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As far back as 1994, Ostomy Wound Management realized there was a crisis at hand. Obesity (body mass index [BMI] >30) and morbid obesity (BMI >40) were becoming increasingly prevalent, impacting all aspects of patient care and provider safety and underscoring the importance of understanding the implications of proper management of the bariatric patient. OWM has published at least 25 articles over the past 2 decades to enhance knowledge of this unique group of patients whose clinical, physical, and emotional needs sometimes remain unmet despite the fact that obesity is now recognized as a disease.
For this endeavor, the articles have been organized by the most obvious care theme (general obesity/bariatric management, relevant technology, skin and wound care, age and/or disease/condition, and surgical considerations), but many overarch several categories. Feature articles that have been indexed appear with their (in some cases, abbreviated) abstracts. Articles that OWM publishes as “Departments” have been edited for space. Articles published after 2000 are available in their entirety at www.o-wm.com; please contact the Editor for copies of older publications.
We are grateful to the authors and researchers for addressing the problems faced by obese persons and their families and care providers. We especially acknowledge the efforts of Dr. Susan Gallagher, who has been a prolific contributor and staunch patient advocate and professional champion in this arena. Our hope is that this compilation of articles will influence bariatric protocols and provider awareness of the many facets of caring for this challenging patient population.
Background
Emerging data on the state of obesity (Gallagher S). It is no surprise an obesity crisis is plaguing health care in general and wound/ostomy care specifically. Many researchers suggest the trend will continue because lifestyles and nutritional habits have changed drastically in the past 50 years. Obesity is one of the biggest drivers of preventable chronic diseases and health care costs in the US. Currently, this economic burden ranges from $147 billion to nearly $210 billion per year. From a wound or ostomy perspective, the literature explains the mechanisms by which obesity increases surgical and wound complications. Potential factors include the intrinsic anatomic properties of excess weight and poor vascularity of adipose tissue. Relative vascular insufficiency and subsequent decreased oxygen tension lead to decreased collagen synthesis, decreased capacity to fight infection, and decreased ability to support the necessary mechanisms of the healing cascade. These data have been available for at least the past 3 decades and are recognized as factors that delay healing. The literature suggests patients with a high degree of adiposity are at greater risk for a number of well-documented concerns than their leaner peers. Adipose tissue acts similar to an endocrine organ and influences hormone and cytokine production and secretion. Dysregulation of cytokines, often observed in the obese patient, facilitates an environment of chronic inflammation. This dysregulation affects every organ of the body, including the intestinal tract, the integumentary system, chronic wound healing, and response to an acute illness. As obesity continues to gain attention, wound and ostomy providers need to consider evidence-based strategies to manage the clinical, humanistic, and economic aspects of bariatric patient care. 2016;62(1):6–7.
General Obesity/Bariatric Management
Innovative methods to better manage the clinical, cost, and humanistic aspects of bariatric care (Gallagher S). Obesity has become a worldwide issue as evidenced by the emerging demographics of obesity among all categories of individuals: 71.4% of Americans are overweight or obese, more than one third of Americans are obese, and 3% to 10% (at least 8 million) people are morbidly obese. As the prevalence of obesity continues to rise across all categories of patients, health care providers and researchers continue to seek innovative and proven methods to better manage the clinical, cost, and humanistic concerns of bariatric patient care. 2015;61(1):6.
Clinician challenges in providing health care for a morbidly obese family member: a bariatric case study (Beitz JM). This case study describes the experiences of a morbidly obese woman in the final years of her life from the perspective of her health professional relative. The patient typifies many of the major risk factors for morbid obesity; her story reveals many of the issues faced as she revolved in and out of the critical care and acute care system. Her substantive health problems affected multiple body systems and included hypothyroidism, congestive heart failure, hyperlipidemia, and subclinical Cushing’s Syndrome, likely related to previous medical therapy (cortisone) for rheumatic fever in childhood. The case description addresses many integumentary system issues the patient experienced; skin injuries and infections that can pose serious life-threatening situations for the morbidly obese patient must be prevented or treated efficiently. Health professionals can learn a great deal and improve the care they provide by listening to morbidly obese patients. 2015;61(1):42–46.
The intersection of ostomy and wound management, obesity, and associated science (Gallagher S). The word obesity originates from the Latin language and refers to the state of becoming fattened by eating. Bariatrics is a term derived from the Greek word baros and refers to issues pertaining to weight. In some circles, the term bariatrics is associated with metabolic surgery. However, the word encompasses much broader meaning; currently, it refers to the practice of health care that relates to the treatment of weight and weight-related conditions. This includes bariatric surgery as well as bariatric gynecology, bariatric reconstruction after massive weight loss, bariatric pediatrics, bariatric wound care, and more. Care of larger, heavier patients has become important in the practice of ostomy and wound care.
Issues related to weight are of interest to the public for several reasons. Bariatrics as a specialty is becoming increasingly important in pace with the growing number of obese and overweight Americans. The problem is pandemic — overweight and obesity are not limited to the US. Worldwide, nearly 2 billion individuals are overweight, exceeding the number of individuals suffering from starvation.
Care challenges are substantial. Consider the effect of obesity-related consequences of care on patients and clinicians. Repositioning for pressure ulcer prevention, turning for examination or treatment of skin injury, or movement of the panniculus for ostomy care all may impact the outcome of patient care if the caregiver is physically unable to perform the task. Further, handling larger, heavier patients may put caregiver safety at risk if these tasks are performed manually.
Providing care for the larger, heavier individual who enters the health care facility for an unplanned event can be more complex and time-consuming than with normal-weight patients; seldom do staffing administrators or reimbursement plans accommodate this difference. Regardless of the practice setting, preplanning becomes an essential component of safe patient care. Therefore, hospitals across the country are creating bariatric teams in hopes of designing processes to control or prevent some of the untoward complications associated with caring for the obese patient. However, limited availability of resources with which to develop appropriate tools and plans presents numerous obstacles. Likewise, skin and wound considerations, adequate nutritional support, intravenous access, appropriately sized equipment, airway management, resuscitation, diagnostic testing, pain control, social and emotional concerns, and prevention of complications all present special and unique concerns. Practical resources such as longer gloves, wider commodes, specialized tracheostomy tubes, bariatric furniture, and mobility devices are important to consider.
With obesity on the rise, clinicians are increasingly responsible for managing the needs of this complex patient population. This is especially true in the case of the obese patient with a wound or ostomy. Caregivers provided the tools, resources, and knowledge to provide good patient care feel good about their efforts and their job satisfaction rises. Satisfaction scores reflect that the happier the caregiver, the happier the patient. Numerous resources are available to clinicians across practice settings, and use of resources in a timely and appropriate manner is thought to improve measurable therapeutic, satisfaction, and cost outcomes. Coordinating these resources in the form of a comprehensive bariatric care plan may ensure the most favorable outcome for the patient with a wound or ostomy.
The obese patient presents numerous care challenges. It is in the interest of health care organizations to meet these care challenges in a dignified and sensitive manner. 2014;60(1):6–7.
Criteria-based protocols and the obese patient: planning care for a high-risk population (Gallagher S, Arzouman J, Lacovara J, Blackett A, McDonald PK, Traver G, Bartholomeaux F). Well-recognized obesity-related health problems pose many challenges in the acute care facility. These challenges include not only physical barriers and complications, but also concern for the well-being of caregivers. Despite these problems, little preplanning of resources occurs. Barriers to bariatric protocol development are discussed and strategies for overcoming these barriers with attention to preventing caregiver injury, optimizing patient care, and limiting associated costs are reviewed. A description of an interdisciplinary, criteria-based bariatric protocol is included. With adequate and appropriate preplanning, the challenge of providing bariatric care can be met. 2004;50(5):32–38.
New and revised overweight and obesity ICD-9 codes (Schaum KD). 2006;52(6):63–64. We have included the original article; updated ICD-10 codes are available at: www. icd10data.com/ICD10CM/Codes/E00-E89/E65-E68/E66-.
Obesity-related Technology
A computer modeling study to evaluate the potential effect of air cell-based cushions on the tissues of bariatric and diabetic patients (Levy A, Kopplin K, Gefen A). Sitting-acquired pressure ulcers (PUs) are a potentially life-endangering complication for wheelchair users who are obese and have diabetes mellitus. The increased body weight and diabetes-related alterations in weight-bearing tissue properties have been identified in the literature to increase the risk for PUs and deep tissue injuries (DTIs). A computer modeling study was conducted to evaluate the biomechanical effect of an air cell-based (ACB) cushion on tissues with increased fat mass and diabetes, which causes altered stiffness properties in connective tissues with respect to healthy tissues. Specifically, 10 finite element (FE) computer simulations were developed with the strain and stress distributions and localized magnitudes considered as measures of the theoretical risk for PUs and DTIs to assess the effects of fat mass and pathological tissue properties on the effective strains and stresses in the soft tissues of buttocks during sitting on an ACB cushion. The FE modeling captured the anatomy of a seated buttocks acquired in an open magnetic resonance imaging examination of an individual with a spinal cord injury. The ACB cushion facilitated a moderate increase in muscle strains (up to 15%) and stresses (up to 30%) and likewise a moderate increase in size of the affected tissue areas with the increase in fat mass for both diabetic and nondiabetic conditions. These simulation results suggest wheelchair users who are obese and have diabetes may benefit from using an ACB to minimize the increased mechanical strains and stresses in the weight-bearing soft tissues in the buttocks that result from these conditions. Clinical studies to increase understanding about the risk factors of both obesity and diabetes mellitus for the development of PUs and DTIs, as well as robust preclinical comparative studies, may provide much-needed evidence to help clinicians make informed PU prevention and wheelchair cushion decisions for this patient population and other wheelchair-bound individuals. 2016;62(1):22–30.
A pictorial overview of technology-assisted care options for bariatric patients: one hospital’s experience (Arnold M, Roe E, Williams D). Best practice guidelines to avoid pressure ulcers and skin breakdown among obese patients include early and progressive mobility, rigorous turning schedules, and proper skin care. However, implementation of some these guidelines may increase the risk of patient and caregiver injury. An acute care hospital implemented safe patient handling protocols that involved equipment purchase and extensive training for all care staff. The new equipment facilitated repositioning, including boosting and turning, lateral transfers, vertical transfers and ambulation, and bathing and toileting. All health care facilities are expected to see an increase in the number of bariatric patients and the need for safe patient handling protocols and procedures. 2014;60(1):36–42.
The effect of using a low-air-loss surface on the skin integrity of obese patients: results of a pilot study (Pemberton V, Turner V, VanGilder C). Obese patients often are immobile, acutely ill, and at high risk for developing pressure ulcers when admitted to acute care facilities. Pressure-relieving mattresses are an integral part of a pressure ulcer prevention plan of care. Patients with a body mass index >35, weight between 250 lb and 500 lb, and a minimum 3-day length of stay were recruited to participate in a pilot study to evaluate the safety and use of a new low-air-loss, continuous lateral rotation bariatric bed. Skin inspection was performed at the beginning and end of the study (maximum 7 days). Participants included 21 consecutively admitted patients (10 men, 11 women, average age 51.7 years [range 32–76], average BMI = 51.4 [range 37–71]) with an average Braden pressure ulcer risk score of 14.7 (range 9–21). Most (n = 11) were receiving treatment in the intensive care unit. Six (6) patients had 10 pressure ulcers (6 Stage I, 4 Stage II). Average length of stay on the surface was 4.8 days (range 2–8 days); ulcers decreased from an average size of 5.2 cm2 to 2.6 cm2. No new pressure ulcers developed. 2009;55(2):44–48.
Skin and Wound Care
Providing quality skin and wound care for the bariatric patient: an overview of clinical challenges (Beitz JM). The purpose of this overview is to address some common skin and wound care issues faced by bariatric patients in order to inform clinicians, patients, and caregivers and enable them to optimize care. For bariatric patients, extra attention must be paid to skin care, cleanliness, skin fold management, perigenital care, odor management, and effective pressure redistribution. Despite these interventions, the multifactorial challenges presented by morbid obesity increase patient risk for serious skin diseases and wound conditions. Implications for practice include how best to educate patients and caregivers for optimal problem prevention. 2014;60(1):12–21.
Intertrigo in the obese patient: finding the silver lining (Muller N). The soaring prevalence of obesity in the past decade has forced health care providers to pay increasing attention to the unique needs of the obese patient. Not the least of these needs is skin care and the risk of moisture-associated skin damage, most often diagnosed as intertriginous dermatitis (intertrigo). Obese patients are particularly vulnerable because the natural cooling mechanisms of their bodies are compromised, making perspiration a virtual constant. In addition, their body mass can limit mobility. As moisture accumulates and remains trapped within skin folds, bacterial, fungal, and viral growth inevitably leads to intertrigo and even skin breakdown.
Intertrigo is first manifested by itching, burning, pain, odor, and erythema. If left undiagnosed or not addressed properly, the condition can progress to intense inflammation, erosion, and crusting. As skin becomes macerated with hyperhydration, skin-against-skin friction increases and weakens epidermal tissue, allowing invasion by external organisms. The ultimate insult of skin breakdown and secondary infection is similar to what occurs in the patient experiencing incontinence-associated dermatitis. Bariatric patients experiencing weight loss-redundant skin also are at risk.
Nurses and aides must routinely inspect the skin inside skin folds and pay particular attention to the axilla, pannus, area just below the breast, groin, gluteal folds and upper thighs, and back of the knee. The incontinent obese patient is even more likely to encounter such skin problems, given the likelihood of both urine and perspiration becoming trapped in skin folds. Whether these patients are in acute care, rehab, extended-care facilities, or home care or hospice, the nursing team responsible for hands-on care must inspect the skin down to the base of folds. Comprehensive nursing protocols for the bariatric patient should encompass bathing, toileting, skin fold management, odor, and genital care.
Over the years, many nurses assumed intertrigo inflammation is fungal in nature and best treated with antifungal or, in some cases, talcum powder. Increasingly, case studies are documenting a diverse number of organisms (eg, Escherichia coli, coagulase-negative Staphylococcus, Enterococcus faecalis, Proteus mirabilis, and Candida albicans) in skin folds. In a recent, hospital-based study, barely 1 in 10 infections (9.5%) was identified as a (frequently suspected) yeast-like fungus. Unfortunately, the costs of cultures can discourage clinicians to take the steps necessary to properly identify the organism at work. However, untimely and inappropriate treatment can lead to even greater expense, wasteful interventions, and more serious complications. Regardless of your practice setting, you are likely to encounter patients with skin fold complications. 2013;59(3):14.
An overview of dermatological conditions commonly associated with the obese patient (Hahler B). Obesity is a chronic disease that may lead to skin problems, including acanthosis nigricans, skin tags, hyperandrogenism, striae distensae, plantar hyperkeratosis, and candidal intertrigo. Although some conditions (eg, skin tags and striae distensae) may simply be annoying or present cosmetic issues, conditions such as acanthosis nigricans and hyperandrogenism may be indicative of systemic diseases. Obesity also may contribute to poor healing of acute and chronic wounds that develop in this population. Some of the most common obesity-related skin disorders and factors affecting wound healing are described with suggestions on how to address these issues. With the continuing increase in the incidence of obesity, investigation into the specific care needs of this population is needed. In clinical practice, measures to reduce friction and shear and improve devices to move the obese patient would enhance care provision. Studies of the incidence of dermatological problems and the best treatments for these conditions are warranted. 2006;52(6):34–40.
Morbid obesity: a chronic disease with an impact on wounds and related problems. (Gallagher SM). Morbid obesity is a chronic disease that manifests as a steady, slow, progressive increase in body weight. Because of both emotional and physical reasons, obese people resist pursuing health care and may be more difficult to care for. In taking a practical approach to skin and wound care, using an interdisciplinary team is valuable. Difficulty in assessment stems from problems such as equipment that is too small or patient uncooperativeness. Skin/wound problems which are common, yet more difficult to manage for these patients, include pressure ulcers, tracheostomy care (potentially resulting from ventilatory insufficiency), candidiasis, tape-related skin tears, incontinence, and lymphedema. In order to offer care and support to these patients and their families, clinicians must acknowledge and manage any personal prejudice they may have toward this patient population. A comprehensive patient-focused plan of care is the goal. Four (4) annotated suggested readings are included introducing topics such as the failure of behavioral and dietary treatments for obesity, theoretical and practical aspects of obesity assessment, current views on obesity (such as a move back to pharmacotherapeutic treatment), and the psychological aspects of severe obesity. 1997;43(5):18–27.
Special Populations and Conditions
The relationship between obesity and calciphylaxis: a review of the literature (Davis JM). Calciphylaxis is characterized by calcification in the medium and small vessel arterioles and can be a life-threatening complication often associated with chronic kidney disease (CKD). A review of the literature was conducted to explore existing evidence about the relationship between obesity and calciphylaxis. A total of 54 publications (published between 1962 and 2015) were identified. Most studies noted a variety of risk factors for calciphylaxis, including CKD, female gender, Caucasian race, liver disease, and lower serum albumin. Obesity was identified as a risk factor in 6 of the 8 studies reviewed. In one study, obesity was found to quadruple the risk of calciphylaxis. The majority of calciphylaxis lesions in obese persons were proximal in distribution; all studies reported proximal lesions are associated with a higher mortality rate than distal lesions. The mortality rate of persons with CKD and calciphylaxis is 8 times higher than that of persons with CKD without calciphylaxis. There is no definitive evidence to support the belief current epidemic rates of obesity, diabetes, (diabesity), and chronic renal disease will predispose more patients to the development of calciphylaxis. However, until more information from the calciphylaxis registries and other studies is available, clinicians should maintain a high index of suspicion when a patient presents with indurated, painful nodules or necrotic ulcers, especially if the patient also has CKD. 2016;62(1):12–18.
Massive localized lymphedema, a disease unique to the morbidly obese: a case study (Fife C). Massive localized lymphedema (MLL) is a unique presentation of lymphedema resulting in a large, benign, painless mass that develops in morbidly obese patients, most commonly on the medial thigh. Because nearly 6% of the United States adult population is morbidly obese, MLL is believed to be underdiagnosed. To better guide the clinician in identifying and treating MLL, a case study of a 44-year-old Caucasian woman with type 1 diabetes who presented to the study wound care clinic with MLL is reported, along with the experience of managing more than 70 patients with MLL. A diagnosis of MLL is usually made based on clinical history and presentation. Routine tissue biopsy is not advisable, and diagnostic tests such as magnetic resonance imaging (MRI) may be impossible due to the morbid obesity of most patients. Complete decongestive physiotherapy (CDP) is recommended. Although surgical removal of the MLL collection may be possible, it is technically difficult and not always advisable due to the risk of perioperative complications, including wound dehiscence. Furthermore, in the author’s experience, recurrence is possible even after surgical removal, particularly if conscientious adherence to compression and weight management do not continue. The advent of advanced pneumatic compression devices designed for the morbidly obese and the possibility of using near-infrared fluorescence imaging to guide treatment may transform the MLL management process. Considering the increasing number of MLL cases, the comorbidities and complexities of treating morbidly obese patients, and associated complications, clinicians caring for the morbidly obese need a heightened awareness of this condition. 2014;60(1):30–35.
Lymphedema in the morbidly obese patient: unique challenges in a unique population (Fife CE, Carter MJ). The population of morbidly obese patients, along with the incidence of lymphedema and massive localized lymphedema associated with this condition, is increasing. A 5-year retrospective review of data (2000–2005) shows that the percentage of patients >350 lb in the authors’ clinic population increased from approximately 7% to 11% and 75% of their morbidly obese patients (body mass index >40) had or have lymphedema. After a differential diagnosis between lipedema and lymphedema (primary or secondary) has been made, lymphedema management options include compression bandaging, manual lymphatic drainage, and localized surgeries. The treatment of morbidly obese lymphedema patients requires additional staff time and specialized equipment to move or position them and may be confounded by other conditions (eg, heart failure and venous insufficiency) that contribute to edema. Lymphedema treatments have been found to be useful, providing patients are able to follow treatment guidelines, especially with regard to weight control. In the authors’ experience, massive localized lymphedema will recur unless the primary issue of obesity is addressed. Establishing clear criteria and patient participation guidelines before initiating a comprehensive localized lymphedema program will improve outcomes. 2008;54(1):44–56.
A patient-centered approach to treatment of morbid obesity and lower extremity complications: an overview and case studies (Fife CE, Benavides S, Carter MJ). The purpose of this overview is to examine common concerns related to morbid obesity and interrelated lower extremity complications, including wound and skin infections, dermatologic conditions, lymphovenous obstruction syndromes, chronic venous insufficiency, and anatomical abnormalities such as massive localized lymphedema. Treatment may include surgery for massive lymphedema localizations, compression bandaging for chronic venous insufficiency as well as lymphedema, manual lymph drainage for lymphedema, and prompt and aggressive management of wound infection and bioburden. Case studies are presented to illustrate some lower extremity complications of morbid obesity and appropriate protocols of care. Although increasing evidence suggests that morbidly obese patients are predisposed to secondary lymphedema and that primary lymphedema can cause adult-onset obesity, the mechanisms by which these events occur remain unclear. However, unless the underlying problem of morbid obesity is addressed, the problems for which these patients seek care will continue to recur. 2008;54(1):20–32.
Managing complex, high-output, enterocutaneous fistulas: a case study (Hahler B, Schassberger D, Novakovic R, Lang S). Gastrointestinal (GI) fistulas are an uncommon but serious complication. Following diagnosis, management strategies may have to be adapted frequently to address changes in fistula output, surrounding skin or wound condition, overall patient clinical and nutritional status, mobility level, and body contours. Following a motor vehicle accident, a 49-year-old man with a body mass index of 36.8 and a history of multiple previous surgeries, including gastric bypass, experienced excessive output from a fistula within a large open abdominal wound measuring 45 cm x 40 cm x 5 cm. Abdominal creases and the need to protect a split-thickness skin graft of the wound surrounding his fistula complicated wound management. During his prolonged 4-month hospital stay, the patient underwent several surgical procedures, repeated wound debridement, and various nutritional support interventions; a wide variety of wound and fistula management systems were utilized. One (1) year after the initial trauma, the fistula was surgically closed. One (1) week later, the patient died from a cardiac event. This case study confirms that GI fistulas increase costs of care and hospital length of stay and require the experience and expertise of a wide array of patient support staff members and clinicians. 2009;55(10):30–42.
Obesity: changing the face of geriatric care (Gallagher Camden S, Gates J). Obesity, coupled with the challenges of aging, leads to an unfortunate burden of chronic disease, functional decline, poor quality of life, and an increased risk of being homebound. Physical assessment of the elderly obese patient should include measurement of height, weight (to determine body mass index), waist circumference (to address central obesity), and consideration of vascular, skin, and mobility issues. Weight management strategies such as diet and hydration should balance nutritional requirements with weight loss; particular attention to protein needs in chair- and bedbound patients is necessary. Additional approaches such as exercise, bariatric weight loss surgery, and weight loss medication should be considered on an individual basis related to their inherent risks in this population. Weight loss/management options framed from an interdisciplinary perspective can improve quality of life for these patients and their caregivers. 2006;52(10):36–44.
The battle of the bulge and ostomy care (Turnbull GB). A 2006 meeting in Florida included an exemplary presentation on diabetes mellitus. The speaker had a frightening set of chronological slides that illustrated the mounting overweight and obesity epidemic in the US over the past several years and its link to the increase in diabetes mellitus — even in children as young as 8 years old. This is not something new, yet we read more and more that this problem is taking an enormous toll — not only on our health, but also on the economy, our nation’s future, and the health care professionals who care for bariatric patients.
Although not a uniquely American phenomenon, Americans seem to be paving this downhill path. As an ex-patriot working in Canada, I see the American overweight trend creeping northward. Peoples with traditionally healthy Asian or Mediterranean diets are being enticed by high-fat, highly processed, high-sugar foods, increasing incidence of obesity, heart disease, vascular problems, and diabetes where these diseases previously had been nearly nonexistent.
The 25-year-long Canadian Health Survey (compiled 1997 to 2004) studied adults and children between the ages of 2 and 17 years. In 1979, 3% of Canadian children and 14% of Canadian adults were listed as obese. By 2004, nearly 30% of Canadian children and 60% of adults in Canada were considered either obese or overweight. It has been reported that the direct cost of obesity in Canada in 1997 (2 years before the Canadian Health Survey began) was more than $1.8 billion (CAD) or 2.9% of the total health expenditures for all diseases. The current nearly 3-fold increase in people who are overweight and obese is anticipated to grow costs exponentially.
The US conducted a similar study between 1985 and 2004 — the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. The results mimic Canada’s data. In 1991, 4 states reported obesity prevalence between 15% and 19%; no state had a prevalence rate at or higher than 20%. In 2004, 7 states reported obesity rates between 15% and 19%, 33 states reported rate between 20% and 24%, and 9 states reported rates higher than 25% (1 state sent no data). The trend continues.
Susan Gallagher Camden illustrates the multifaceted problems relating to caring for the obese patient, subsequently generating questions regarding the impact of obesity on ostomy, wound, and continence care. Her book reaffirms the absolute imperative of preoperative stoma site marking to facilitate the ability of the overweight or obese patient to care for an ostomy after surgery and attain some level of normalcy and self-control. Ostomy care providers may have to revisit previous notions about when and how convex ostomy pouching systems should be used.
The obesity epidemic reminds us of the difficulty associated with healing in the overweight patient or the patient with diabetes. The emergence of bariatric medicine is a testament. Ostomy care is one of many specialties that require extra attention, expertise, and understanding in order to provide quality health care to an increasing number of patients. 2006;52(4):22, 24.
Challenges of ostomy care and obesity (Gallagher S, Gates J). In the United States, 13 to 16 million people are morbidly obese to the extent that medical intervention, simply based on obesity-related comorbidities, is needed. The challenge of ostomy care and the very obese patient lies in the skill and planning required for successful physical, emotional, and spiritual recovery. It is commonly believed that from the onset, the obese patient having surgery is at a significant disadvantage. Care of the obese patient requiring ostomy surgery includes considerable challenges — from preoperative preparation, including finding an optimal location for stoma placement, to the challenge of preventing complications during the intraoperative and postoperative phases of care. Concerns regarding pain management, immobility, skin injury, respiratory issues, embolic threats, and caregiver injury increase when treating the obese patient and must be addressed specifically. A case study approach is used as a framework to discuss the ostomy experience. 2004;50(9):38–46.
Needs of the homebound morbidly obese patient: a descriptive survey of home health nurses (Gallagher SM). The purpose of this descriptive survey was to identify challenges encountered by the home care provider when caring for a morbidly obese client in the home care setting and to provide recommendations to those involved in the transition of the patient from the acute care setting to the home. This descriptive study used a convenience sample of 25 RNs employed in 1 of the many referral home care agencies in the greater Los Angeles, California area. The referral home care agencies were selected randomly. Criterion for inclusion was that the nurse had cared for at least 3 patients in the past 12 months with a body mass index >40. A semi-structured interview was completed using a 10-item survey tool that included open-ended questions. One hundred percent (100%) of persons approached participated (N = 25). The home care setting was their primary place of employment for at least 2 years (mean 5 years), and each RN had cared for an average of 4 patients with a BMI >40 in the past years. Challenges expressed by the nurses in the home care setting included equipment (n = 25), reimbursement (n = 25), access to resources (n = 18), client motivation (n = 8), and family/significant other support (n = 10). 1998;44(4):32–38.
Surgery-related Issues
The role of obesity in the patient undergoing colorectal surgery and fecal diversion: a review of the literature (Colwell JC). The obese colorectal surgery patient may face several challenges, including a high risk for the development of colorectal cancer, an increased risk for complications with diverticular disease, and surgical risk factors including anastomotic leaks, inability to perform a low anastomosis, and septic complications. The purpose of this literature review was to examine available data on the implications of obesity on colorectal disease and colorectal surgery, particularly stoma surgery. Obesity has been documented as a risk factor for colorectal disease, but results of studies examining surgery-related problems secondary to obesity are inconsistent. However, clinicians generally believe obese patients undergoing colorectal surgery may be at higher risk of complications than their non-obese counterparts. The obese patient requiring the creation of a fecal diversion may encounter stoma-related issues such as stenosis, retraction, and inability to maintain a consistent pouching system seal. Stoma site marking can be challenging because of the large shifts in subcutaneous tissue and the inability for a person with a large abdomen to be able to visualize the stoma if the stoma is placed too low on the abdomen. Additional research to elucidate complication rates and risk factors is needed to help clinicians develop optimal plans of care. 2014;60(1):24–28.
Bariatric surgery: patient incision care and discharge concerns (Pieper B, Sieggreen M, Nordstrom C, Kulwicki P, Freeland B, Palleschi MT, Sidor D, Bednarski D, Burns J, Frattaroli M). Because they provide greater and more durable weight reduction than behavioral and pharmacological interventions for the morbidly obese, the number of bariatric surgeries is increasing. One such procedure is the Roux-en-Y gastric bypass. A cross-sectional study was conducted to examine incision care knowledge and discharge concerns of patients who had undergone this type of gastric bypass bariatric surgery. Participants (N = 31; 28 women, 3 men; mean age 45 years), recruited from a bariatric surgery center in a large, urban teaching hospital, had undergone a Roux-en-Y gastric bypass by either the open (n = 29) or laparoscopic (n = 2) method. Patients scheduled to be discharged home, 21 years of age or older, and able to understand and respond in English were eligible to participate. Participants completed questionnaires that included demographic information and rating scales regarding incision care knowledge, fears, and discharge concerns. Mean time from hospital admission to study participation was 1.1 ± 3 days. Knowledge of incision care and amount of information received about incision care were rated low. The 5 most frequently mentioned post-discharge concerns included bowel trouble at home, wound pain at home, looking for wound complications, watching for wound infection, and activity limitations. The higher the amount of information received about incision care, the higher the patient’s knowledge (r = .57, P<.001). Lower incision care knowledge scores correlated with a higher fear of incision care (r = .46, P = .008) and patients reporting greater pain had more concerns about discharge (r = .49, P<.005). Little is known about preparing the bariatric surgery patient for discharge home. To improve outcomes, research that examines issues including discharge teaching methods, patient concerns, and information for persons undergoing bariatric surgery is needed. 2006;52(6):48–56.
Obesity and the surgical patient: nursing alert (Jacobson TM). The risk for postoperative wound complications such as dehiscence and wound infection increases in the obese patient. Patients with postoperative wound complications may experience additional pain, prolonged hospitalization with its associated expenses, and emotional stress. When caring for the obese surgical patient, the nurse is challenged to anticipate potential postoperative complications and implement strategies to optimize the wound healing environment. In order to successfully meet this challenge, knowledge of the wound healing process (ie, 4 stages of healing), the core elements necessary for wound healing (oxygen, nutrients, blood cells), and the effects of obesity on wound healing (the role of adipose tissue, impaired perfusion, increased likelihood for infection) is needed. 1994;40(2):56–63.