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Keywords:

  • Bariatric patient;
  • safe patient handling;
  • psychosocial care;
  • veterans

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Acknowledgments
  5. References

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.”


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Acknowledgments
  5. References

Bariatric patients can present unique challenges for nurses. These challenges will increase as the incidence and severity of obesity increases in the population. The purpose of this article is to describe the care of Mr. K., a “super bariatric” patient, using a case study approach, to share valuable lessons learned in preparing for and delivering patient-centered care. Mr. K. weighed 550 pounds and had a body mass index (BMI) of 73 when admitted to our hospital. We will focus on challenges and lessons learned regarding equipment, patient care, and effects on staff. In this case study, we have changed the details to protect the patient's confidentiality.

Language shapes our perceptions, opinions, feelings, and reactions to others and that is true for the language used to describe patients (Zuzelo & Seminara, 2006). Bariatric patients are classified based on their BMI using the following language: Obese (BMI > 30), morbidly obese (BMI > 40), super obese (BMI > 50), and super super obese (BMI > 60) (Taylor, Leitman, Hon, Horowitz, & Panagopoulos, 2006). A common and accepted medical term to define a 500+ pound patient, such as Mr. K., is “morbidly obese.” The word “morbid,” however, is synonymous with “morose,” “gloomy,” “dark,” “bleak,” “dreary,” “sullen,” “nasty,” “grisly,” “gruesome,” and “grotesque” (Kipfer & Chapman, 2010). Before our experience of caring for Mr. K., we were not familiar with the literature indicating that obese patients are self-conscious about their weight; are afraid they will hear disparaging, negative, or inappropriate comments from healthcare providers and staff; and have a history of negative experiences with the healthcare system (Camden, 2009; Camden, Brannan, & Davis, 2008; Medical Care for Obese Patients, 2007; Pantenburg et al., 2012). Most of our staff had never taken care of a “morbidly obese” patient like Mr. K. Although we knew it would be a new and challenging experience, we did not anticipate how challenging it would be. As a result of this experience, we chose to use the term “super bariatric” to describe our patient. We wished to counteract the negative stereotypes associated with the term “morbidly obese” and to emphasize the positive lessons learned in caring for Mr. K. (Gumble & Carels, 2012).

Mr. K.'s Story

Mr. K. had been transferred to our hospital from another facility following a cardiac arrest (ventricular fibrillation) and a 10-day intubation complicated by urosepsis and an acute kidney injury. On admission, he had a DNR (do not resuscitate) order that was subsequently changed to DNI (do not intubate). His past medical history included obstructive sleep apnea, obesity hypoventilation, chronic obstructive pulmonary disease, pulmonary embolus, type II diabetes, degenerative joint disease, depression, chronic pain, cellulitis, and lower extremity venous stasis. He was 56 years old.

Before transfer to our step-down unit, the patient had been in the surgical intensive care unit (SICU) for 5 days. The SICU transfer report described a “morbidly obese patient,” with “difficult behaviors” and episodes of delirium requiring the use of restraints. The SICU nurses also reported that repositioning Mr. K. required four to five staff members. Mr. K. was transferred from the SICU to our step-down unit on 4 L oxygen by nasal cannula with a recommendation for bi-level positive airway pressure (BiPAP) (that he declined), at risk for aspiration, with a Foley catheter because of difficulty using a urinal, a peripheral IV, and on telemetry. Mr. K. also had umbilical pressure ulcers, a deep tissue injury of the coccyx, and a pressure ulcer on his back. We later learned from Mr. K. that he had a devoted wife and children and dearly loved pets.

Our first challenge occurred during the transfer from the SICU and was a foreshadowing of the challenges to come. The bariatric bed that had been rented for the SICU was too large to fit on the hospital elevator requiring that it be dismantled and reassembled in the patient's room. When the bariatric bed was reassembled in the patient's room, it became apparent that the room was not large enough. The bathroom door had to be removed to accommodate all of the equipment and to provide space for staff members to care for the patient. A usually simple transfer down four floors took over an hour. Mr. K. spent the hour waiting on a bariatric cart that was too small causing his pannus to hang over the side of the cart. The patient was in pain and agitated, and the staff was stressed. The patient arrived on our unit at 15:20, just as RN shift hand-off was to start and notably the busiest time of day. Mr. K was severely deconditioned and unable to bear weight or provide much assistance with positioning. The initial patient assessment took several hours to complete. Four staff members were required to complete the transferring and positioning. Two nurses were needed to lift his pannus to assess the skin and wounds.

On admission, the plan was for a 1–5 day hospitalization followed by transfer to a rehabilitation facility. A 29-day stay had commenced.

Equipment

The equipment needed to care for Mr. K. presented numerous challenges including the amount of equipment needed, sling availability, bed and ceiling lift compatibility, bed assembly, and the recall of lift equipment requiring special operating instructions. All of these challenges were compounded by the physical layout and space limitations of Mr. K.'s room. The safe patient handling coordinator was an integral member of Mr. K.'s interdisciplinary team and was instrumental in helping the nursing staff meet these challenges.

Larger rooms are necessary to accommodate all of the equipment needed to care for the bariatric patient (Hignett & Griffiths, 2009; Muir & Archer-Heese, 2009). The hospital did not have rooms designed to handle the seven pieces of bariatric equipment required in Mr. K.'s care. Because of the size and layout of Mr. K.'s room, the equipment could obstruct access to Mr. K. and cause delays in care while it was rearranged. To accommodate the essential equipment and provide the necessary unobstructed space, the bathroom door had to be removed (See Figure 1).

image

Figure 1. Photos of Mr. K's room with all of the essential equipment needed for his care.

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The nursing staff received training annually on the use of lifts, however, there were many details unique to repositioning a super bariatric patient that were unanticipated and required the staff to “think outside the box” when problems arose. One example is the first time the ceiling lift was used to move Mr. K. from the bariatric chair to the bed. The ceiling lift was unable to raise Mr. K. high enough to clear the bed's mattress. To meet this challenge, the mattress was deflated and a slick sheet was used for transfer. To prevent this problem in the future, a lower profile bed was ordered. However, a bed change presented another challenge because it required Mr. K. to wait on the uncomfortable, bariatric (yet too small for this patient) cart that resulted in physical discomfort and emotional distress. His distress increased with each successive bed change as he anticipated the pain and discomfort. Unfortunately, Mr. K. had to change beds a total of three times within the first week of admission.

A second equipment challenge occurred when, after a few initial transfers, the overhead bariatric lift failed leaving the patient suspended above the commode. Physical therapy and safe patient handling staff immediately assisted in returning Mr. K. to bed using two inflatable pieces of equipment, a Hoverjack and Hovermatt. These were inflated underneath the patient, and he was then laterally transferred back to bed. The lift was outdated and the batteries had failed to recharge, in part due to inadequate time on the charger. A replacement lift was installed.

Inconsistent labeling of equipment also complicated care. There is no industry standard for labeling equipment as “bariatric.” Because of this, different pieces of equipment marketed as bariatric can have very different weight capacities. Inconsistent weight capacities caused confusion and delays at the point of care when a piece of equipment turned out to be unsuitable due to weight limitations. In Mr. K.'s case, the bariatric commode was unusable, adding to his distress and discomfort until weight-appropriate equipment was located.

A valuable lesson learned from these equipment difficulties was the importance of coordination and communication among patient and staff. McGinley and Bunke (2009) recommend being proactive, anticipating a “patient's needs from door to door,” working as an interdisciplinary team, and using assistive equipment properly to prevent injury.

Reminders about equipment operation were posted on the walls, and in-service education was provided to individuals on all shifts to ensure that all users were comfortable with the equipment and aware of Mr. K.'s unique needs. These actions were consistent with Muir and Archer-Heese's suggestions that lifting plans be “established based on the Safe Patient Handling assessment findings, and communicated in a readily accessible place in the patient's room” (p. 3, 2009). Our experience with Mr. K. exposed limitations in our response to equipment failures and highlighted the value of effective communication and teamwork. We are now labeling all equipment with weight capacities and have a central posting of equipment weight capacities. We have trained special peer leaders to bring expertise to all shifts and trained staff to always return the lift to the charger.

The importance of checklists was a particular lesson learned. The care of a super bariatric patient is a rare event in this hospital, and rare events pose the risk of knowledge decay. Checklists were developed as a means to consolidate the lessons learned. We established a series of checklists for use by everyone along the care continuum in the hospital when patients over 500 pounds are admitted (Muir & Archer-Heese, 2009). Using Atul Gawande's Checklist for Checklists (Gawande, 2010), key stakeholders were consulted. The stakeholders were multidisciplinary as recommended by McGinley and Bunke (2009) and included nursing staff, laundry workers, maintenance workers, bed coordinators, and safe patient handling staff. This work resulted in a short, one-page checklist. The unit clerks and charge nurses are trained on the implementation of the checklist annually.

Skin and Wound Care

Both the quantity and quality of Mr. K.'s skin and wound cares issues required innovative thinking and treatment. Mr. K. had three pressure ulcers to the umbilical area that were unstageable and difficult to visualize due to the depth and size of the umbilicus. Mr. K. had a deep tissue injury to the coccyx that was present on admission. He had areas of excoriation to the skin folds on the back, groin, and pannus. During the course of his hospital stay he developed a total body rash. The total body rash caused intense itching that led to further skin excoriation, agitation, and restlessness. Immobility, mental status changes, occasional constipation, loose stools, and urinary leakage from an indwelling catheter all contributed to skin and wound care problems. With input from the interdisciplinary team, the primary wound care nurse devised an innovative plan to care for Mr. K.'s skin.

The wound care nurse first focused on the unstageable pressure ulcers to the umbilical area. Due to the unique location of the pressure ulcers, the wound care nurse treated these wounds with a hydrofiber dressing. The rationale was to keep the wound beds moist to aid healing but also to wick the drainage away. A large sheet of the dressing was placed into the umbilical area, but the recommended secondary dressing was not applied because of the depth of the wounds and the difficulty with getting the dressing to stay in place. In Mr. K.'s case, a secondary dressing would have caused additional pressure and increased trauma to the surrounding skin. In addition, a secondary dressing was not needed to hold the hydrofiber dressing in place because the weight of the pannus was sufficient to accomplish this. With this treatment, these wounds greatly improved over a number of weeks.

The second area of focus was the deep tissue injury to the coccyx. Due to the location of the wound, its size, and a contributing factor of incontinence, conservative management was used. Skin protectant creams were applied around the area to allow the wound care nurse and staff nurses to evaluate the patient's wound frequently to ensure that the wound was not deteriorating. The patient reported that the creams were comfortable and worked well because staff could apply them frequently. Toward the end of his care, we attempted to use a dressing to help cover the wound. The dressing did not work well due to excess moisture and displacement during repositioning. However, by the time Mr. K. was discharged the wound was almost completely closed.

Our third area of focus was Mr. K.'s skin folds. On admission, it was noted that he had excoriation of the pannus, groin, and back. The standard treatment for moisture management in patients' skin folds was not feasible (Camden, 2011). Dressings that the wound care nurse would normally use were too small, the wound would have required multiple dressing changes, and there was a risk of not being able to remove all of the dressing. The goal was to develop a treatment that the patient would find comfortable and that would wick moisture away from the area. The solution was to thoroughly clean the skin fold underneath the pannus, dry the area, and place cotton pillow cases in the fold. The pillow case was changed each shift or earlier if moist. With this treatment, his skin greatly improved and at discharge, was free from redness or excoriated areas.

Doing a full skin assessment every shift is the standard of care at our facility. For a patient of Mr. K.'s size, a team approach was vital. According to McGinley and Bunke (2009), this entails having the right equipment at the right time with enough people to complete the task. Mr. K. asked for frequent reassurance on the progress of his wounds and having a team approach and a consistent relationship with his primary team were especially comforting to him.

We learned valuable lessons regarding the unique skin issues that can develop in the super bariatric patient (Lowe, 2009). Pressures sores may be atypical or unusual, resulting from pressure within skin folds or around tubes and catheter or from ill-fitting chairs and wheelchairs (Camden, 2011). Planning a toileting schedule and ensuring the right sized equipment can prevent skin breakdown from incontinence. Using innovative ideas and unique treatments and thinking outside of the box were invaluable in the successful treatment of this patient's wounds.

Mental Status Changes

At times, Mr. K. exhibited signs of delirium. During the day he was generally oriented but became confused and agitated during late evening and at night. Nursing staff collaborated with staff from pharmacy and psychiatry to address these mental status changes. Medications associated with delirium, such as benzodiazepines, were discontinued. Psychiatry staff provided psychotherapy, medication management, and consultations with nursing staff about behavioral interventions.

Other potential causes of altered mental status in super bariatric patients are “obesity hypoventilation syndrome,” which occurs in 10% of these patients, and severe sleep apnea, which occurs in up to 50% (Piper & Grunstein, 2011). Continuous positive airway pressure (CPAP) therapy is recommended, but Mr. K. declined this treatment. We kept Mr. K. in a semi-fowlers position to maximize air exchange, which did result in some improvement in symptoms.

Two self-selected unit RNs championed Mr. K.'s care. One RN with a background in mental health nursing cared for Mr. K. on the day shift, and one RN with expertise in lift and transfer devices cared for Mr. K. on the evening shift. Continuity of care between the two RNs was crucial in the early identification of mental status changes and the implementation of consistent interventions. Reporting on both was an essential part of the bedside day-to-evening nursing shift handoff. To ensure consistency in care, the two core RN's educated other staff about Mr. K.'s unique care needs, mentored them as they learned his complex care needs, and supported the staff in their development of a trusting relationship with Mr. K. This consistency was instrumental in fostering a trusting relationship with Mr. K. As trust developed, Mr. K. became less anxious and more cooperative.

Pain and Symptom Management

Dealing with chronic and acute pain was very challenging because we needed to balance pain control with mental status changes. Mr. K. had chronic pain from severely arthritic joints and a torn right rotator cuff. Because he was right-handed, both caused considerable mobility limitations. We used cold packs, warm packs, distraction, physical therapy, occupational therapy, pillows, positioning, and narcotics to help manage his pain. Several different slings were tried to find one that caused the least pain during transfers. Dermatologists were consulted about Mr. K.'s painful and severely pruritic rash, but they were unable to identify the source. The rash may have been due to an antibiotic given at the previous hospital. Intravenous, oral, and topical therapies were prescribed, including entire tubes of medicated creams that were applied multiple times daily. We learned that the absorption and distribution of drugs may be affected by the large amounts of adipose tissue in bariatric patients, but this phenomena is not well understood (Brill et al., 2012). We also learned the vital importance of monitoring for drug reactions and working closely with other healthcare providers to identify drug interactions and suggest possible alternatives.

Fall Risk

Preventing falls was a major challenge in the care of Mr. K. He was at high risk for falls (Himes & Reynolds, 2012). He was often impulsive and unaware of his limitations and would attempt to get out of bed even though he was unable to walk. He could not be placed closer to the nurse's station for observation because the bariatric bed was too large for the room. His specialty bariatric bed was not equipped with a bed alarm, and the portable bed alarm often did not work properly. Mr. K. would not wear any clothing or a hospital gown because of the discomfort they caused him, therefore the door to his room needed to be closed to protect his privacy and dignity and that of other patients and visitors. As Mr. K. began to regain his strength, he often overestimated his abilities and on several occasions attempted to transfer and ambulate on his own. Staff used ongoing education with Mr. K. about his limitations and need for assistance, and direct observation of Mr. K. was increased, including the use of sitters. In the end, however, Mr. K. did fall one time. Lying on the floor, he called out for assistance and informed the responding nurse that she was correct: He was not able to stand on his own despite his best effort to do so. Luckily, he was not injured, and staff were able return him to bed with the Hoverjack (see Figure 2).

image

Figure 2. Photo of Hoverjack.

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Nutrition

Mr. K. needed enough caloric intake to achieve proper wound healing and to provide the necessary energy to meet the demands of his physical therapy goals. Unfortunately, many healthcare providers are not informed about the importance of adequate caloric intake for healing and recovery, even in super bariatric patients (Liebovitz et al., 2013). Without adequate caloric intake, the body will break down healthy muscle and tissue. This leads to a decrease in muscle mass, disruption of vital organ systems, poor wound healing, and an inability to participate in rehabilitation goals (Barker, Gout, & Crowe, 2011). A nutritional assessment estimated that Mr. K. needed between 3,000–4,000 kcal and 162–188 g of protein per day. Even at this high level of caloric intake, it was estimated that he would lose approximately 5 pounds per week. Nurses and staff from nutrition provided education about the need for a healthy, well balanced diet as well as assistance at mealtime to enhance his oral intake. Unfortunately, Mr. K. would not eat the diet provided, and his caloric intake was less than 500 calories a day. Mr. K. declined a feeding tube to supplement his caloric intake and nutritional needs. To increase caloric intake, the patient's food preferences were honored, and his wife provided food from home. Danish sweet rolls and brownies were his most frequent requests. Mr. K. eventually started to eat and regain strength and improve his dietary choices.

Psychosocial Issues

The physical aspects of caring for a super bariatric patient were challenging, but our greatest challenges were the psychosocial ones. Mr. K. could be impatient and impulsive. If he needed something, he would call out loudly for help and those calls were distressing for other patients, visitors, and staff. Complicating the situation, Mr. K. was VRE+ (vancomycin resistant enterococcus positive), requiring staff to don gowns before entering the room, which was perceived by Mr. K. as a delay in responding. Other actions by Mr. K. – refusing telemetry, refusing BiPaP, and pulling out a peripherally inserted central catheter (PICC) line – along with mental status changes raised concerns for his safety. A sitter was instituted to address this safety risk.

A valuable lesson learned was the importance of fostering autonomy and dignity. A master schedule was created with Mr. K. for toileting, bathing, wound care and physical therapy so that he would know what to expect and when, and feel more in control of his day. Mr. K. was a partner in all decisions, and the staff was committed to meeting his requests whenever possible. For example, Mr. K. did not like the wheelchair that was provided so arrangements were made to bring his own wheelchair from home. Transferring took a great deal of time and energy, but staff tried to always transfer to the commode instead of using the bedpan. Mr. K. received frequent shaves and haircuts that he said made him feel more like a “regular person.” Staff facilitated wheelchair rides throughout the hospital and out-of-doors to break the monotony of an extended hospital stay.

Numerous phone calls were made to his wife, and family photos were posted throughout his room. We engaged Mr. K. in sharing his feelings and thoughts about his wife, his beloved dogs, and his children. All of this provided a diversion for Mr. K. and kept him focused on getting stronger and returning to the home he loved.

Another valuable lesson learned was the importance of a trusting relationship. The two nurses who consistently cared for Mr. K. and had trusting relationships with him developed an informal mentoring process with other RNs. The mentoring included teaching the physical and technical aspects of his care and the psychosocial and behavioral nursing care needs. Mr. K. was very skeptical of “new” nurses. Informal mentoring allowed “new” nurses to learn Mr. K.'s routines and build some trust in advance of caring for him. In addition, staff consciously took the time to “check in” with one another about how things were going and if staff caring for Mr. K. needed assistance. An unanticipated outcome of this mentoring process was the strong bond that developed between the nursing staff and the rest of the interdisciplinary team. Caring for Mr. K. was at times physically and emotionally difficult. We learned that we needed to rely on one another for support if we were to deliver the highest quality of care to Mr. K.

Staff Care and Workload Management

Good patient care necessitates that the physical and emotional health needs of staff are also addressed and met. Additional staff was scheduled to accommodate the increased workload. Staff rotated as much as possible to decrease staff “burnout,” and a workload tool was used to ensure a “lighter” load for staff when they were caring for Mr. K. Healthcare professionals from physical therapy, occupational therapy, wound care, safe patient handling, and social work were invaluable in providing direct support. This interdisciplinary team effort was the main reason so many positive outcomes were achieved.

Key Practice Points
  • Super bariatric veterans who are patients pose unique and complex challenges to providing quality nursing care.
  • Having the right equipment in the right place at the right time is essential for providing safe and compassionate care that protects the veteran's dignity.
  • Super bariatric patients have unique skin care, respiratory, pulmonary, metabolic (nutrition and healing), and psychosocial needs and concerns requiring an educated and individualized approach to care.
  • A multidisciplinary, patient-centered approach with advance planning and coordination is necessary to ensure the delivery of safe, high-quality nursing care to super bariatric veterans with complex health problems.

Discharge Planning

Social work staff was instrumental in finding a rehabilitation facility equipped for a super bariatric patient. After 26 referrals, a facility was found. Unfortunately, the initial day of discharge was canceled because the needed equipment had not arrived at the facility. Although Mr. K. was somewhat dejected and depressed about the delay, he was successfully discharged several days later. Mr. K. called the hospital staff several times after discharge to keep staff informed about his progress and concerns. Those conversations always ended in a “thank you” to staff for their “great care.” At last report, Mr. K was living at home with his wife and dogs and ambulating independently.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Acknowledgments
  5. References

We thank our patient for his willingness to share his story with the goal of improving care of the bariatric patient. In addition, we thank Sizewise for the use of their equipment in the photograph.

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References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Acknowledgments
  5. References
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