Chapter 48 obesity

Obesity part 1

Obesity is defined by the World Health Organization (WHO) as an "abnormal or excessive fat accumulation that may impair health" (WHO, 2016, p. 1). As a response to endorsements by multiple health care organizations and societies, including the American College of Cardiology, the Endocrine Society, and the American College of Surgeons, to name a few, the American Medical Association (AMA) House of Delegates in 2013 officially resolved that obesity should be diagnosed as a disease (AMA, 2013). This resolution was based upon the scientific observation that obesity followed criteria commonly used for defining a disease; namely, it can be said that obesity impairs normal bodily function, possesses characteristic signs and symptoms, and causes morbidity (AMA, 2013). Epidemiology of Obesity Worldwide, over 600 million adults have obesity, and another 1.4 billion are overweight (WHO, 2016). The prevalence of obesity has more than doubled since 1975. In particular, 3% of the world's men and 6% of the world's women had obesity in 1975, whereas 11% of the world's men and 15% of the world's women had obesity in 2014 (WHO, 2016). The burden of obesity is significant in both developed and developing nations. The WHO (2016) notes that many developing nations are now facing a "double-burden" effect from disorders linked to nutrition and metabolism; that is, these nations must simultaneously deal with the public health threats of both undernutrition and obesity. In developing nations, obesity has become particularly prevalent in urban settings (WHO, 2016). The proportion of adults with obesity in the United States had risen every decade for over three decades until 2012, when those rates were reported to have plateaued. However, the prevalence of obesity and overweight in the United States remains among the highest in the world (Ogden, Carroll, Kit, et al., 2014). Among American adults, an estimated 36.5% have obesity (Ogden, Carroll, Fryar, et al., 2015); an estimated 68.5% have obesity or are overweight (Levi, Segal, St. Laurent, et al., 2014). The prevalence of obesity is higher among American women than American men, and among African Americans and Hispanics than among Caucasians or Asian Americans (see Fig. 48-1). In general, those who are less educated and earn less income are more likely to have obesity, reflecting socioeconomic disparities in the disease burden of obesity (Segal, Rayburn, & Martin, 2016). Being overweight or obese is the primary reason why young American adults are excluded from military service (Segal et al., 2016). Figure 48-1 • Prevalence of obesity among adults aged 20 and older, by gender and race/ethnicity in the United States (2011-2014). Adapted from Ogden, C. L., Carroll, M. D., Fryar, C. D., et al. (2015). Prevalence of obesity among adults and youth: United States, 2011-2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. The economic burden of obesity to American society extends beyond limiting young adults with obesity from pursuing military service commitments. It is estimated that annual health care costs tied to obesity are $147 billion, and that average annual health care expenditures for Americans with obesity are $1429 higher per person than for those Americans without obesity (Mozaffarian, Benjamin, Go, et al., 2016). Obesity Risks The causes of obesity are complex and multifactorial, and include behavioral, environmental, physiologic, and genetic factors. While there are certain demographic groups who seem to be at risk for obesity (see Fig. 48-1) and while there are notable familial patterns of obesity, identification of risk factors that specify odds of being diagnosed with obesity are not as clearly elucidated as those for other diseases (Centers for Disease Control and Prevention [CDC], 2016a), such as coronary artery disease (see Chapter 27) and cerebrovascular disease (see Chapter 67). What is abundantly clear, however, is that obesity incurs a greater overall risk of mortality. Obesity is associated with a 6- to 20-year decrease in overall life expectancy (Moyer, LeFevere, Siu, et al., 2012). Furthermore, obesity is associated with morbidity and mortality from numerous other diseases (see Fig. 48-2 and Chart 48-1). For instance, as body mass index (BMI) increases, so does the overall risk of cancer and risk for death from cancer; obesity is responsible for up to 90,000 deaths from cancer annually. Having obesity increases the likelihood of having type 2 diabetes by 10-fold and the likelihood of having either asthma or hypertension by nearly 4-fold (American Society for Metabolic and Bariatric Surgery [ASMBS], 2015b). Adults with obesity are twice as likely to eventually be diagnosed with Alzheimer disease than those adults who maintain a normal weight (Mozaffarian et al., 2016). (Hinkle 1358-1360) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Obesity part 2

Pathophysiology Obesity is a chronic, relapsing disease characterized by an excessive accumulation of body fat and weight gain (ASMBS, 2015a). These increases in body fat cause adiposopathy (i.e., dysfunction of adipose tissue), which promotes the development of metabolic, biomechanical, and psychosocial diseases and disorders (Bays, Jones, Jacobson, et al., 2016). Dysfunctional adipose tissue cells release biochemical mediators that cause chronic inflammatory changes, which can lead to a multitude of diseases, including heart disease, hypertension, and type 2 diabetes (ASMBS, 2013b). At the most fundamental level, obesity results from a metabolic imbalance, characterized by an excess of caloric consumption relative to caloric expenditures. That is, too many foods are consumed and too little physical activity is conducted over the long term, resulting in weight gain (Grossman & Porth, 2014). According to the "thrifty gene" hypothesis, the human genome (i.e., the total complement of genes in humans) was sequenced during times when finding and storing food sources expended more energy than during contemporary times. Hunting for scarce food sources during prehistoric times consumed a lot of energy, and food sources were not abundant. Storing fat to provide energy sources during times of food scarcity was a physiologic adaptive response to these environmental challenges (Budd & Peterson, 2014). The "thrifty gene" hypothesis has come under scrutiny in recent years, however, as human genome sequencing research findings suggest that a far more complex genetic explanation may be responsible for the recent global obesity pandemic. Research findings suggest that having at least one of over 25 different genetic mutations can strongly predispose people who have ready access to food sources to having obesity (Kolata, 2016). For instance, the presence of a variant mutation of the FTO gene is associated with more daily meals, snacks, and fat and sweet intake (Budd & Peterson, 2014). However, these type of single genetic mutations are relatively rare occurrences, and therefore cannot account for the high prevalence of obesity. Most people who are predisposed to obesity are thought to have a collection of several genetic mutations from more than 300 possible mutated genes that each can contribute to several pounds of additional body fat (Kolata, 2016). The types and quantities of foods consumed affect complex digestive and metabolic pathways. Certain processed and high caloric foods that contain fructose corn syrup, simple sugars, or trans fats, are hypothesized to be obesogenic (i.e., promote weight gain) because they are associated with food cravings consonant with other type of addictive cravings (Budd & Peterson, 2014). Furthermore, the portions of foods served in restaurants and packaged on grocery shelves have increased over the past 20 years, subtly affecting consumers' feelings of satiety (i.e., feeling of having eaten sufficient amounts of food) (National Heart, Lung, and Blood Institute [NHLBI], 2016a). For instance, a typical bagel was 3 inches in diameter 20 years ago, but today is about 6 inches in diameter. Likewise, the average cheeseburger 20 years ago was 333 calories but today is larger and has 590 calories (NHLBI, 2016a). Multiple hormones that control food cravings and feelings of fullness could be affected by individual genes. In response to periods of fasting, the hormone ghrelin is secreted by the stomach and the hormone neuropeptide Y (NPY) is secreted by the small intestines. These hormones are orexigenic, meaning that they stimulate appetite through central nervous system (CNS) pathways that lead to the hypothalamus, signaling higher neural pathways that lead to eating behaviors. Once eating occurs, multiple hormones are released throughout the gastrointestinal (GI) tract that promote satiety, including somatostatin, cholecystokinin (CCK), and insulin, to name a few. CCK also slows gastric motility and emptying, stimulates gallbladder contraction and release of bile into the duodenum, and stimulates the release of pancreatic digestive enzymes, all of which serve to enhance the digestive process. Somatostatin also slows gastric emptying but has other effects that are in opposition to CCK, such as decreasing the secretion of bile, depending on foods consumed and metabolic needs (Bays, Kothari, Azagury, et al., 2016). Increases in fat stores, or adipose tissue, result in increases in the hormone leptin, which is secreted by fat cells. Leptin also has the effect of signaling satiety in the hypothalamus. Patients with obesity who lose weight are thought to also have drops in leptin levels that persist for the long term, creating persistent feelings of hunger, which may partially explain why many patients with obesity who lose weight tend to regain it (Budd & Peterson, 2014). The GI tract microbiota, which is the complement of microbes within the gut, has been found to contain up to 100 trillion microbes, or 10 times the cells present in the human body (Davis, 2016). The collective genome of the microbiota, or the gut microbiome, has more than 100 times more genes than in the human genome (Davis, 2016). It has long been known that gut microbes perform numerous digestive, metabolic, and immunologic functions. The composition and diversity of these microbes may very well be tied in with obesity. For instance, patients with obesity tend to have less diverse microbiota than patients who are lean. In turn, these patients with obesity who have less diverse microbiota typically also have dyslipidemia, impaired glucose metabolism, and low-grade generalized inflammatory disorders. The effects of "Western-style diets," high in processed foods, fat, and sugars, and low in fiber, is thought to not only negatively affect the diversity of the gut microbiota, but also negatively affect the complement of Bacteroidetes species microbes, which are associated with a leaner type of microbiome (Davis, 2016). Whether or not it is possible to regulate the composition of the gut microbiota and prevent or treat obesity is the focus of ongoing research (Davis, 2016). Assessment and Diagnostic Findings Patient height and weight is measured to determine the body mass index (BMI). The BMI is the definitive measure used to determine whether or not a patient is overweight or has obesity; this is based upon a ratio of body weight in kilograms and height in meters (see Chapter 5, Table 5-1). Patients identified as overweight or pre-obese have a BMI of 25 to 29.9 kg/m2 and those with obesity have a BMI that exceeds 30 kg/m2. Those with a BMI exceeding 40 kg/m2 are considered to have severe or extreme obesity (previously referred to as morbid obesity) (WHO, 2015) (see Fig. 48-3 and Table 48-1). TABLE 48-1 Body Mass Index (BMI) Classification for Overweight and Obesity Classification BMI Range (kg/m2) Overweight/Pre-obese 25-29.9 Class I Obesity 30-34.9 Class II Obesity 35-39.9 Class III (also called "extreme" or "severe") Obesity ≥40 Adapted from Centers for Disease Control and Prevention (CDC). (2016b). Defining adult overweight and obesity. Retrieved on 1/24/2017 at: www.cdc.gov/obesity/adult/defining.html Patients with obesity may also have their waist circumferences assessed. Women with waist circumferences more than 35 inches and men with waist circumferences more than 40 inches have greater risks for obesity-related morbidity (see Chart 48-1) than those with smaller waistlines (Fitch, Everling, Fox, et al., 2013). The hip may also be measured and the waist-to-hip ratio assessed. Women with waist-to-hip ratios greater than 0.80 and men with waist-to-hip ratios greater than 0.90 are presumed to have proportionally more visceral (i.e., abdominal) fat stores. This morphological appearance is called android obesity, and is sometimes referenced as an "apple-shaped" appearance. Patients with android obesity have greater risk for developing hypertension, coronary artery disease, stroke, and type 2 diabetes, than patients who have gynoid obesity, also called the "pear-shaped" body (Weber & Kelley, 2014) (see Fig. 48-4). Figure 48-3 • Body mass index table. Adapted from National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. (2016b). Aim for a healthy weight: Body mass index table. Retrieved on 3/2/2017 at: www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi_tbl.pdf Figure 48-4 • A. Android obesity, with greater visceral/abdominal fat stores. B. Gynoid obesity. Reprinted with permission from Weber, J. R., & Kelley, J. H. (2014). Health assessment in nursing (5th ed.). Philadelphia, PA: Wolters Kluwer. Patients with obesity or who are overweight may have other diagnostic laboratory studies done to screen for cardiovascular diseases, such as cholesterol and triglycerides (see Chapter 27), for type 2 diabetes, such as fasting blood glucose and glycosylated hemoglobin (hemoglobin A1c) (see Chapter 51), or for nonalcoholic fatty liver disease, such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (Orringer, Harrison, Nichani, et al., 2016) (see Chapter 49). In some instances, obesity may be secondary to other diseases or disorders, such as hypothyroidism or Cushing syndrome (see Chapter 52). In those particular cases, the diagnostic workup follows that prescribed for the primary disease or disorder, and, when the therapeutic regimen is implemented, the patient may lose weight and the obesity may even resolve (Orringer et al., 2016). In addition, some patients who are overweight or have obesity may develop secondary diseases or disorders (see Chart 48-1) and may be prescribed medications aimed at treating those secondary diseases or disorders that can exacerbate weight gain (see Chart 48-2). Other patients may not have had a previous history of being overweight or having obesity, but may gain weight after being prescribed specific medications associated with weight gain. A history of weight gain that parallels the timeframe of commencing treatment with specific prescriptive medications may suggest that the medication has a key role in promoting weight gain. In some instances, prescription medication dosages may be adjusted or another medication may be prescribed. For instance, patients with type 2 diabetes and obesity may reap the dual benefits of achieving better glycemic control and weight loss by taking the prescription drug metformin (Glucophage) (Apovian, Aronne, Bessesen, et al., 2015). (Hinkle 1360-1362) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Obesity part 4

Antiobesity medications work by either inhibiting gastrointestinal absorption of fats, or by altering central brain receptors to enhance satiety or reduce cravings (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2016). Each of these medications has distinct side effects and contraindications; therefore, selection of these agents is very individualized. The patient is monitored while taking the selected medication; if the patient does not lose at least 5% body weight after 12 weeks, the prescription may need to be changed, or the patient may be referred for other weight-reduction therapy (e.g., bariatric surgery) (NIDDK, 2016). The class of antiobesity medications known as the sympathomimetic amines have been FDA approved for many years. However, they are only supposed to be prescribed for short-term use (i.e., no longer than 12 weeks). They have many side effects (see Table 48-2), and patients do tend to regain weight once they are no longer taking these medications (NIDDK, 2016). Nonsurgical Interventions Adult patients with obesity that does not respond to lifestyle interventions or antiobesity medications and who have either Class III/severe/extreme obesity (i.e., BMI in excess of 40 kg/m2) or Class II obesity (BMI 35-39.9 kg/m2) with obesity-related diseases or disorders (e.g., obstructive sleep apnea, type 2 diabetes) may be candidates for bariatric surgical interventions (see later discussion). As an alternative, some patients may elect to pursue minimally invasive interventions that were approved by the FDA in 2015. These types of interventions include vagal blocking (i.e., neurometabolic modulation) or intragastric balloon therapy (Ali, Moustarah, Kim, et al., 2015; Papasavas, El Chaar, Kothari, et al., 2016). Vagal blocking therapy involves placement of a pacemaker-like device (vBloc™) into the subcutaneous tissue in the lateral thoracic cavity with two leads that are laparoscopically implanted at the point where the vagus nerve truncates, at the gastroesophageal junction. A pre-programmed, pulsating signal is delivered for 12 hours daily. This signal causes intermittent "blocking" of the vagus nerve. Vagal blocking results in diminished gastric contraction and emptying, limited ghrelin secretion, and diminished pancreatic enzyme secretion; these cause increased satiety, decreased cravings, and diminished absorption of calories, all of which lead to weight loss (Papasavas et al., 2016). Results from a randomized controlled trial found greater initial and 18-month sustained weight loss with participants with obesity who received vagal blocking versus control sham device implantation (Ikramuddin, Blackstone, Bracatisano, et al., 2014; Shikora, Wolfe, Apovian, et al., 2015). There are few adverse effects noted with use of this device, which include GI symptoms (e.g., heartburn, belching). Patients must be educated to recharge the device twice weekly for about an hour with an external coil device. Intragastric balloon therapy involves endoscopic placement of a saline-filled balloon (ORBERA™) or a saline-filled dual balloon (ReShape™) into the stomach. The mechanism by which these devices result in weight loss is poorly understood, but thought to be related to increased feelings of satiety and decreased gastric emptying. Post-insertion, the intragastric balloon(s) remain in place for 3 to 6 months, and are then deflated and removed. Studies suggest greater weight loss with these than with sham therapy or with lifestyle interventions alone (Ali et al., 2015). Early adverse effects include complaints of nausea and vomiting, which are generally transient and do not require balloon removal. Balloon rupture can occur over the long term, however, which may infrequently lead to intestinal obstruction. In order to monitor for this serious complication, it is recommended that the balloons be impregnated with methylene blue pre-insertion so that patients with silent ruptures can report the presence of green urine to their primary providers and receive timely interventions to remove the deflated balloons before they cause obstruction. Patients who seem unlikely to return for follow-up appointments should not be candidates for intragastric balloons. Balloons should be removed within 6 months of placement; longer placement periods are associated with increased likelihood of rupture and intestinal obstruction (Ali et al., 2015). Gerontologic Considerations According to findings from the United States National Health and Nutrition Examination Survey (NHANES), the prevalence of obesity for adults over the age of 60 is 38.5%, slightly higher than the prevalence of obesity among all adults (Segal et al., 2016). Climbing rates of obesity among older adults mirrors the rate increases among all adults over the past few decades. As adults age, lean skeletal mass decreases and adipose tissue increases. Adipose tissue does not burn calories as efficiently as lean skeletal mass; furthermore, basal metabolism drops by 2% for each additional decade of adult life. Therefore, older adults are more likely to gain weight unless they either increase activity levels or decrease their caloric intake (Eliopoulos, 2018). Research suggests that older adults with obesity are at risk for complications that may negatively affect their quality of life. In particular, older adults with obesity may be at greater risk of falls (Joen, 2013) and mobility impairments (Murphy, Reinders, Register, et al., 2014). More older adults with obesity are admitted to nursing homes than normal weight older adults (Felix, Bradway, Chisholm, et al., 2015). One study found that older adults with obesity had lower resting hemoglobin-oxygen saturation levels (i.e., SpO2 levels), which presumably could lead to hypoxemia, dyspnea, and ischemic complications (e.g., myocardial infarction) (Kapur, Wilsdon, Au, et al., 2013). Another study found that in one long-term care facility, more older adult residents who were overweight had indwelling urinary catheters than their counterparts who were leaner, which presumably could lead to urosepsis (Felix, Thostenson, Bursac, et al., 2013). There is some evidence that older adults with an overweight body mass (i.e., between 25 and 29.9 kg/m2) have reasonably good health outcomes; therefore, overweight older adults are not necessarily counseled to lose weight (Orringer et al., 2016). However, older adults with obesity (i.e., with BMIs in excess of 30 kg/m2) should be encouraged to engage in lifestyle modifications, including diet and exercise, much as younger adults (Orringer et al., 2016). Along with decreasing dietary caloric intake, older adult patients should be counseled that the quality of calories consumed should be the focus of the daily diet (see Chapter 11, Fig. 11-2). Fats should be limited to less than 30% of total calories, while proteins should comprise 10% to 20% of the daily diet. Intake of soluble fibers (e.g., oats, pectin) is particularly important since these can lower cholesterol levels and prevent cardiovascular diseases and cancers. Fewer than one third of older adults consume the recommended five servings of fruits and vegetables daily (Eliopoulos, 2018). Identifying barriers to consumption of these important sources of nutrients may help the older adult patient with obesity lose weight and adopt healthier eating habits. For instance, the older adult who has difficulty chewing raw fruits may enjoy fruit smoothies. Whether or not older adult patients with obesity should be candidates for bariatric surgery (see later discussion) has been a point of contention. The Centers for Medicare and Medicaid Services (CMS), which provides insurance for most adults older than 65 years of age, had limited insurance coverage for bariatric surgery to only ASMBS Centers of Excellence (COEs). This policy was rescinded, however, after empirical research findings demonstrated no improvement in postoperative outcomes among patients who did and did not have their bariatric procedures done in COEs (Dimick, Nicholas, Ryan, et al., 2013). Other study findings suggest that many older adults with obesity benefit from bariatric surgery, although their weight loss tends to be less than that of younger adults who have bariatric surgery (Caceres, Moskowitz, & O'Connell, 2015). At present, there are no guidelines that identify the profile of which older adult patients with obesity can most benefit from bariatric surgery. Nursing Management Patients with obesity report feeling socially marginalized, judged, and unsupported by society at large. Many times, patients with obesity report that they suffer stigmatization by their health care providers, including nurses (Buxton & Snethen, 2013; Gilmartin, 2013; Puhl, Phelan, Nadglowski, et al., 2016). The bias that nurses may have against patients with obesity may not directly affect their nursing care; however, indirectly, the consequences of this stigmatization can lead to poor health outcomes. Patients with obesity who feel stigmatized by their health care providers report increased depression, low self-esteem, and avoidance of health care appointments and health maintenance activities (e.g., diet and exercise) (Budd & Peterson, 2015). Nurses need to approach patients with obesity with the same respectful, courteous, and empathetic behavior that they extend to patients without obesity. Confronting their own attitudes and beliefs about patients with obesity may help to mitigate biases. For instance, using patient-first language for all patients with diagnosed diseases, including the disease of obesity, can be an effective way to dispel bias. By referencing the patient with obesity, the nurse is effectively noting that the patient, not the disease, is the central point of concern and that the disease is amenable to treatment. On the other hand, referencing the obese patient tends to define the person by having obesity, which can lead to subliminal impressions that the patient is somehow responsible for having obesity. Research studies report that many health care providers, including nurses, hold negative attitudes toward patients with obesity and believe that they are indulgent, lazy, and lack willpower (Puhl et al., 2016). The patient with obesity who requires medical/surgical nursing care, whether it is because the patient is admitted to the hospital, needs home care, or is admitted to a transitional care setting, merits special considerations. Obesity can adversely affect the mechanics of ventilation and circulation, pharmacokinetics and pharmacodynamics, skin integrity, and body mechanics and mobility. These adverse effects are more common with higher BMIs; thus, the patient with Class III obesity (BMI in excess of 40 kg/m2) is particularly vulnerable. Obesity can result in anatomical remodeling, including compression of the oropharynx and increased neck circumference and chest diameter. These changes can predispose the patient with obesity to obstructive sleep apnea (OSA; see Chapter 22), respiratory failure (see Chapter 21), and obesity hypoventilation syndrome. Obesity hypoventilation syndrome is characterized by daytime hypoventilation with hypercapnea (i.e., PaCO2 >45 mmHg) and hypoxemia (i.e., PaO2 <80 mmHg), and sleep-disordered breathing. Potential adverse effects of obesity hypoventilation syndrome can be mitigated by maintaining the patient in the low Fowler position, which maximizes diaphragmatic chest expansion. Continuous pulse oximetry monitoring many be advisable, as well as supplemental oxygen therapy (see Chapter 21) and frequent respiratory assessments (at least every shift). For the patient with a known diagnosis of OSA, ensuring that the patient utilizes prescribed therapy (e.g., oral appliance, continuous positive airway pressure [CPAP]) if newly hospitalized or in a different transitional care environment is important in order to ensure breathing effectiveness and avert respiratory failure (Berrios, 2016; Dambaugh & Ecklund, 2016; Sturman-Floyd, 2013). The patient with obesity may have central and peripheral circulatory compromise. Heart failure is more commonplace among patients with obesity (see Chapter 29). Hypertension is also more prevalent; the nurse must use appropriately sized blood pressure cuffs to obtain valid blood pressure readings (see Chapter 31). Peripheral blood flow can be compromised for the patient with obesity, resulting in stasis of blood flow, one of three components of Virchow triad, which are the broad categories of risk for venous thromboembolism (VTE) (see Chapter 30, Chart 30-7). Peripheral circulatory compromise not only can increase the risk for VTE formation (e.g., pulmonary embolism [PE] and deep vein thrombosis [DVT]), but it can also make finding venous access difficult when the patient with obesity requires intravenous (IV) therapy. Finding appropriate venous access can be exacerbated by the presence of increased adipose tissue in the extremities. Ultrasound guidance may be required in order to successfully gain IV access and place an IV cannula in the patient with obesity (Berrios, 2016; Dambaugh & Ecklund, 2016). The patient with obesity may have differences in both pharmacokinetics (i.e., the movement of drug metabolites within the body) and pharmacodynamics (i.e., how drugs are metabolized and the effects of drugs) that can affect drug dosages, drug effectiveness, and patient safety. The effectiveness of many drugs is affected by the ratio of lean skeletal muscle mass to adipose tissue. The active metabolites of many drugs are protein bound in the plasma. In patients with greater adipose tissue, more of these active metabolites can be unbound in plasma, or free, and exert greater effects. Some drugs readily bind to adipose tissue, which may either inactivate them or prolong their effects. In addition, increased adiposity can have indirect effects on metabolic pathways within the liver, resulting in changes in drug metabolic pathways, which can result in either increased or decreased drug metabolism, depending upon the drug and the affected metabolic pathway. In other words, some drugs have enhanced effects while others have diminished effects with patients with obesity compared to patients of normal weight. For instance, one research study found that patients with obesity who were critically ill required proportionally lower dosages of IV drip norepinephrine, which is typically given based upon weight-based calculation, than patients with normal weight (Radosevich, Patanwal, & Erstad, 2016). On the other hand, patients with obesity who require opioid agents to treat pain many times require higher dosages of opioid agents to achieve pain relief, but are more likely to have serious adverse effects of sedation and respiratory depression (D'Arcy, 2015). The nurse should be cognizant that weight-based calculations of drug dosages for patients with obesity may need to be altered, depending upon the patient and the drug, and should consult with clinical pharmacologists and the patient's primary provider as needed to ensure optimal drug effectiveness and patient safety (Berrios, 2016). Patients with obesity are particularly vulnerable to developing pressure ulcers. Increased adipose tissue can diminish the supply of blood, oxygen, and nutrients to peripheral tissue. The presence of more folds in the skin is associated with more skin moisture and increased skin friction, which are pressure ulcer risks. Moreover, skin folds may be present in uncommon areas, including under the breasts, under the lower abdomen, within gluteal folds, and at the nape of the neck (Berrios, 2016; Dambaugh & Ecklund, 2016; Sturman-Floyd, 2013). In addition, patients with obesity many times have more limitations in mobility than patients of normal weight. Immobility is another risk for pressure ulcer development (Hyun, Li, Vermillion, et al., 2014) (see Chart 48-5). Consultation with a wound-ostomy-continence (WOC) nurse may be advisable to ensure that pressure ulcer risks for the patient with obesity are minimized. The nurse must ensure that the appropriate specialty equipment is utilized as needed so that the patient with obesity who is immobilized is turned and mobilized as indicated to prevent pressure ulcers. The typical nursing protocol is that the patient who is immobilized and bedfast should be turned every 2 hours to prevent pressure ulcers (Berrios, 2016). Nurses should be familiar with and comfortable using specialized durable medical bariatric equipment (e.g., lifts, transport equipment, commodes) so that the patient with obesity receives necessary care. It is also important to enforce and implement safe patient handling protocols so that the nurse does not incur musculoskeletal injury (Berrios, 2016). Surgical Management Bariatric surgery, or surgery for obesity, is typically performed after other nonsurgical attempts at weight control have failed. Insurance coverage for bariatric surgery varies widely, but most insurance companies will consider surgery as a treatment if the patient has Class III obesity or Class II obesity with a related medical condition (e.g., type 2 diabetes, OSA) (see Table 48-1) (Obesity Action Coalition [OAC], 2015a). Chart 48-5 NURSING RESEARCH PROFILE Pressure Ulcers Among Critically Ill Patients With Extreme Obesity Hyun, S., Li, X., Vermillion, B., et al. (2014). Body mass index and pressure ulcers: Improved predictability of pressure ulcers in intensive care patients. American Journal of Critical Care, 23(6), 494-500. Purpose The Braden Scale is a validated tool used to assess pressure ulcer risk among multiple populations of patients at risk for pressure ulcers, and is commonly used in hospitals in the United States in a variety of settings. Patients who are admitted to intensive care units are at heightened risk for pressure ulcers. Those patients who are critically ill and who also have obesity are presumably at even higher risk for pressure ulcers, because they have heightened immobility problems as a consequence of their weight. This study sought to investigate whether or not body mass index (BMI) could serve as an additional predictor for pressure ulcer development that could complement Braden Scale Scores among patients who are critically ill who also had obesity. Design This retrospective study examined electronic health record data from adult patients admitted to the adult critical care units in one Midwest academic health center over a 3-year period. Patients were sorted into four groups; underweight, with a BMI less than 19 kg/m2; normal weight, with a BMI between 19 and 25 kg/m2; obese, with a BMI between 25 and 40 kg/m2, and extremely obese, with a BMI greater than 40 kg/m2. Patient demographics, the incidence of pressure ulcers, and Braden Scale Scores were compared and analyzed between groups. Findings Data gathering yielded information on 2632 patients admitted to both medical and surgical intensive care units. The incidence of pressure ulcers in the underweight cohort was 8.6%, in the normal weight cohort was 5.5%, in the obese cohort was 2.8%, and in the extremely obese cohort was 9.9%. Logistic regression analysis revealed that patients who were underweight or who had extreme obesity were more likely to develop pressure ulcers. The odds of pressure ulcer development, based upon BMI cohort groups was not more predictive than Braden Scale Scores, however. Nursing Implications Results from this study validated that the Braden Scale is a useful tool for predicting pressure ulcer risk among adults who are critically ill and who have obesity. BMI scores, although not more predictive of risk than Braden Scale Scores, may be roughly equivalent measures of ascertaining pressure ulcer risk. In particular, findings from this study suggest that patients who are critically ill and who have extreme obesity (i.e., with BMIs in excess of 40 kg/m2) are at high risk for developing pressure ulcers. This is particularly concerning, since 26% of this study sample of adults who were critically ill had extreme obesity. Additional nursing considerations for patients with extreme obesity who are critically ill are needed so that pressure ulcers may be prevented. These considerations may include the use of specialty lifts, turning devices, and other safe patient handling devices so that these patients may be appropriately mobilized to prevent pressure ulcers. According to estimates by the ASMBS (2014), the number of bariatric surgeries performed in the United States grew by nearly 15% between 2011 and 2013. Bariatric surgical procedures work by restricting a patient's ability to eat (restrictive procedure), interfering with ingested nutrient absorption (malabsorptive procedures), or both. The different types of bariatric surgical procedures require unique lifestyle modifications. In order to optimize their success, patients should be well informed about the specific lifestyle changes, eating habits, and bowel habits that may result from each type of procedure. Bariatric surgery typically results in a weight loss of 10% to 35% of total body weight within 2 to 3 years postoperatively (Colquitt, Pickett, Loveman, et al., 2014; OAC, 2015b), with the majority of weight loss occurring within the first year (Courcoulas, Christian, Belle, et al., 2013). Comorbid conditions such as type 2 diabetes, hypertension, and OSA may resolve; and dyslipidemia improves (ASMBS, 2013a; Courcoulas, Belle, Neiberg, et al., 2015). Bariatric surgery has been extended to carefully selected adolescents with severe obesity and comorbidity because of the positive results it has achieved in adults (Michalsky, Reichard, Inge, et al., 2012). Patient selection is critical, and the preliminary process may necessitate months of counseling, education, and evaluation by a multidisciplinary team, including social workers, dietitians, a nurse counselor, a psychologist or psychiatrist, and a bariatric surgeon. The selection criteria for patients has changed considerably since the advent of bariatric surgery, with patients with BMIs as low as 30 kg/m2 now considered candidates for surgical intervention if they have comorbid conditions that may demonstrably improve post weight loss (e.g., type 2 diabetes) (Mechanick, Youdim, Jones, et al., 2013) (see Chart 48-6). Because bariatric surgery involves a drastic change in the functioning of the digestive system, patients need counseling before and after the surgery. Guidelines have been developed to assist in the care of patients having bariatric surgery (Broome, Ayala, Georgeson, et al., 2015; Mechanick et al., 2013). Roux-en-Y gastric bypass (RYGB), gastric banding, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch are the current bariatric procedures of choice. These procedures may be performed by laparoscopy or by an open surgical technique. The RYGB and the sleeve gastrectomy are the two most commonly used procedures (ASMBS, 2014); a systematic review found that outcomes were equally favorable between RYGB and sleeve gastrectomy, and generally better than outcomes with gastric banding (Colquitt et al., 2014). Biliopancreatic diversion with duodenal switch tends to result in the most postoperative weight loss, and is therefore more commonly indicated for patients with very high BMIs (Colquitt et al., 2014). The RYGB is a combined restrictive and malabsorptive procedure. The gastric banding and sleeve gastrectomy are restrictive procedures, and the biliopancreatic diversion with duodenal switch combines gastric restriction with intestinal malabsorption. Figure 48-5A-D provides additional details about these procedures. (Hinkle 1366-1369) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Obesity part 3

Medical Management Treatment of obesity generally includes lifestyle modification, pharmacological management, and nonsurgical or surgical interventions. Lifestyle Modification The first approach used to treat obesity consists of lifestyle modification aimed at weight loss and then weight maintenance. The U.S. Preventive Services Task Force (USPSTF) recommends that all adults with BMIs in excess of 30 kg/m2 be advised to engage in multicomponent behavioral interventions that include (Moyer et al., 2012): Setting weight-loss goals, Improving diet habits, Increasing physical activity, Addressing barriers to change, and, Self-monitoring and strategizing ongoing lifestyle changes aimed at a healthy weight. The most effective behavioral interventions are those considered high intensity; that is, they consist of 12 to 26 sessions annually, which may include individual counseling sessions between the primary provider and patient, group nutrition education sessions, and physical activity sessions, to name a few (Moyer et al., 2012). The USPSTF notes that modest weight loss of 5% total body weight can be associated with significant clinical improvements and benefits to patients with obesity (Moyer et al., 2012). A patient with obesity should be counseled to plan a caloric deficit of between 500 and 1000 calories daily from baseline, in order to achieve a 5% to 10% reduction in weight within about 6 months. This can be achieved through increasing physical activity and decreasing caloric dietary intake (Orringer et al., 2016). Chart 48-2 PHARMACOLOGY Selected Medications That Affect Body Weight Many medications prescribed to treat a variety of chronic diseases and disorders have the untoward side effect of weight gain, whereas others are associated with weight loss. The following list contains some examples of each of these. Medications Associated with Weight Gain Anticonvulsant Medications: carbamazepine (Tegretol) gabapentin (Neurontin) pregabalin (Lyrica)a valproate (Depakote)a Antidepressant Medications: Selective Serotonin Reuptake Inhibitors (SSRIs) (Note - these tend to be associated with early weight loss followed by gain within 6 months in some patients): citalopram (Celexa) fluvoxamine (Luvox) paroxetine (Paxil) sertraline (Zoloft) Tricyclic Antidepressants: amitriptyline (Elavil) doxepin (Sinequan) imipramine (Tofranil, Tofranil PM) mirtazapine (Remeron) nortriptyline (Aventyl) trimipramine (Surmontil) Antihistamines: cetirizine (Zyrtec) diphenhydramine (Benadryl) Antihypertensive Medications: Beta Blockers: atenolol (Tenormin) metoprolol (Lopressor, Toprol) propranolol (Inderal) Dihydropyridine Calcium Channel Blockers: amlodipine (Norvasc) felodipine (Plendil) nifedipine (Procardia, Procardia XL) Antipsychotic Medications: asenapine (Saphris) chlorpromazine (Thorazine) clozapine (Clozaril)a iloperidone (Fanapt) olanzapine (Zyprexa)a paliperidone (Invega) quetiapine (Seroquel) risperidone (Risperdal) Diabetes Medications: Insulins: insulin aspart (Novolog) insulin glulisine (Apidra) insulin lispro (Humalog) Meglitinides: nateglinide (Starlix) repaglinide (Prandin) Sulfonylureas: chlorpropamide (Amaryl) glimepiride (Glynase) glipizide (Glucotrol, Glucotrol XL) glyburide (Diabeta, Micronase) tolbutamide (Diabinese) Thiazolidinediones: Pioglitazone (Actos) Hormones: Corticosteroids: prednisone budesonide (Pulmicort) Hormonal contraceptives: Medroxyprogesterone (Depo-Provera) Mood Stabilizers: lithium (Lithobid) vigabatrin (Sabril) Medications Associated with Weight Loss Anticonvulsant Medications: lamotrigine (Lamictal) topiramate (Topamax) zonisamide (Zonegran) Antidepressant Medications: bupropion (Wellbutrin, Zyban) Diabetes Medications: metformin (Glucophage) aMedications associated with significant weight gain. Adapted from Bays, H. E., Seger, J. C., Primack, C., et al. (2016). Obesity algorithm, presented by the Obesity Medicine Association. Retrieved on 1/7/2017 at: www.obesityalgorithm.org; Budd, G. M., & Peterson, J. A. (2015). The obesity epidemic, part 2: Nursing assessment and intervention. American Journal of Nursing, 115(1), 38-46.; Kyle, T., & Kuehl, B. (2017). Prescription medications & weight gain - What you need to know. Retrieved on 1/7/2017 at: www.obesityaction.org/educational-resources/resource-articles-2/general-articles/prescription-medications-weight-gain Increasing physical activity through promotion of an exercise regimen is a key recommendation that can burn calories and result in weight loss. Physical activity recommendations for all adults (those with and without obesity) include at least 150 minutes of moderate-intensity aerobic exercise weekly or 75 minutes of vigorous-intensity aerobic exercise weekly. In addition, muscle strengthening exercises that engage all major muscle groups should be done at least twice weekly (Fitch et al., 2013; Orringer et al., 2016). Patients with obesity who were previously sedentary and deconditioned may not be able to achieve this at the start; however, as little as 10 minutes of daily physical activity can result in weight loss and improved exercise tolerance (Fitch et al., 2013). Patients with obesity should be counseled that reducing dietary caloric intake is a necessary component of weight loss therapy. This must also include a change in dietary habits in order for weight loss to be sustained over the long term. It is important to identify current dietary patterns and typical daily caloric intake in order to recommend an appropriate diet plan. Assessing food records or 24-hour recalls or conducting dietary interviews are all effective methods to gather baseline dietary information from patients (see Chapter 5: Dietary Data). There are a plethora of commercial diets that patients may select (see Chart 48-3). To date, there have not been sufficiently rigorous longitudinal studies to determine which diet plans are superior to others in terms of achieving long-term weight loss (Katz & Meller, 2014). Chart 48-3 Select Popular Commercial Diets Atkins Diet, www.atkins.com eDiets, www.ediets.com Jenny Craig, www.jennycraig.com Medifast, www.medifast1.com/index.jsp Nutrisystem, www.nutrisystem.com/jsps_hmr/home/index.jsp Optifast, www.optifast.com/Pages/index.aspx South Beach Diet, www.southbeachdiet.com/home/index.jsp The Biggest Loser Diet, www.biggestloserclub.com Weight Watchers, www.weightwatchers.com/us/ Zone Diet, www.zonediet.com Patients need not purchase commercial diet plans in order to achieve weight loss and embrace healthy diet habits. Most nutritionists advocate that healthy diets include few processed foods, sugars, and trans fats, and are heavy in plant-based foods (Katz & Meller, 2014). The Dietary Approaches to Stop Hypertension (DASH) diet is an example of a superior healthy noncommercial diet. Although initially promoted to manage hypertension, the DASH diet also provides a solid foundation for achieving and maintaining weight loss (Goldstein, Aoun, Gaar, et al., 2014) (see Chapter 31, Table 31-3: The DASH Diet). Other healthy diet plans that may form a basis for weight loss, though not specifically designed for this purpose, include the Mediterranean Diet and the Therapeutic Lifestyle Changes (TLC) Diet (see Chapter 27 for description of both diets, see Table 27-1: The TLC Diet). Patient education tips for managing ongoing healthy eating strategies are noted in Chart 48-4. In addition to promoting healthy exercise and diet habits, ensuring healthy sleep habits is an additional lifestyle strategy that is associated with weight loss and maintenance of a healthy weight. It is posited that sleep deprivation can cause changes in cortisol levels that promote weight gain (Orringer et al., 2016). Advising patients with sleep disturbances to plan to be in bed with lights out at least 7 hours prior to wake-up time, to create a dark, relaxing bedroom environment, to avoid activities that can cause arousal around bedtime (e.g., texting), and to avoid beverages with caffeine after lunchtime can all be helpful strategies aimed at ensuring a restful night's sleep that is consonant with weight reduction (Orringer et al., 2016). Pharmacologic Therapy Patients who are not successful at meeting weight loss goals from lifestyle modification alone may be prescribed antiobesity medications. Some patients may exhibit initial success with lifestyle modifications, but be stymied with attempts to maintain a lower BMI over the long term. These patients may also benefit from antiobesity medications. Patients who are prescribed antiobesity medications should be counseled that these prescriptions are meant to supplement, not supplant diet modification and exercise (Yanovski & Yanovksi, 2014). Indications for antiobesity medications include a BMI >30 kg/m2 or a BMI >27 kg/m2 with concomitant morbidity that is related to being overweight (e.g., type 2 diabetes, hypertension) (Apovian et al., 2015; Bays, Seger, Primach, et al., 2016). Chart 48-4 PATIENT EDUCATION Healthy Eating Strategies The nurse instructs the patient about the healthy eating strategies outlined below. Limit or eliminate the following: Processed foods with limited nutritional value (e.g., packaged cakes, cookies, chips) High caloric beverages (sugar-sweetened, juices, cream-enhanced) Fast foods Vending machine foods Foods high in sugars (e.g., candies) and saturated fats (e.g., fried foods, hot dogs) Track the following: Daily food intake (food journals, diaries, smartphone, and tablet applications) Nutritional value and caloric content on food labels Encourage the following: Reduce portions; use smaller plates and measure foods Schedule and plan meals and snacks in advance for each day; prepack lunches and snacks when you are out of the home (e.g., for work) Eat at home more often than you would eat outside the home; when eating out, avoid fried foods and choose lean meats and vegetables and salads with condiments on the side Eat breakfast Limit snacks Eat a variety of nutritious foods; monitoring quality of foods consumed is as important as the quantity of foods consumed Drink plenty of water Stay within your daily caloric intake plan; do not become discouraged if one day you do not adhere to your plan Adapted from Fruh, S. M., Mulekar, M. S., & Dierking, J. (2013). Guiding patients to safe weight loss. The Nurse Practitioner, 38(10), 1-7; Orringer, K. A., Harrison, A. V., Nichani, S. S., et al. (2016). University of Michigan Health System Clinical Alignment and Performance Excellence Guideline: Obesity prevention and management. Retrieved on 1/25/2017 at: www.med.umich.edu/1info/FHP/practiceguides/obesity/obesity.pdf The U.S. Food and Drug Administration (FDA) has had a long history of approving antiobesity drugs and then rescinding those approvals. Thyroid hormone was approved in 1893 and then taken off the market for obesity treatment in 1949. Amphetamines were approved in 1937 and taken off the market in 1971 for cardiovascular toxic effects. More recently, fenfluramine was approved in 1973 and taken off the market in 1997, phenylpropanolamine was approved in 1960 and taken off the market in 2000, and sibutramine (Meridia) was approved in 1997 and taken off the market in 2010, all for life-threatening adverse effects (Bendich, 2013). Today, there are five antiobesity medications that may be prescribed over the long term to assist in decreasing and then maintaining a lower BMI. Of these, only one, orlistat (Xenical), was FDA approved prior to 2012 (Bendich, 2013) (see Table 48-2). It is estimated that less than 3 million Americans take antiobesity medications, although many more may benefit from these prescriptions. It is thought that concerns about the safety of antiobesity medications coupled with the relatively recent FDA approval of safe and effective antiobesity medications likely account for the relative dearth of these prescriptions (Yanovski & Yanovski, 2014). (Hinkle 1362-1364) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing process obesity

NURSING PROCESS The Patient Undergoing Bariatric Surgery Assessment Preoperatively, the nurse assesses for contraindications to major abdominal surgery. Previous attempts at losing weight are also assessed, including strategies such as nutritional counseling, dieting, or exercise programs. The nurse ensures the patient has received education and counseling regarding the possible risks and benefits of bariatric surgery including the complications, postsurgical outcomes, dietary changes, and the need for lifelong follow-up. The nurse also confirms that the patient has been screened for behavioral disorders that may interfere with postsurgical outcomes. Dietary counseling is initiated preoperatively to prepare for postoperative dietary changes (Mechanick et al., 2013; OAC, 2015b). The nurse ensures that preoperative screening tests are obtained and scrutinizes the results. Typical laboratory tests include a complete blood cell count CBC, electrolytes, blood urea nitrogen (BUN), and creatinine. See Appendix A on for normal values for these laboratory tests. Patients with obesity may have OSA, gastroesophageal reflux disease (GERD), heart disease, nonalcoholic fatty liver disease, diabetes (or prediabetes), and vitamin and mineral deficiencies; thus, other screening tests that may be obtained include a sleep study, upper endoscopy, electrocardiogram (ECG), lipid panel, AST, ALT, glucose, and hemoglobin A1c, as well as iron, vitamin B12, thiamine, folate, vitamin D, and calcium levels. p. 1369 p. 1370 Figure 48-5 • Bariatric surgical procedures. A. Roux-en-Y gastric bypass. A horizontal row of staples across the fundus of the stomach creates a pouch with a capacity of 20 to 30 mL. The jejunum is divided distal to the ligament of Treitz, and the distal end is anastomosed to the new pouch. The proximal segment is anastomosed to the jejunum. B. Gastric banding. A prosthetic device is used to restrict oral intake by creating a small pouch of 10 to 15 mL that empties through the narrow outlet into the remainder of the stomach. C. Sleeve gastrectomy. The stomach is incised vertically and up to 85% of the stomach is surgically removed, leaving a "sleeve"-shaped tube that retains intact nervous innervation and does not obstruct or decrease the size of the gastric outlet. D. Biliopancreatic diversion with duodenal switch (also called sleeve gastrectomy with duodenal switch). Half of the stomach is removed, leaving a small area that holds about 60 mL. The entire jejunum is excluded from the rest of the gastrointestinal tract. The duodenum is disconnected and sealed off. The ileum is divided above the ileocecal junction, and the distal end of the jejunum is anastomosed to the first portion of the duodenum. The distal end of the biliopancreatic limb is anastomosed to the ileum. Postoperatively, the nurse assesses the patient to ensure that goals for recovery are met and that the patient exhibits absence of complications secondary to the surgical intervention. See Chapter 19 for general assessment of the postoperative patient. Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: Deficient knowledge about the dietary limitations during the immediate preoperative and postoperative phases Anxiety related to impending surgery Acute pain related to surgical procedure Risk for deficient fluid volume related to nausea, gastric irritation, and pain Risk for infection related to anastomotic leak Imbalanced nutrition: less than body requirements related to dietary restrictions Disturbed body image related to body changes from bariatric surgery Risk for constipation and/or diarrhea related to gastric irritation and surgical changes in anatomic structures from bariatric surgery COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Hemorrhage Venous thromboembolism Bile reflux Dumping syndrome Dysphagia Bowel or gastric outlet obstruction Planning and Goals Preoperative goals include that the patient will become knowledgeable about the preoperative and postoperative dietary routine/restrictions and will have decreased anxiety about the surgery. Postoperative goals include relief of pain, maintenance of homeostatic fluid balance, prevention of infection, adherence to detailed diet instructions to include progression of food intake as well as fluid intake (to prevent dehydration), knowledge about vitamin supplements and the need for lifelong follow-up, achievement of a positive body image, and maintenance of normal bowel habits (ASMBS, 2013a; Mechanick et al., 2013). Nursing Interventions ENSURING DIETARY RESTRICTIONS The nurse counsels the patient anticipating bariatric surgery to ingest nothing but clear liquids for a specified period of time preoperatively and postoperatively (typically about 24 to 48 hours before and after surgery). Nutritional support for patients scheduled for bariatric surgery is tailored to meet each patient's individual need to ensure optimal consumption of micronutrients. Bariatric diets usually follow a progression from clear liquids to full liquids to soft solids and eventually solid foods. This slow progression is necessary to maximize weight loss, and to prevent complications such as nausea, vomiting, bile reflux, and diarrhea. The patient's diet will be limited upon discharge from the hospital; because of this, patients scheduled for bariatric surgery are given guidelines prior to surgery on which foods and liquids they may consume postoperatively so that they may stock up on these items at home before they are admitted to the hospital. These typically include sugar-free drinks, gelatins and puddings, flavored electrolyte drinks, fat-free milk, protein drinks, sugar-free applesauce, and low-fat soups (Cole, Beckman, & Earthman, 2014; Isom, Andromalos, Ariagno, et al., 2014; Mechanick et al., 2013). REDUCING ANXIETY The nurse provides the patient preparing for bariatric surgery anticipatory guidance as to what to expect during the surgery and postoperatively. In addition, the nurse may encourage the patient to join a bariatric surgery support group preoperatively, with the intent that the patient will continue to participate in this group postoperatively. Most bariatric surgery centers sponsor patient support groups that meet in person or online. These support groups provide a forum where patients contemplating bariatric surgery may talk with patients who have had the surgery and may provide them with guidance and tips that can help to lessen their anxiety (Mechanick et al., 2013). RELIEVING PAIN After surgery, analgesic agents may be given as prescribed to relieve pain and discomfort. Patients are usually prescribed opioid agents via patient-controlled analgesia (PCA) pumps; the nurse should educate the patient about its use and monitor its effectiveness. It is especially important to provide adequate pain relief so that the patient can perform pulmonary care activities (deep breathing and coughing) and leg exercises, turn from side to side, and ambulate. The nurse assesses the effectiveness of analgesic intervention and consults with other members of the health care team if pain is not adequately controlled (Patil & Melander, 2015) (see Chapter 12). Positioning the patient in a low Fowlers position promotes comfort and emptying of the stomach after any type of gastric surgery, including bariatric procedures. ENSURING FLUID VOLUME BALANCE Patients who have had bariatric surgery usually receive intravenous (IV) fluids for the first several hours postoperatively. Once they are awake and alert on the surgical unit, they are encouraged to begin intake of sugar-free oral fluids. Introducing small volumes of these liquids is believed to stimulate GI peristalsis and perfusion and thwart gastric reflux. Sugar-free fluids are preferred because they are not implicated in causing dumping syndrome (see later discussion). With a typical regimen, patients are encouraged to slowly sip 30 mL of these fluids every 15 minutes. Patients should stop ingesting fluids, however, if they feel nauseated or full. Antiemetic agents may be prescribed to relieve nausea and prevent vomiting, which could cause strain on the surgical site and cause either a hemorrhage or anastomotic leak (Mechanick et al., 2013). PREVENTING INFECTION/ANASTOMOTIC LEAK Disruption at the site of anastomosis (i.e., surgically resected site) may cause leakage of gastric contents into the peritoneal cavity, causing infection and possible sepsis. Patients at risk for this particular complication tend to be older, male, and with greater body mass. In addition, anastomotic leak is more commonly associated with open rather than laparoscopic procedures. Patients with anastomotic leaks typically exhibit nonspecific signs and symptoms that include fever, abdominal pain, tachycardia, and leukocytosis. This may progress to sepsis and possibly septic shock if not recognized and treated early (see Chapter 14). The nurse must be astute in recognizing these manifestations and alerting the patient's primary provider should they occur (Dunham, 2013; Patil & Melander, 2015). A patient suspected of having an anastomotic leak may have an upper GI series that includes follow-up computed tomography (CT) scan with contrast dye, which may find leaking contrast dye, thus confirming the diagnosis. Treatment varies depending on the timing (early or late postoperatively) and severity of the leak. CT-guided drainage of the area may be appropriate for a less severe leak in the later postoperative phase of recovery, but an early or severe leak requires immediate open surgical intervention to repair the leak (Jacobsen, Nergard, Leifsson, et al., 2014). ENSURING ADEQUATE NUTRITIONAL STATUS After bowel sounds have returned and oral intake is resumed, six small feedings consisting of a total of 600 to 800 calories per day are provided, and consumption of fluids between meals is encouraged to prevent dehydration. The nurse instructs the patient to eat slowly and stop when feeling full. Eating too much or too fast or eating high-calorie liquids and soft foods can result in vomiting or painful esophageal distention. Gastric retention may be evidenced by abdominal distention, nausea, and vomiting. A nutritionist is typically consulted to assist with diet restrictions and diet progression (Mechanick et al., 2013) (see Chart 48-7). Common dietary deficiencies in patients who have had bariatric surgery include malabsorption of organic iron, which may require supplementation with oral or parenteral iron, and a low serum level of vitamin B12; the patient may be prescribed monthly vitamin B12 intramuscular injections to prevent pernicious anemia (Dunham, 2013; Isom et al., 2014) (see Chapter 33 for further discussion). SUPPORTING BODY IMAGE CHANGES Most patients post bariatric surgery report greatly improved perceptions of their body image, as well as improved quality of life. However, some patients report lingering dissatisfaction with their body images. In particular, some patients may report dissatisfaction related to loose skin folds and may eventually seek elective body-contouring surgical options (e.g., breast reductions, breast lifts, abdominoplasty). The nurse provides support to the patient who reports dissatisfaction with body image post weight loss by acknowledging the patient's feelings as real, sharing that these perceptions are not unusual, and providing links to live or online supports groups or counselors, as necessary (Gilmartin, 2013; Pfeil, 2014; Schauer, Woodruff, Hotz, & Kegler, 2014). ENSURING MAINTENANCE OF BOWEL HABITS Patients may complain of either diarrhea or constipation postoperatively. Diarrhea is more common an occurrence post bariatric surgery, particularly after malabsorptive procedures (Mechanick et al., 2013). Both may be prevented if the patient consumes a nutritious diet that is high in fiber. Steatorrhea also may occur as a result of rapid gastric emptying, which prevents adequate mixing with pancreatic and biliary secretions (Mechanick et al., 2013). In mild cases, reducing the intake of fat and administering an antimotility medication (e.g., loperamide [Imodium]) may control symptoms. Persistent diarrhea or steatorrhea may warrant further diagnostic testing, such as an upper endoscopy or colonoscopy with biopsies to rule out the presence of additional pathology, such as celiac diseases or Clostridium difficile infection (Mechanick et al., 2013) (see Chapter 47). Chart 48-7 PATIENT EDUCATION Dietary Guidelines for the Patient Who Has Had Bariatric Surgery The nurse instructs the patient to: Eat smaller but more frequent meals that contain protein and fiber; each meal size should not exceed 1 cup. Eat only foods high in nutrients (e.g., peanut butter, cheese, chicken, fish, beans). Consume fat as tolerated. Ensure a low carbohydrate intake; in particular, avoid concentrated sources of carbohydrates (e.g., candy). Eat two protein snacks daily; animal protein may be poorly tolerated after Roux-en-Y gastric bypass, however. Eat slowly and chew thoroughly. Assume a low Fowler position during mealtime and then remain in that position for 20-30 minutes after mealtime—this delays stomach emptying and decreases the likelihood of dumping syndrome. Know that antispasmodic agents, as prescribed, also may aid in delaying the emptying of the stomach. Do not drink fluid with meals; instead, consume fluids up to 30 minutes before a meal and 30-60 minutes after mealtime. Do drink plenty of water; refrain from drinking liquid calories (e.g., alcoholic beverages, fruit drinks, nondiet sodas). Take prescribed dietary supplements of vitamins and medium-chain triglycerides. Follow up with primary provider for monthly injections of vitamin B12 and iron as prescribed. Walk for at least 30 minutes daily. Adapted from Mechanick, J. I., Youdim, A., Jones, D. B., et al. (2013). Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: Cosponsored by the American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surgery for Obesity and Related Diseases, 9(2), 159-191. MONITORING AND MANAGING POTENTIAL COMPLICATIONS After surgery, the nurse assesses the patient for complications from the bariatric surgery, such as hemorrhage, venous thromboembolism, bile reflux, dumping syndrome, dysphagia, and bowel or gastric outlet obstruction. Hemorrhage. Postoperative hemorrhage may be a complication following bariatric surgery. Intra-abdominal hemorrhage may be evident by frank, bright red oral or rectal bleeding, tarry melena, bloody output from the wound or drains, if present, as well as typical clinical manifestations of severe bleeding and hemorrhagic shock (e.g., tachycardia, hypotension, syncope) (see Chapter 14). Bleeding within the first 72 hours postoperatively is most likely caused by disruption in a staple or suture. Bleeding 72 hours to 30 days postoperatively is most likely from formation of a gastric or duodenal ulcer (Patil & Melander, 2015) (see Chapter 46). p. 1372 p. 1373 Venous Thromboembolism (VTE). Patients who have bariatric surgery are at moderate to high risk of VTE, including both PE and DVT. Patients who are older, have higher BMIs, and have a prior history of a VTE or coagulation defect are at higher risk (Brethauer, 2013). ASMBS guidelines for VTE prevention specify that in the immediate postoperative period, patients who have had bariatric surgery should be prescribed mechanical compression (e.g., intermittent pneumatic compression devices) and prophylactic anticoagulation with subcutaneous low molecular weight heparin (LMWH) agents (e.g., dalteparin [Fragmin], enoxaparin [Lovenox]). The duration of time that mechanical compression and anticoagulation should continue postoperatively are not described, however, and are left to the discretion of the patient and primary provider. In addition to implementing this prescribed therapy, nurses caring for patients post bariatric surgery should encourage them to begin early ambulation to further deter the advent of VTE (Brethauer, 2013) (see Chapter 30). Bile Reflux. Bile reflux may occur with procedures that manipulate or remove the pylorus, which acts as a barrier to the reflux of duodenal contents. Reflux of bile can cause inflammation of the stomach (i.e., gastritis) or esophagus (i.e., esophagitis). Burning epigastric pain and vomiting of bilious material manifest this condition. Eating or vomiting does not relieve the symptoms. Bile reflux may be managed with proton pump inhibitors (e.g., omeprazole [Prilosec]) (Sifrim, 2013). Dumping Syndrome. Dumping syndrome is an unpleasant set of vasomotor and GI symptoms that commonly occurs in patients who have had bariatric surgery. For many years, it had been theorized that the hypertonic gastric food boluses that quickly transit into the intestines drew extracellular fluid from the circulating blood volume into the small intestines to dilute the high concentration of electrolytes and sugars, resulting in symptoms. Now, it is thought that this rapid transit of the food bolus from the stomach into the small intestines instead causes a rapid and exuberant release of metabolic peptides that are responsible for the symptoms of dumping syndrome (Patil & Melander, 2015). Symptoms of dumping syndrome typically occur 15 minutes to 2 hours after eating and include tachycardia, dizziness, sweating, nausea, vomiting, bloating, abdominal cramping, and diarrhea (Patil & Melander, 2015). These symptoms typically resolve once the intestine has been evacuated (i.e., with defecation). Later, blood glucose rises rapidly, followed by increased insulin secretion. This results in a reactive hypoglycemia, which also is unpleasant for the patient. Vasomotor symptoms that occur 10 to 90 minutes after eating are pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and even drowsiness. Anorexia may also result from dumping syndrome, because the patient may be reluctant to eat (Patil & Melander, 2015). Concept Mastery Alert Dumping syndrome is a physiologic response to the rapid emptying of gastric contents into the jejunum. The rapid transit of the food bolus from the stomach into the small intestines causes a rapid and exuberant release of metabolic peptides that are responsible for the symptoms of dumping syndrome. Dysphagia. Dysphagia, or difficulty swallowing, may occur in patients who have had any type of restrictive bariatric procedure. If it occurs, it tends to be most severe 4 to 6 weeks postoperatively and may persist for up to 6 months after surgery. Dysphagia may be prevented by educating patients to eat slowly, to chew food thoroughly, and to avoid eating tough foods such as steak or dry chicken or doughy bread. Patients with severe dysphagia who have had gastric banding may benefit from having their bands adjusted. Patients who have had other restrictive procedures may experience relief of symptoms after having stomal strictures relieved endoscopically (Mechanick et al., 2013). Bowel and Gastric Outlet Obstruction. Bowel or gastric outlet obstruction may occur as a complication of bariatric surgery. The typical manifestations and treatments of gastric outlet obstruction are described in Chapter 46; however, there is a key difference in the treatment of a patient who has undergone bariatric surgery with a gastric outlet obstruction. It is contraindicated to insert a nasogastric (NG) tube in patients that have had bariatric surgery, even if they have a gastric outlet obstruction. Alternative treatment options may include endoscopic procedures aimed at relieving the obstruction, such as balloon dilation, or surgical revisions (Patil & Melander, 2015). Quality and Safety Nursing Alert Insertion of NG tubes is contraindicated in the patient post bariatric surgery. This procedure may disrupt the surgical suture line and cause anastomotic leak or hemorrhage. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Patients are usually discharged from the hospital within 4 days postoperatively (this may be within 24 to 72 hours for patients who have had laparoscopic procedures) with detailed dietary instructions (see Chart 48-7) as well as instructions about how to either begin or resume an appropriate exercise regimen. Instructions on making follow-up appointments with the bariatric surgeon for routine postoperative visits or for complications are shared with the patient (Mechanick et al., 2013). Educating Patients About Self-Care. The nurse provides education with the patient about nutrition, nutritional supplements, pain management, the importance of physical activity, and the symptoms of dumping syndrome and measures to prevent or minimize these symptoms. Patients who undergo laparoscopic or open RYGB procedures may have one or more Jackson-Pratt drains, which may remain in place after discharge. The nurse educates the patient or caregiver about how to empty, measure, and record the amount of drainage. Patients should be instructed to avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen [Motrin]) postdischarge, as they have been implicated in development of stomach ulcers (Mechanick et al., 2013). The nurse must emphasize the continued need for follow-up (even after weight-loss goals are met) and continued support group participation (Wykowski & Krouse, 2013). Continuing and Transitional Care. After bariatric surgery, all patients require lifelong monitoring of weight, comorbidities, metabolic and nutritional status, and dietary and activity behaviors because they are at risk for developing malnutrition or weight gain. Women of childbearing age who have bariatric surgery are advised to use contraceptives for at least 18 months after surgery to avoid pregnancy until their weight stabilizes. After weight loss, the patient may elect additional surgical interventions for body contouring. These may include breast reductions, lipoplasty to remove fat deposits, or a panniculectomy or abdominoplasty to remove excess abdominal skin folds (OAC, 2015b; Mechanick et al., 2013; Wykowski & Krouse, 2013). Evaluation Expected patient outcomes may include the following: Relief of pain Reports relief of pain Engages in early mobilization activities as prescribed Maintenance of fluid balance Able to tolerate progressive fluid intake without complaints of nausea or gastric reflux Voids 0.5 mL/kg/h Maintenance of asepsis No evidence of infection (e.g., no fever, no leukocytosis, no complaints of abdominal pain) Achievement of nutritional balance Able to consume small, frequent meals as prescribed Adheres to prescribed intake of vitamins and supplements Achieves and maintains weight reduction goals Promotion of positive body image Verbalizes continued satisfaction with weight reduction plan and its effect on body image Maintenance of usual bowel habits No evidence of diarrhea No evidence of constipation Has no complications (e.g., no bleeding, VTE, bile reflux, dumping syndrome, dysphagia, or bowel or gastric outlet obstruction) (Hinkle 1369-1374) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.