Meeting the Challenges Associated with Morbidly Obese Patients
Obesity is one of the most common chronic health problems in the United States. Because of the many diseases associated with obesity, an increasing number of obese individuals are in need of healthcare services. Caring for the morbidly obese patient poses a significant challenge. However, careful planning for the continuum of care of morbidly obese patients using a multidisciplinary approach associated with appropriate training and equipment will help prevent adverse outcomes and injuries. Planning and correct implementation also ensure that facilities can treat morbidly obese patients with the same dignity and respect as any other patient.
Hospitals in the northwest region of Pennsylvania have reported adverse diagnostic and treatment delays in caring for the morbidly obese patient. Further review of these events has identified causal factors such as weight and circumference restrictions for computed tomography scanning, inadequate transport equipment, and lack of appropriately sized resuscitation and monitoring equipment such as ventilation masks and blood pressure cuffs. According to the Centers for Disease Control and Prevention’s report, “State Specific Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults: United States, trends 1976-1980 through 2007-2008,” 49 states have obesity rates greater than 20%.1
Morbidly obese individuals often resist seeking healthcare and frequently defer hospitalization until the last minute.2 Morbidly obese patients may not present until late in the course of their illness due to mobility and transportation problems. Also, embarrassment and perceived or real resentment from healthcare providers may dissuade morbidly obese patients from seeking treatment.
According to the U.K.’s Dartford and Gravesham NHS Trust, morbidly obese patients represent a variety of medical, physical, and emotional challenges for healthcare providers, including the following:3
Hyperventilation is the typical respiratory pattern of many morbidly obese patients, because the lungs do not increase in size with the patient.
The diaphragm is unable to fully descend because of adipose tissue and chest expansion is impaired, which results in decreased vital capacity and tidal volume that compromises tissue oxygenation.
The heart is typically enlarged as a result of the strain of supplying oxygenated blood to all tissues.
Obesity can cause venous hypertension, which increases the risk of pulmonary embolism and decreases mobility due to insufficient circulation.
Intravenous access can be difficult because the excessive amounts of subcutaneous tissue present in morbidly obese patients makes it difficult for the veins to be seen and very difficult to palpate.
If an intravenous line is inaccessible, a central line has to be considered, but the morbidly obese patient is at risk for a possible yeast infection in the skin folds.
The ratio of skin area to body mass is lower in the morbidly obese patient in comparison to the average-weight patient and this larger body mass, combined with smaller relative skin areas, leads to increased perspiration and difficulty controlling body temperature.
Airway management of a morbidly obese patient is difficult due to a tendency for the morbidity obese patient to have a short thick neck, increased soft tissue (“double chin”), and an enlarged tongue, as well as the potential for subcutaneous emphysema.
Morbidly obese patients will desaturate oxygen rapidly due to decreased functional reserve capacity.
Morbidly obese patients have different body types that each need different treatment and techniques. The body type can affect breathing and tolerance to movement as well as the risk of falls sustaining unexpected injuries. For example, an “apple-shaped” patient will have excessive adipose tissue in the viscera or abdominal area. This adipose tissue can press on the aorta, vena cava, and small capillaries, causing increased stress on the cardiovascular and respiratory systems, increasing the risk of positional asphyxiation.
Morbidly obese patients are at a higher risk of cellulitis and for skin breakdown associated with impaired mobility.
Morbidly obese patients are subjected to intense prejudice and discrimination because their condition is often perceived to be under the control of the individual which leads to low self esteem.
Because these medical and physical limitations pose significant clinical risks to the morbidly obese patient, some hospitals have taken a more proactive approach. For example, UPMC McKeesport, an acute care community hospital in the southwest region of Pennsylvania, conducted a failure mode and effects analysis in an effort to anticipate patient and staff needs associated with the care and treatment of morbidly obese patients. The hospital identified opportunities for improvement associated with equipment availability, facility design, repositioning/transfer protocol, and the patient discharge process. To assist staff, the hospital developed algorithms for repositioning that addressed the lateral transfer to and from bed-to-stretcher/stretcher-to-bed and the transfer to and from bed-to-chair/chair-to-toilet/chair-to-chair. The hospital also developed morbidly obese patient discharge flow diagrams that address routine discharge and discharge with durable medical equipment.
In addition to meeting the medical and physical challenges of morbidly obese patients, it is also important for healthcare providers to effectively interact with and demonstrate consideration for morbidly obese patients. One paradigm healthcare providers can follow is the RESPECT Model, which identifies key patient needs and concerns as follows:4
Obesity is a costly condition that can reduce quality of life and increases the risk for many serious chronic diseases and premature death. Careful planning and the development of training programs designed to educate staff on the medical, physical, and social needs of the morbidly obese patient can help ensure that these patients receive the same level of care and intensity of services as any other patient.
Bleich SN. The role of health professionals in reducing obesity disparities. Bariatr Nurs Surg Patient Care 2009 Mar;4(1):3-5.
Bejciy-Spring SM. R-E-S-P-E-C-T: A model for the sensitive treatment of the bariatric patient. Bariatr Nurs Surg Patient Care 2008 Mar;3(1):47-56.