Assess obese patients for cardiac conditions
There probably will be some degree of cardiac involvement in any morbidly obese patient, stresses Sandra L. Schutz, RN, MSN, CCRN, an ED clinical nurse specialist at Swedish Medical Center in Seattle.
"Obesity often causes related and/or aggravated hypertension," she says. "This in turn may cause left ventricular hypertrophy." Here are some cardiac-related items to consider with morbidly obese patients:
• Order an ECG if there is any question of chest pain. Risk of coronary heart disease death and nonfatal acute myocardial infarction increases with increased body mass index, says Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, a clinical nurse specialist for trauma/critical care at MetroHealth Medical Center in Cleveland.
Obesity is associated with prolonged QT interval (electrocardiographic interval from the beginning of QRS complex to end of the T wave), which is associated with sudden cardiac death, says Steinmann.
Obesity is also associated with dyslipidemia, hypertension, and Type II diabetes, so these patients are at increased risk of coronary events, says Steinmann. It’s obvious that an ECG should be obtained with chest pain, but it also should be obtained with some of the more atypical coronary presentations, such as increased dyspnea, fatigue, and weakness, she says. "Remember that diabetics do not often present with the classic coronary syndrome presentations."
• Realize you might not be able to auscultate crackles/rales because of decreased transmission of breath sounds through the increased tissue of the chest wall. When assessing for congestive heart failure, looking for peripheral edema might not be helpful, as these patients characteristically have edematous lower extremities, says Steinmann. "Just be cognizant that this may be occurring."
• Assume patients are hypertensive, have some form of ventricular failure, and are diabetic until proven otherwise. If the morbidly obese patient smokes and/or has pulmonary problems, anticipate that they have some degree also of right ventricular failure, Schutz advises. "I usually seek to disprove those issues, all the while realizing that one of them may become a comorbid issue."
Anticipate comorbid issues with these patients, Schutz advises. "Don’t assume the young are OK and just obese," she says. "It doesn’t work that way."
For more information on management of obese patients, contact:
• Sandra L. Schutz, RN, MSN, CCRN, Swedish Medical Center, P.O. Box 70707, Seattle, WA 98107. Telephone: (206) 781-6144. Fax: (206) 781-6142. E-mail: [email protected].
• Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, Clinical Nurse Specialist, Trauma/Critical Care, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109. Telephone: (216) 778-3326. Fax: (216) 778-4219. E-mail: [email protected].
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