Do you know how to safely treat obese patients?
Is your ED providing safe and dignified care to morbidly obese patients? These patients present both physiologic and logistical challenges, according to Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, a clinical nurse specialist for trauma/critical care at MetroHealth Medical Center in Cleveland.
Mortality increases with body mass indexes over 25, and five out of the 10 leading causes of death in the United States are linked to obesity, so it’s key to assess for medical complications when treating those patients, says Steinmann. (See related stories on clinical presentations of obese patients, p. 101; cardiac conditions, p. 101; and risk factors of obese patients, p. 102.) Here are several ways to improve care of obese patients:
• Use appropriate-size cuffs for accurate measurement of hypertension. You should have normal, large, and extra-large adult cuffs, says Steinmann. "But it’s not reasonable to expect that any ED is equipped with a cuff to check a brachial blood pressure on a 900-lb. patient," she says. "It doesn’t work; we tried it."
Instead, ask the patient where they measure his/her blood pressure, suggests Steinmann. "You will need to be creative, and place the most appropriate-size cuff on an extremity where it will fit."
Realize that the measurement may not be as accurate, but an inaccurate measurement that you can trend over time is better than no measurement at all, says Steinmann. "Remember that cuffs applied to obtain radial and/or pedal pressures will be higher than brachial blood pressures. Also remember to convey to the inpatient units how the blood pressure is being measured."
• Check for skin infections. Obese patients may have bacterial and fungal infections from skin folds that were abrased or open from continued touching of skin surfaces, and/or inability to clean those areas of their body, says Schutz.
• Position patient sitting upright or lying on side.
Position patients upright or on their side so the weight of the abdomen does not impinge on the ability to move the chest wall, says Steinmann. Laying the patient flat on the back can precipitate or exacerbate respiratory distress. "There is increased work of breathing because moving the chest wall expends considerable energy."
Rapid and shallow respirations are the norm, says Steinmann. "ABGs frequently demonstrate respiratory acidosis, hypoxemia, and hypercapnia."
If the patient is a trauma case, or needs to be supine for any reason for any length of time, you’ll need to consider compression issues, says Schutz. "Use the logic of the OR — that anything subjected to pressure needs to be padded."
The obese patient may have difficulty being supine, especially if he/she is a smoker, says Schutz. "They may have an inability to breathe, due to abdominal contents filling the subdiaphragmatic space and shortening their lung volumes," she says. "Also, it is extremely hard to move that much weight with each breath."
• Assess whether crutches are a safe option for fractures and sprains. Assess whether crutch walking is a realistic option for lower-extremity injuries, says Steinmann. "I would not give out crutches without assurance [from the manufacturer] that the crutches can support that much weight," she advises. Walkers or wheelchairs, specially ordered from bariatric equipment suppliers, might be a much safer option.
• Consider logistical issues in advance. Make sure you have the appropriate size cart, bed, and wheelchairs, says Steinmann. There are safety issues to consider for both for the patient and the staff, so make sure you have enough personnel to move the patient from point A to point B, she advises. "We were so proud of ourselves for ordering a specialty bed for one of our patients," she recalls. The prehospital, ED, and security staff assisted in transferring the patient over to the bed. "It then took 14 people to transport the patient on the bed to the elevators up to the inpatient floor, only to find that the bed did not fit through the doorway of the room."
To avoid such scenarios, draft a plan in advance, for how to logistically manage a morbidly obese patient from arrival to admission, she advises.
• Realize that patients are at high risk for diabetes.
The obese patient is at high risk of Type 2 diabetes, which is frequently undiagnosed, says Sandra L. Schutz, RN, MSN, CCRN, an ED clinical nurse specialist at Swedish Medical Center in Seattle. "If in fact they have diabetes, they may have a hypoglycemic threshold that is much higher than a normal patient and thus will become symptomatic at much higher blood sugars than you would expect."
An example is the patient who is confused, shaky, and diaphoretic at a blood sugar level of 120, says Schutz. "This may simply be from a protracted time of having high sugars, and thus when they get to 120, they are truly hypoglycemic."
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