SAMPLE Orientation Assessment: Caring for Morbidly Obese Patients Department: Employee Name: Start Date: Completion Date: Preceptor Name: Competency 1. Staff member behaviors, actions and attitudes toward the morbidly obese patient 2. The person and not the morbid obesity should be the focus of treatment. 3. Pulmonary hygiene and airway management of the morbidly obese patient 4. Management of nasogastric, surgical and parenteral tubes Attend to needs of comfort, safety, and selfesteem. Morbidly obese patients may be emotionally vulnerable about their weight and body image. An obese patient s airway, circulation and pulmonary status are often altered, making assessments and treatments challenging. When caring for patients who are morbidly obese, these aspects of care are at higher risk due to the size and alterations of typical physical landmarks, making physical assessments challenging. Chronic medical conditions add to patient assessment and treatment challenges. 1
5. Venous thromboembolism care and cardiopulmonary assessments Morbidly obese patients who have major surgical procedures and post-operative immobility are at a high risk for developing a DVT which could lead to development of a pulmonary embolism. 6. Equipment and mobility safety 7. Physical and rehabilitation therapy Appropriate use of ergonomic principles, weightbased limitations, lifting techniques, transfer maneuvers and use of medical devices will assist nursing staff members in minimizing potential injury to themselves as well as ensuring the safety of the patient. Physical therapy and rehabilitation staff members encourage patients to increase pre-operative and post-operative activity. Guidance and monitoring of physical activity will assist morbidly obese patients to remain as physically active as their condition warrants. Deleted:, 8. Recognition of common potential comorbid conditions and/or complications (e.g., diabetes, cardiac, respiratory, vascular conditions, sleep apnea) Morbid obesity predisposes patients to comorbid diseases which affect nearly every organ system. 2
PATIENT CARE AREAS A. Surgical staff Additional training for surgical staff members include the following: 1. Medical and anesthesia clearance Morbid obesity increases the risk of respiratory/pulmonary complications in the surgical patient. 2. Patient positioning Morbid obesity increases the risk of pulmonary, nerve and skin complications in surgical patients. 3. Ventilation Patients should be carefully monitored for pulmonary compromise such as rapid oxyhemoglobin desaturation and respiratory depression after extubation. 4. Venous thromboembolism care Morbid obesity increases the risk of venous complications in surgical patients. 5. Monitoring devices Accurate placement of devices (e.g., pulse oximetry) and interpretation of results are essential for early recognition of complications. Increased body mass may impact the accuracy of monitoring devices. 6. Pain management Pain control, which is a goal of post-operative pain management, will also promote patient participation in activity, but may be difficult to achieve with morbidly obese patients. 3
7. Transfer Understanding and following safe ergonomic principles when transferring morbidly obese patients at all points of care will assist in reducing patient and staff member injuries. 8. Equipment safety Lifting and transfer equipment must be used according to the manufacturer s instructions to be effective and safe. Ensure that all equipment is appropriately weight-based for morbidly obese patients. B. Critical Care Staff Advanced training in the care and management of the bariatric patient 1. Cardiopulmonary management 2. Venous thromboembolism care Pulmonary embolism has been identified as a leading cause of death for morbidly obese patients. Morbidly obese patients undergoing surgical procedures are at a high risk for the development of peri-operative and post-operative venous thromboembolism. 4
C. Medical/Surgical Staff Continuum of care through to discharge: 1.Post-operative care 2. Discharge planning and follow-up for patients undergoing weight loss procedures: a. Social service support b. Nutritional services c. Post-discharge counseling d. Group therapy, ongoing and longterm follow-up e. Exercise program/physical activity Post-operative care for morbidly obese patients should include monitoring of fluid balance, hypoxemia, anastomotic leak, tachycardia, peripheral nerve injury, and risk of skin irritation, infection, ulceration in skin folds, and decubitus ulcers. Potential complications most likely to occur in the early discharge phase include: dehydration, pulmonary embolisms and anastomotic leaks. After weight-loss procedures, nutritional deficiencies (including Vitamin B-12, folate, and iron) may occur. Post-operative support groups may improve post-operative results and limit relapse. The participation of patients in support groups may improve their outcomes after having weight-loss procedures. 3. Patient/family education Patients should be advised of required behavioral and dietary changes and other reasonable and foreseeable consequences of weight-loss surgery that could affect health or quality of life in a substantive way (e.g., gastrointestinal symptoms, cosmetic effects, Deleted: 5
nutritional restrictions). D. Emergency Room Staff 1.Caring for morbidly obese patients 2. Caring for the patient who presents with a post-weightloss surgical complication Obese patients require more staff members to position and transfer them from the ambulance stretcher to the cart/bed. Moving and/or supporting heavy limbs and excess body weight can make it difficult to perform assessments. Understanding and following safe ergonomic principles when transferring obese patients at all points of care will assist in reducing patient and/or staff member injuries. Morbid obesity predisposes patients to comorbid diseases which affect nearly every organ system. E. Perinatal Staff The care of obese gravida patients poses unique problems, which may vary throughout the patient s pregnancy. Caring for obese gravida patients often requires more intense nursing care to help mitigate potential complications the patient/fetus may have. 6
1.Preeclampsia Antepartum concerns include hypertension, preeclampsia, and gestational diabetes. 2.Gestational diabetes 3. Difficult labor monitoring 4. Dysfunctional labor 5. Higher cesarean section rates 6. Greater blood loss 7. Difficulty with regional (spinals/epidurals) anesthetic placement 8. Positioning challenges 9. Higher rate of stillbirth/prematurity 10. Wound infection Postpartum concerns include wound infection and disruption, deep vein thrombosis, endometritis and ultimately greater length of stay. 11. DVT 7
12. Endometritis 12. Greater length of stay 8