble, RN CEN


About this article:

  • This article is intended to introduce the Emergency Nurse to issues and problems in caring for obese and morbidly obese patients in the Emergency Department setting.

  • It is in no way intended as criticism or denigration of obese persons.

  • The suggestions are intended as possible or practical solutions for problems which may occur; use of them must be considered in relation to local resources, regulations,
    and policies and not in any manner or circumstance which may be unsafe.

  • The basis of this article (other than as referenced) is the clinical observations and experience, education and training, of a working Emergency Nurse and former Paramedic
    who is sympathetic to the needs of obese patients.

  • Our DISCLAIMER completely and specifically applies to all and any part of this article.


        "Can you come out and help us unload this patient? We’ve got a four hundred pounder."
This request from an EMT, or as an early report by radio, may be the only warning of some sizeable nursing issues to arise.
Patients who exceed ordinary parameters of stature or weight may require understanding of their special issues, availability of
special beds or equipment, and their size may confound examination or make treatment more complicated, and airway
problems may be difficult.
 

"Obesity has become a national health problem in the United States. Nearly 97 million American adults are overweight. Of the 97 million overweight American adults, it is estimated that 4 million are severely obese and 1.5 million are morbidly obese. From 1960 to 1990, the incidence of obese American adults increased from 13 to 35%. .  . . the prevalence of obese American adults is expected to increase. .  .  . The annual health care costs for obesity-related diseases   in the United States have increased from $39 billion in 1993 to $100 billion and represent 5.5% of total annual health care costs." (1)

CDC Map of 1985-2007 Percent of Obese (BMI > 30) in U.S. Adults


ISSUES:

Airway:

        Airway management problems in obese patients are rightfully dreaded. Difficult intubation is common, but prediction rules may over-predict and intubation may be, but not invariably, easier than anticipated. Several factors increasing risk and difficulty of intubation may be present:

  • Formulate an airway management plan when first encountering the obese patient. If difficult intubation is anticipated, or intubation becomes necessary, have back-up help present.

  • Facial anatomy needs appropriate mask selection for close fit and ease of holding by the "airway manager.".

  • Increased mass of soft tissues needs special techniques.

  • Macroglossia – large tongue may need oral airway for mask ventilation, and obscures laryngoscopy.

  • Weight of head increases exertion during laryngoscopy.

  • Head Tilt & "Sniffing Position" may require building up towels or blankets under the back, scapulae, and shoulders, as well as the head and neck, in order to provide sufficient "lift" and visual alignment of the axes of mouth, pharynx, and trachea for intubation. This also may be necessary to augment the nasopharyngeal airway or oropharyngeal airway used in spontaneously breathing patients.

  • CPAP [constant positive airway pressure] may be needed to distend airway walls and prevent collapse during negative pressure phases of respiration.

  • Bi-level Non-Invasive Ventilation may be needed to support breathing and airway issues.

  • Mask ventilation may require two persons: one to use two-handed mask technique with triple airway maneuver, airway device, and CPAP; with another to bag the patient and monitor effectiveness. The preferred ventilating bag would be a "Jackson-Rees Circuit" anesthesia bag, if a skilled user is available. However, as the anesthesia bag is dependant on a constant supply of compressed gas, a self-refilling Bag-Valve-Mask should always be at hand in case the tank becomes empty or other failure of compressed gas supply occurs.

  • Use an appropriately sized oropharyngeal or nasopharyngeal airway whenever possible, and especially use an OPA if the patient is edentulous.

  • The Intubator may be more comfortable and prudent if another skilled Intubator or Anesthesiologist is present to assist or to initiate Difficult Airway intubation.

  • Must be certain of ability to mask ventilate, if intubation should be difficult or impossible, before sedation or paralysis deprives the patient of ability to breathe spontaneously:
                    -beware of "can’t ventilate, can’t intubate" situations!

  • "Bull Neck" – short, thick neck inhibits mobility and makes visualization of the larynx difficult during laryngoscopy.

  • Have "rescue" alternative airway devices ready to hand: e.g., Laryngeal Mask Airway (LMA) or Intubating LMA (Fastrach™); Elastic Gum Bougie; Lighted Stylet; Esophageal Combi-Tube™; Fiber-optic Laryngoscope or Bronchoscope.

  • The first intubation attempt should be by the most experienced intubator available working under optimized conditions.
    Each additional "attempt" worsens subsequent laryngoscopy conditions with swelling and airway trauma from repeated instrumentation.

  • If the first best attempt determines difficult or impossible laryngoscopy or intubation, change to either Rescue Airway plan (if patient condition is critical), or early Fiberoptic Intubation before airway trauma worsens the situation.

  • Fiberoptic laryngoscopy/bronchoscopy may be facilitated by using CPAP with an endoscopy mask, such as the Patil-Syracuse, which permits ventilation and simultaneous passage of the endoscope through an elastic port. Oxygenation and CPAP might also be delivered via a nasopharyngeal airway to which an endotracheal tube connector of the same size is fitted.

  • "Bull Neck", neck edema, or subcutaneous emphysema, may make landmarks for cricothyrotomy or tracheotomy difficult to discern or impossible to use.

  • Large breasts may get in the way of the laryngoscope handle. It may be necessary to insert the laryngoscope blade separately into the mouth and then hook it to the laryngoscope handle. Half-size handles are available.

  • Response to induction agents is less predictable.

  • Auscultation of breath sounds is distant.

  • Confirmation of endotracheal intubation should be by three or more methods including either capnometry or capnography.

  • Respiratory distress may necessitate "awake" intubation in sitting position.

  • Obese patients will desaturate oxygen rapidly due to decreased functional reserve capacity, weight of viscera upon diaphragm, compliance changes and weight of chest wall to elevate with accessory muscles of respiration. If blood pressure will tolerate it, it may be best to tip the gurney into Reverse Trendelenberg's Position (perhaps with knees cranked up somewhat to minimize sliding) to decrease visceral weight on the diaphragm and increase functional reserve capacity. Doing so with the gurney at a lower height may help the short intubator manage the angles involved. It will be important to "Ramp-Up" the patient's torso and head/neck position so that the External Ear Canal should be at the level of the sternal notch for intubation.

  •  All seriously ill obese patients (in the emergency setting) should have supplemental oxygen regardless of room air SpO2, in this writer's opinion, until the situation is clear. All obese patients with airway problems or impending intubation should have 100% oxygen to de-nitrogenate their tissues. Monitor patient for fatigue of respiratory muscles; as the patient becomes "quieter" and sleepy---hypercapnia may be increasing!

  • Percutaneous cricothyrotomy or surgical tracheostomy may be difficult due to additional distance (deeper) from skin to tracheal wall and less-easily identifiable landmarks.
    --If feasible, such procedures should be deferred to the Operating Room and Team, or be done with a flexible fiberoptic bronchoscope that can ventilate the patient and confirm the intratracheal placement of the tracheostomy cannula without false passage into other planes of tissue.
    --For surgical tracheostomy, use of a skin hook to "maintain the hole" by holding onto cartilage during the procedure and placement of "stay sutures" to retract the wound in the event of accidental decanulation would be highly prudent precautions.

  • Provide extension tubing between the resuscitation bag and the non-rebreathing valve for intubated patients being transported so as to lessen risk of extubation. Such transports are necessarily cumbersome, require long "reaches", and have extra people in the way.


Abdominal Exam & Imaging:

        Auscultation and palpation of viscera may be very difficult, and reliance may need to be placed upon imaging studies to determine pathology. However, there may be a finite limit to patient weight permitted by the scanner, e.g., 450 pounds, or a practical one as to the width of the scanner table or the diameter of the opening for the beam. If unfeasible, or the patient is too critical to tolerate transfer to a specialized radiology suite, one may be limited to the less definitive data provided by bedside exam by portable X-ray, portable flouroscopy, or portable ultrasound.

 

Activities of Daily Living [ADLs]:

        ADLs may be severely impaired by patient size, mobility, chronic pain, inability to view the task, and need for special adaptive devices, home modifications, or vehicles. Determining the patient's baseline in ADLs may be predictive of support needed while in the hospital. If the patient has a Case Manager or home health care agency, valuable insights may be available for the planning of future care, or of placement to some other setting. Patients who are totally dependant on others will severely challenge hospital staffing budgets. Physical and Occupational Therapists should be part of interdisciplinary care teams assigned to the patient, while an in-patient, and may provide useful advice for outpatients as to resources and adaptive devices.

 

Analgesia, Anesthesia, & Sedation:

        Doses should be carefully calculated, and titrated incrementally (from an amount closer to lean weight). Bear in mind that many agents are lipophilic (to cross the blood-brain barrier), and may cause a prolonged recovery time. Short-acting agents are to be preferred; i.e., it would be better to use Methohexital, get the procedure over and done with (brief Deep Sedation), than to give him 7.5 mgms. of Midazolam which will last much longer (Moderate Sedation, but longer lasting and with potential for respiratory depression beyond the period of merely wakening). Using an NSAID adjuvantly may lessen the narcotic or sedative requirement. A proficient airway manager should be present.

 

Arterial Blood Gas [ABG] Measurement:

        Obtaining a specimen of arterial blood for measurement of dissolved gasses can be very difficult in the obese or morbidly obese patient. If repeated sampling is foreseeable, it may be prudent for the physician to insert an arterial cannula for sampling or to do real-time blood pressure monitoring.

        An approximation of respiratory status may be done without an arterial sample by pulse oximetry to determine oxygen saturation and capnography with a close fitting mask to determine expired carbon dioxide levels. Venous Blood Gas samples can indicate systemic pH.

 

Arthroplasties:

        Prevalent musculoskeletal problems and degenerative joint disease may mean that your patient has "hardware": one or more hip or knee arthroplasties which when functioning well can restore mobility and decrease pain. However, the patient may suffer from a failed device with a loose cup or ring, which may require surgical revision, may dislocate their arthroplasty which introduces issues of acute reduction as a sedated procedure versus preparing the patient for admission and the operating room. Concerns regarding adequate analgesia and sedation versus airway/ventilatory risks thereby ensue. If the patient has fever without an obvious source, infection of the hardware may be either the source or a target in consequence of "seeding" carried through the bloodstream.

 

Asking the Patient:

        If uncertain as to how best to adapt care to a problem, e.g., size of equipment, ability of patient to use it, ADL or mobility equipment, don't hesitate to ask the patient "what works for you?" or "how has this been done for you in the past?" It is considerate, affords the patient some control over the situation, and the patient is the "best expert" on himself.

 

Bed, Choosing a patient's:

        Knowing the availability of, and calling for a hospital bed instead of the customary Emergency Department stretcher or gurney, or of special beds for tall or wide patients or those with skin care problems, can make for greater comfort, maneuverability, and staff safety. Likewise, knowing the physical limits of size or weight of CT or MRI scanners will alter the planning of diagnosis and treatment. Beds with weighing capability are useful. If no wide bed is available, two gurneys can be strapped together, however, this may seriously impair   transportation as doors and elevators may not allow for the double width. Wheels would need to be aligned so that the casters would trail correctly to allow for steering. An expedient for a "too tall" patient would be to remove any footboard and extend the bed's length with a board tucked under the mattress with pillows upon it.

 

Bed, Moving Self in/Throwing body:

        Large patients are often dependent on their own efforts to aid in their movement in bed unless many helpers or a suitable lift are available. Many times patients will tug and pull until a point is reached when only a little more effort gives impetus to overcome inertia and the body achieves momentum to accomplish the final turn. This can translate to electrode wires, and IVs being tugged during the kicking and pushing. Make extra effort to secure them well. Avoid splinting hands
with IVs so they may be free to grasp rails, etc. A sheet or rope tied to the foot of the gurney may allow the patient to pull himself upright without rattling the rails or to ease the burden of adjusting the head of the bed. If the patient can ambulate, be able to lower beds and provide a sturdy footstool and support points. A large blanket or fire department tarpaulin "salvage cover" under the patient may be used by a team to lift, turn, or pull the patient. Be wary of shearing forces worsening skin problems if the patient is dragged in bed. At any moment when a gurney/bed is not being moved, the wheels must be locked to prevent accidents from shifts of balance. The lowest height of an elevating bed will also be the most stable. However, pushing of a bed will be easier on one's back if it is raised to a suitable height so that one's back is straight; provided that the bed does not become unstable or top-heavy in balance.

 

Blood Pressure Measurement:

        The blood pressure cuff must be appropriately sized for the limb being used. Often a "thigh" cuff will need to be used on the arm. Even that may not be large enough. It may be necessary to use the distal portion of the extremity. Frequently, the conical taper of the arm may make the cuff band tend to pop off as the balloon rises around the band. It may be necessary to wrap the cuff with bandage or secure with tape. Critical patients should be considered for an early arterial
pressure monitoring line.

        Automated oscillometric vital signs machines have the advantage of sensitivity but may be poorly tolerated by the patient pressure due to long measuring time and "tight" pressure. Persuade the patient to keep the arm motionless during the reading for accuracy and avoiding the "re-take."

        A Doppler stethoscope may be needed to validate "manually" "by ear" when the patient is hypotensive, has a very irregular pulse, or Korotkoff Sounds are hard to hear due to obesity and loud background noise.

        Elevating or exsanguinating the limb may make the first systolic "click" more audible, or may precede determining approximate BP by "flush method" (noting the pressure when color first returns to the exsanguinated limb).

 

Body Mass Index [BMI]:

        BMI is a useful way of having one numerical figure account for proportion of height and weight. The formula is: Weight in kilograms height in meters2 = BMI One can then more easily compare one patient with another or represent patient size on the chart. Ideal weight in kilograms = height in centimeters - 100. Loosely, 2 X ideal weight, or ideal weight + 100 pounds have been used as definitions of morbid obesity.

        Online BMI Calculators (Metric & English units) and tables from the National Institutes of Health can be found at: <http://www.nhlbisupport.com/bmi/bmicalc.htm>

BMI
kg/m2
Classification
20 Healthy Weight
25 Overweight
30 Obese
35 Severely Obese
>35 Morbidly Obese
(if has concomitant
obesity-related
morbidity)
40 Morbidly Obese
40 kg/m2 = ~>100   lbs. over ideal body weight
 

Body Mechanics:

        Using good body mechanics is essential self-protection for staff. Don’t endure an injury due to lack of foresight in planning each patient movement or failing to summon enough help. There is "safety in numbers", i.e., there is no substitute for enough persons to help. The load is thereby divided. Provide, too,  enough extra reserve should anyone slip.

 

Breathing/Aspiration/Ventilation:

        Lungs do not increase in size as the patient becomes obese. The enlarged stomach may not empty efficiently and Gastro-Esophageal Reflux Disease is common. The weight of abdominal viscera may press against the diaphragm (which is responsible for 60% of respiratory effort, and intercostal muscles are easily fatigued. Obese patients desaturate oxygen more rapidly. Obstructive Sleep Apnea is common. Patients with severe OSA should have CPAP or Bi-PAP™ equipment (although some are undiagnosed or intolerant of the CPAP/Bi-PAP™) and/or may have home oxygen for nocturnal use. Patients should be nursed, whenever possible, in a high Fowler’s Position (45) or a lateral position. Prone and supine position can be fatiguing to respiration if the patient’s body mass is great.{ c.f. Pickwickian Syndrome, below.}

 

Canes, Crutches, Walkers, Wheelchairs:

        Large patients put an incredible number of pounds per square inch (kg/cm2) on their joints and vertebral column (much of it anterior to the axis of the body, thus by leverage, multiplying the forces). Degenerative joint disease, sedentary lifestyle, and demineralization of bone, and diminished cardiopulmonary reserve, make the patient dependent on any aids to mobility that he uses. Some devices may be "special order" sizes with higher cost and delays in availability and shipping when ordered. Be careful not to lose them. Label them with the patient’s name at first chance. The patient’s own wheelchair or mobility chair may be the only way to move the patient (other than pushing the bed) without the delay and expense of the hospital leasing special equipment. Remember to keep electrical devices charging when not in use.

 

Cellulitis:

        Obese patients, in part because of poor peripheral circulation, perhaps in conjunction with diabetes, not infrequently will suffer from cellulitis. Difficulty in self-care of wounds compounds the problem. If diabetic, control of the disease and of blood sugar levels may be lost as the patient becomes overwhelmed by systemic infection.

 

Clothing & Hospital Gowns, Footwear:

        As the patient’s mass increases, and ADLs decrease, such clothing choices as are available may be chosen for comfort and simplicity, e.g.,

  • Large tee-shirts, sweatshirts and sweatpants, overalls;

  • slip-on loafers, Velcro™ fastened shoes, bedroom slippers, or "thongs" rather than "tie" shoes;

  • suspenders versus belts;

  • open neck shirts worn outside the pants;

  • housedress, dashiki, or muu-muus;

  • and, in extreme cases of bed-bound patients, simply coverage with a sheet.

 

Commodes, Bedside:

        A bedside commode may make toileting easier. Determine if an extended range size is available suitable for the weight and width of the patient. It is not uncommon for a standard commode to uncomfortably pinch or for a patient to "get stuck" between the hand rails. Assistance with perineal and perianal cleansing afterwards may be necessary, often in a standing position with one person to steady the patient and another to cleanse.

 

Condom Catheters:

        Applying and keeping a condom catheter in place may be difficult to impossible in obese males as the pendulant adipose in the pubic area pushes forward, it causes the penis to seemingly "retract" and vanish. Warmth and humidity in the area makes adhesion a problem; and, the patient's generally large size makes drainage tubing easily tugged.

 

Debris (Medical) in Patient's Bed:

           Take care as you work, to remove from the bed and blankets all "medical debris" such as plastic caps, wrappers or boxes, that accumulate during procedures. They are easily displaced and lost within the bed and covers perhaps to end up as an object of pressure against the patient's skin.

 

Depression & Psychiatric Concerns:

        Body-image concerns, perhaps life-long taunting endured or sensitivity to "humor", practical difficulties in ADLs, worry about health, provoke loss of self-esteem, and tend to depression. Increase of weight may occur secondary to anti-depressant medication effects.

 

Diet & Electrolytes:

        The patient should be asked as to his current dieting regimen (prescribed, or self-selected) which may affect his nutritional status, overall fluid balance and electrolytes. {c.f. "Nutritional Assessment", below.}

 

Dosage, Correct, of Medications:

        Consult pharmaceutical references or hospital pharmacist if there is doubt as to accuracy of dosing in a weight-based calculation, or whether dosing should be based upon lean, ideal, or proportion of actual weight. When accepting an order for weight-based dosing of a medication, discuss with the physician the basis of calculation, measured or assumed weight, and manner of adjustment or titration.

 

Eating Disorders:

        Screen the patient for bingeing, purging, and other current behaviors in dietary regulation.

 

Floor, The patient who is on the:

        Every preventive effort should be made to avoid an outsize patient falling or taking up a position on the floor. When he must be gotten up, it must be done without injury to the staff.

        Do not just reach out and "pull the patient up." The angles, leverage, strain, and risk of injury are too great for both of you. Bring a footstool or solid chair close at hand as a balance point or resting spot for the patient. Squat or kneel close to the patient’s side facing the opposite direction. Keep your back straight. Grasp his upper arm firmly with your closer arm, using your other hand under the patient’s elbow to give impetus to his efforts and to keep his arm from "winging" outwards. With the strength of your legs, rise with him to the vertical position. Additional helpers can be used on his other side, or to move a chair underneath him.   A weak patient might be brought into a sitting position by a team placing a strong chair underneath him (or behind him, if he is lying on his side) and using the chair to tilt or turn him into a sitting position.

        A helpless patient, who is very large, will require blankets or canvas to be rolled and maneuvered under him that then can be used as a hammock or stretcher with which to lift him. In the meantime, nurse him on the floor until all preparations are ready; ---remember, he cannot fall any further. Emergency Services crews are especially useful here with their experience in the lifting and moving of patients in adverse circumstances. In small facilities, it may be advisable to call for a fire or ambulance crew for assistance when insufficient staff is present. Consider sending for a sling lift if one is available with rated capacity for the situation. If possible,   lift the blanket only enough to slide a hand stretcher or spine board under the patient from one end; this, then, can be used to more efficiently and safely lift the patient.

 

Foley Catheters, Placing:

        Male patients need to have suprapubic adipose "retracted" by the heel of the operator’s hand. A massive abdomen in either sex may need retraction by tape or assistants in order to visualize the perineum. An overhead or portable surgical light may be used to illuminate the female perineum and introitus. With very large women, a catheter may be more easily placed with fewer assistants when the patient is laterally recumbent, and the upper leg flexed or lifted by a helper. In either sex, large thighs may make the catheter relatively short when affixing the drainage tubing to the thigh for "tug" protection. Extension tubing (taped connection) may be needed.

 

Gait Assistance & Mobility Testing:

        A typical gait may be noticed which is wide-based and "rolling". The gait is wide-based for balance and due to girth of the legs. The arms may be held away from the body (girth, parasthesias) and swung to increase forward impulsion. The head may be erect, the shoulders thrown back, the back arched with an appearance of walking on heels –all to counterbalance the gravitational pull on the "forward" center of gravity. Ill patients might grunt with each step. Debilitated patients with mobility problems may lose an upright posture and lean heavily upon their cane, crutch, or walker.

        The main goal of the Emergency Physician may be to evaluate the complaint, ease pain and symptoms, and return the patient to his home environment for outpatient follow-up if the patient is able to satisfactorily pass a test of ambulating and mobility. Be sure any proposed assistive devices are available. Provide for safety and assistance during such an ambulation trial. If possible, test the patient with the equipment (walker, quad-cane, commode, etc.) that he will use. It may be necessary to hold discharge until absolute assurance of delivery and set-up of assistive devices, bed, or oxygen equipment can be guaranteed.

        If the patient is unsteady, have reliable back-up help present . . . I recall a patient, many years ago, who frequently needed our ambulance service and was 6’5" and 400 pounds. The "routine" was to send a second ambulance crew, give oxygen, "assist" the patient’s walking to the ambulance, and have him sit up in the front of the Cadillac™ (it was that long ago) as he was too large and heavy for the stretcher. On one occasion, he was surrounded by the four EMTs but stumbled and staggered. As immediate action, I dropped my hips flexing my legs for strength, kept my back straight, moved closely to the axis of the patient seizing his arm in two places so as to keep him straight and upright (which did prevent the fall) only to find that all of my "co-workers" were scattering like lumberjacks avoiding the falling tree!

 

Glucose, Assessing:

        As increasing age and obesity are risk factors for Diabetes Type 2 wherein the body becomes less responsive to endogenous insulin, it is worthwhile checking a fingerstick glucose on all ill or dehydrated obese patients, and any who report "thirst", "fatigue", "weakness", increasing urination.

 

Gynecological Examination:

        Conventional positioning for pelvic examination may be uncomfortable for the patient due to pressure of abdominal contents upon the diaphragm. Leg holders may be uncomfortable. Assistants to manually position legs, lift a pendant abdomen, or retract labia and vulvar tissue may be needed. Pelvic tilt with blankets may be needed or by a metal bedpan instead of the common plastic bedpan. Other aids to the examiner may be the use of an examining light worn on the head, transilluminated plastic speculum, or portable surgical light.

        If pregnant, the gravid uterus may lie upon the inferior vena cava and aorta compromising perfusion to the fetus or the patient. Lateral tilt of the patient’s body or manual displacement of the gravid uterus to the left may be necessary.

        If the vagina has redundant tissue obscuring vision for the examiner, a condom, glove finger, finger cot, or plastic sleeve can be placed over the speculum blades. (Ask the patient if she has a latex allergy, appropriately, first.) Opening the tip of the condom allows visualization of the cervix.

 

Hot Weather Problems:

        Large persons may suffer considerably in hot weather, as the extra fat inhibits heat loss, ill-fitting clothes and redundant flesh make rashes and chafing likely, other disease or medication  (e.g., anti-depressants, anti-histamines, or anti-cholinergic medicines) may alter thermoregulation. Decreased ADLs make it hard to seek one’s hydration. Considerable water loss through perspiration can occur.

 

Hygiene:

        Personal hygiene may be impaired by physical inability to see or reach anatomical areas customarily reached by slim persons, and by risk of falls. Excreta may irritate perineal tissue or be trapped in clefts of skin. The umbilicus may be deep and difficult to clean.

 

Injections:

        For the injectate to truly be deposited intramuscularly, one may need to carefully choose location and compress the fatty subcutaneous layer with one hand when using the ordinary 1.5-inch needle. If still doubtful, use a spinal needle upon the syringe instead. Conceal it behind one’s back when approaching the patient, and ask the patient to "turn away from me" (so as not to see the needle) before injecting.

 

Intertrigenous Rashes:

        It is common to find rashes in the groin and perineum, inframammary areas, axillae, and in large folds of skin due to warm moist conditions which foster the growth of yeast and fungi.

 

Intravenous Access:

            As with chubby babies, the excessive subcutaneous fat makes it hard to locate deeper veins. The ordinary rubber tourniquet is also less efficient (and uncomfortable). Using an appropriately sized blood pressure cuff as a tourniquet may help better distend veins in a comfortable way. Choose cannula size thoughtfully. If it is not essential to have a "large-bore" IV, use a 24 or 22 gauge cannula to spare veins for future use. Use a pump for consistent flow and suitable alarms so the line will not clot off.

        External jugular vein IVs may not be feasible with short thick necks. Longer (2") cannulae may be needed. Even if successfully inserted, the vein may be too "positional" making steady flow difficult. Minimize time spent in Trendelenburg's Position by the patient due to visceral shift impairing diaphragmatic excursion. Valsalva's Maneuver may be briefer and better tolerated by the patient who controls his effort. Supplemental oxygen would be useful.

        Femoral vein central access can be complicated by difficult landmarks, the necessity of having to retract the abdomen from the operative field, and yeast infections in the inguinal folds.

        Vascular access may need to be assisted by utrasonography.

 

Late Presentation:

        Patients may not present until late in the course of their illness due to mobility and transportation problems, sedentary life-style, and depression. It takes a great deal of effort to come to an ED, and the patient may fear any perceived resentment or embarrassment. For the patient to actually come to the ED may mean that there is significant pathology and sense of being unwell.

 

Lumbar Puncture:

        Careful positioning is needed. The operator may need to "mark" the intended puncture site by firmly indenting the skin with the open end of the needle cover before inserting the needle. Conventional length needles may be too short and "go to the hub". Extra long needles (5.5 inch) may be needed. If failing to puncture the dura in the conventional position, one may need to do the LP in sitting position with the patient safely braced. ("Opening pressure" is not valid in the sitting position.)

        Very difficult cases may need to be done by Interventional Radiology with imaging equipment. Consider giving emergent antibiotics empirically while awaiting imaging assistance.

 

Musculoskeletal Problems:

        An outsized habitus on a common-sized frame leads to musculoskeletal problems from the "wear and tear" due to increased "pounds per square inch" loading. It has been said that each extra pound anterior to the spine is equal to 4-5 pounds directly loading on the spine, therefore, complaints of chronic back pain are common. Flattening of the arches of the feet contributes to painful or difficult ambulation.

        If footing is uncertain and abdominal girth is large, it may not be possible for the patient to see over the belly to see his feet and their placement. Station and gait may be wide-based to accommodate a top-heavy mass upon a narrow base of support and increased mass of thighs may tend for the legs to be farther apart than in slender persons; unsteadiness may increase if the patient is weak. A quad-cane or walker may then be useful.

        Transient parasthesias of the arms may be common from binding of circulation at the axilla by bunched clothing or arm position due to flexion or crossing of the midline.

 

Nutritional Assessment:

    Generally, in the short-term period of care in an Emergency Department, when a patient is severely stressed physiologically or psychologically, it would be fruitless and detrimental to attempt change in the patient's diet. Starvation of the patient, "because he can live off his fat", is cruel and disadvantages the patient's recovery. If dietary indiscretion has contributed to the etiology of the problem, e.g. sodium or potassium intake in congestive heart failure or end stage renal disease, diabetic ketoacidosis or hyperglycemic hyperosmolar non-ketotic coma, then assessment and counseling are useful to the resolution of the problem. It is useful to know if the patient has been observing a Very Low Calorie diet, has been "medically Fasting", has been attempting a fad diet, or using "dietary aids" such as herbal medications or "food supplements" that are not within the physician's prescribed regimen.

 

Operating Room:

       Give the earliest possible advance warning to operating room staff and anesthesiology if the patient is to have surgery. It will be necessary to prepare a special table (or extra table); have additional instruments; have sufficient manpower; preparation time for vascular access, monitoring, and operative site, pre-operative anesthetic & airway evaluation; placement of an epidural line for anesthesia; or double-preparation of both laparoscopic and open instrumentation.

       If the patient's airway is unintubated, and his condition worrisome, transport the patient with all critical-care precautions and a competent airway manager.

 

Pickwickian Syndrome:

      Obesity Hypoventilation Syndrome (Pickwickian Syndrome), at the extreme end of the spectrum of obesity related breathing problems, comprises awake symptomology with:

Hypercarbia
Hypoxemia
Polycythemia
Hypersomnolence
Pulmonary Hypertension
Biventricular Failure

 

Pulmonary Embolism and Pneumonias:

        Due to potential problems from decreased mobility and circulatory insufficiency, consider strongly the possibility of pulmonary embolus as the cause of otherwise unexplained hypoxia, resting tachypnea, or subjective complaint of chest discomfort or dyspnea.

        Pneumonia is a likely cause of pulmonary problems, and may not be well-demonstrated by auscultation or sub-optimal radiographic studies. Consider CT scanning, when available, to aid in differential diagnosis.

 

Restraints for Behavioral Management:

        Restraints may need to be adapted to the large person (i.e., "ankle" restraints used on the patient's wrists) and consideration should be provided for anatomic positioning and comfort in view of the prevalence of musculoskeletal and circulatory problems. Do not fasten wrists behind back Adjust knee crank of bed to lessen strain on knees and prevent slumping downwards. Remember to keep the patient in a high Fowler's Position to maximize respiratory efficiency. Offer Range of Motion exercise as often as can be done if behavior has subsided. The obese patient will suffer more pain and disability from enforced positions of restraint. Plan early release and use appropropriate environmental, psychosocial, or pharmaceutical interventions to facilitate early release. {c.f., next section}

 

Speed, Strength, & Stamina:

        Large persons can be surprisingly fast and powerful in "fight or flight" situations, as when agitated or combative. (It takes a great deal of strength to move their mass and perform ADLs.) Many were, at one time, strong persons who have since become obese and less fit. Personality changes, mood swings, and irritability are common results of untreated obstructive sleep apnea or sleep deprivation.

        Physical deconditioning, the relative lack of activity other than the essential ADLs due to fatigue, co-morbid disease and degenerative problems, all tend to lessen the endurance. Pain from musculoskeletal problems and dyspnea on exertion can severely limit activity.

 

Stressed Staff:

        Take time to support each other, and acknowledge the challenge of meeting the patient’s needs. We all "can get by with a little help from our friends." Keep up a positive outlook, and avoid blaming the patient for his woes. Look upon your efforts and labors as a successful challenge to your nursing assessment, skills, and judgements. It should not be your "bad luck" to have the patient, but his "good luck" to be able to rely upon your skills and good-heartedness.

 

Surgical History:

        Surgical History may be of importance in evaluating the patient's complaints. In addition to conventional surgeries such as cholecystectomy, appendectomy, lysis of adhesions, etc., inquire specifically as to bariatric surgeries such as gastroplasty, banding, etc., which may have impact. Gut shortening procedures may lead to malabsorbtion problems affecting electrolytes, nutrition, and hydration.

 

Transport, Intra-hospital:

   Plan the transport. Be sure that the receiving area is prepared for the patient. Send an advance scout ahead to clear the path (especially if there are no wide-angle safety mirrors at hallway turnings and intersections), open doors, obtain elevators, etc. If one must encounter ramps while transporting the patient by wheeled stretcher or bed, recruit additional helpers to provide additional push on upward slopes and retard the stretcher upon downward slopes.

 

Weighing Patients:

        Know the limits of one’s scale. Consider the following tip to "extend the range" of that scale. When arranging an
inpatient bed, suggest that one with weighing capability be used (what is its limit?) Find out if an extended range scale is
available at Physical Therapy or upon the loading dock.

 

Need To Weigh A Too-Heavy Patient On The Balance Scale?

  1. Hang a small object on the balance beam, then . . .

  2. Weigh the patient (with the object in place).

  3. Next, weigh another person (whose weight is within the scale's usual range) with the hanging weight in place.

  4. Remove the hanging weight and weigh again.

  5. Calculate the difference, and . . .

  6. Add it to the measured weight of the outsize patient as checked with the weight in place. Voila'.

i.e., Pt's weight = measured weight + "the off-scale increment"
(represented by the additional hanging weight on the beam;
-the amount determined by measuring under same conditions a person or object that is "within the scale's range" )


References:
  • (1) "The Surgical Treatment of Morbid Obesity" F. Charles Brunicardi MD, Patrick R. Reardon MD, Brent D. Matthews MD; Ch 15 in Townsend: SabistonTextbook of Surgery, 16th ed., Copyright 2001 W.B. Saunders Company
  • "Obesity" F. Xavier Pi-Sunyer, MD Ch. 228 in Goldman: Cecil Textbook of Medicine, 21st ed., Copyright 2000 W.B.Saunders Company pp. 155-1162
  • "Obesity" Marc R. Blackman, MD Ch.76 in Principles of Ambulatory Medicine editors, L. Randol Barker, John R. Burton, Philip D. Zieve: associate editor, Thomas E. Finucane -- 5th ed. 1999 Lippincott Wiliams & Wilkins, Philadelphia [pp1150-1167]
  • "Management of the Obese Critically Ill Patient" in Endocrine and Metabolic Dysfunction Syndromes in the Critically Ill
        by Joseph Varon MD & Paul Marik MD. Critical Care Clinics, Volume 17, Number 1 January 2001 W. B. Saunders Company
  • "The Label, "Morbid Obesity"" http://www.beyondchange-obesity.com/psySpeaking/theLabelMorbidObesity.html
        Lana Boutacoff,      Ph.D.; Walter Rupp, MD; Walter Lindstrom, Jr. Esq. 2000 JKS Associates accessed 6/2001
  • "Morbid Obesity" by Don Martin, MD http://discuss.hmc.psu.edu/intranet/handbooks/preop/obesity
  • "Preoperative Pulmonary Evaluation" by Don Martin, MD http://discuss.hmc.psu.edu/intranet/handbooks/preop/pulmonary
  • "Obstructive Sleep Apnea in the Adult Obese Patient: Implications for Airway Management" by Jonathan L. Benumof, MD
        J Clin Anesth 2001 Mar;13(2):144-56 2001 Elsevier Science Inc. [Abstract]
  • "Expanding the care plan for a morbidly obese patient" by Diane E Holland; Yvonne A Krulish; Heidi K Reich: Jill D Roche; Nursing 12/01/2000 ISSN: 0360-4039; Vol. 30 No. 12; p.HN1-HN4 obtained from http://www.northernlight.com 5/28/01
  • "Effects of Morbid Obesity" http://www.liv-lite.com/obesity/effects.cfm
  • The Modified Nasal Trumpet Maneuver. - Beattie, C Anesth Analg 2002 Feb;94(2):467-9
You may also be interested in reading
(not used in preparation of this article)
:
Judy E. Davidson, MS, RN, CNS 
Michael W. Kruse, PharmD 
Deborah H. Cox, RN 
Ron Duncan, RCP 

Critical Care of the Morbidly Obese
Critical Care Nursing Quarterly
April/June 2003 
Volume 26 Number 2
Pages 105 - 116


PubMed ID: 12744591
Douglas D. Brunette, MD Resuscitation of the Morbidly Obese Patient
American Journal of Emergency Medicine
2004 January;22(1):40-47


PubMed ID: 14724877

"Outsize Patients --A Big Nursing Challenge" [http://ENW.org/Obese.htm]
is a webarticle presented by
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2001,2008 Tom Trimble, RN [Tom@ENW.org]
Last Editing of Page: 01/01/2009
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