Caring for Obese Patients

[vdodili]

Hello everyone! I am an NP currently working as full-time faculty in an ADN program, and doing per diem work in an occupational health setting. I have been asked to present at a hospital-based healthcare conference on the topic of "bariatric sensitivity" in nursing, and I am looking for your input. This topic is so important, but it is also so broad! Caring for obese patients is certainly challenging, and sometimes even back-breaking. However, there does seem to be a great deal of "acceptable" prejudice toward obese patients (I have even heard nurses make derogatory comments right in patients' rooms, not to mention the talk that goes on at the nurses' station). I would welcome your thoughts and observations on this topic as I plan this presentation. I want to make it relevant to the nurses and other health care providers who will be listening. Thank you in advance for your input!

[iluvgusgus]

Well, I would say that there may be resentment toward a very obese pt because nursing is a hard enough job with normal sized pts, when a pt is 500 lbs and you need to turn them every 2 hours and need a crew of 6 to do it, 6 very busy people, it becomes very tiring to round up and wait on 5 other people. What if this very obese person has stage 4 pressure ulcers all over their body that need extensive dressing changes and now you need to round up another 5 people to do these changes which will keep you in the room 1-2 hours? It is very labor intensive on not one, but 3,4,5 other people. Ive done it, and I was sweating at the end of one of these dressing changes on 3 stage 4 pressure ulcers that required 2 people to lift skin folds to help. What if this 500 lb pt has cdiff and has diarrhea every hour, diarrhea that we cant stop because it is cdiff, now you have to round up 5 people even more frequently. So it is a lot of work and I would say there is a lot of resentment that someone would let themselves get to a size where they cant even help themselves.

I dont think it is right to say rude remarks in front of the pt, I dont think it is right to privately make rude remarks about it to other nurses, it is unprofessional.

I believe that lifestyles people lead are choices and everything else I hear people saying is an excuse. I think that our culture and society make it too easy to be fat. We live in cities that are not very pedestrian friendly, drive thru everything. Eating healthy is expensive. I did not even know where the stairs in my hospital were for a year until the other day, they should have a sign leading you to them instead of taking the elevator. My hospital has chick fil a, wendys, a frozen yogurt spot, a bagel restaurant, and pizza everyday in the food court. What a great example to set for healthy living to have all that right off your front lobby of your hospital. I hate when people stalk me for my spot in a parking lot if it's close to the store when there are hundreds of other ones a little bit farther away, would it kill you to walk an extra 20 feet, my goodness!

I am overweight now, was not always I used to be very active. How my body is now was a conscious choice - I chose not to work out regularly for the past 3 years, I chose to indulge in whatever food I wanted, knowing it was bad. I now am choosing to change my lifestyle and I choose to bring salad for lunch, I choose to work out 3 times a week. So when we as people all know you know better and this is the life you chose and now we have to break our backs, there will be resentment.

[Anna Flaxis, BSN, RN]

I do believe that in many, many cases, obesity is the result of lifestyle choices. I believe that our society (U.S.A.) and environment promote those lifestyle choices. We don't have to move around much to find food. Food is abundant. We can get it with very little effort any time of day or night. Getting from point A to point B requires very little effort. One can walk a few steps from their front door to their car and drive wherever they want to go. The business of life is very easy and convenient and requires very little physical effort, and yet we eat more calorie dense foods than ever before. Portion sizes are larger and modern processed foods are full of calories.

I also believe that sometimes, morbid obesity is the result of emotional and psychological trauma. I believe that some people turn to food for comfort, much like some people turn to drugs.

And lastly, I believe that circumstance beyond one's control can lead to morbid obesity. Certain illnesses and the medications that treat them, spinal cord injuries, and a whole host of other factors can create the perfect environment for weight gain. So-called "Lifestyle Choices" become unrealistic for the person in this situation.

So yes, sometimes it is the person's own fault that they're fat. Sometimes, it is not that simple.

But in the end, what does it really matter? They are a human being who needs your help, and it's your job to help them.

I frequently try to remind myself that my fortune can change in the blink of an eye, and there but for the grace of God (or whatever) go I.

[AmyRN303, BSN, RN]

Well that says it all - you don't care about actual research done on this topic, you just want to judge everyone who stays fat. Continuing to discuss this with you is just going to be an exercise in beating heads against the wall but I'll give it a try.

1. You would lose those dollars.

2. BMR = Basic Metabolic Rate. This is the absolute MINIMUM requirements for your body to exist and do nothing more than breathe, digest, live. If you do ANY exercise beyond lying in bed and breathing, your body requires more calories. Eating below your BMR, especially for an extended period of time, puts you into starvation mode . . . which means your body will hoard fat stores and surprise! You won't lose weight. What's more, encouraging someone to eat so little that they are in starvation mode, regardless of their starting weight, is encouraging disordered behavior. You would never tell a skinny anorexic "wow, you've got so much self-control, to eat so little and lose so much weight!" (At least I hope you wouldn't.) You should never say anything to a fat person that you wouldn't say to a skinny person if they did the same thing.

3. If eating something that tastes good is more important to me than eating what you determine to be "healthy," why do you care? If spending time cuddling my dogs is more important to me than hitting the gym, why do you care? Do you care so much that people are dying their hair more these days than in the past? Because that has about as much true effect on actual health as weight does.

Here's some links for you, both research based and opinion articles.

Health vs Weight Focus

An explanation of why BMI is a poor indicator of health (written in easy to understand language with citations included).

5 health care myths (with 29 references for you to peruse if you want more detailed research).

Publishing bias - AKA why you should ALWAYS follow the money (and the weight loss industry is a multi-billion dollar industry.)

The answer to the obesity crisis.

Health at Every Size - that it is and what it isn't.

"From the perspective of efficacy as well as ethics, body weight is a poor target for public health intervention."

Lots of resources located here - all the links below are taken from that page.

"Conclusion - Individuals with obesity receive numerous instructions about what to do to address their weight, but very few are given appropriate long term guidance or support with which to follow through those instructions. Understanding the positive role of social networks may be particularly important in engaging individuals in physical activity."

"There are serious ethical concerns regarding the continued use of a weight-centered paradigm in current practice in relation to beneficence and nonmaleficence."

"It should also make us pause to consider how propagating the idea of an 'obesity epidemic' furthers the political and economic interests of certain groups, while doing immense damage to those whom it blames and stigmatizes."

"Obese persons experience a high degree of stress, and this stress plausibly explains a portion of the BMI-health association. Thus, the obesity epidemic may, in part, be driven by social constructs surrounding body image norms."

"As physical activity expenditure has not declined over the same period that obesity rates have increased dramatically, and daily energy expenditure of modern man is in line with energy expenditure in wild mammals, it is unlikely that decreased expenditure has fuelled the obesity epidemic."

To the OP: I recommend reading through some of those research articles (here's the link again for the Fat Nutritionist's research page, which is a good starting point). Most of the research these days is showing that encouraging self-acceptance, regardless of size, leads to better health. Helping patients learn to love themselves as they are reduces the stress and anxiety of negative self-esteem, which helps with starting and maintaining healthy habits. If you are less stressed, you are less inclined to stress-eat, for example. If you are sensitive to judgmental stares from others when you put on workout clothing, you are less likely to keep up an exercise regimen of any kind. Focusing on other health goals instead of weight - such as ability to run a mile, or lower cholesterol, or decreased BP, etc - often coincides with reducing weight as well.

I don't have any data on this (only anecdotes, which are not research I know!), but I have heard MANY stories of patients who do not receive appropriate medical care because their physicians blame any health issue on being fat and do not look harder for an underlying cause. Reducing the stigma of being fat can help with that.

Fetch, you are my hero. I love The Fat Nutritionist, and bonus points for the HAES link.

[LadyFree28, BSN, LPN, RN]

Instead of emphasizing bariatric sensitivity you should be advocating for a no lift environment complete with ceiling lifts! Sensitivity is all well and good, but should be part of being a compassionate person! What healthcare workers really need is hospitals stepping up and providing a safe no lift environment so workers do not have to be injured or live in chronic pain because of caring for obese patients!

I know too many coworkers who have been injured, some permanently, others living in chronic pain because of the refusal of hospitals to buy and maintain lift equipment such as ceiling lifts. This problem is also one of the main reasons nurses leave the bedside!

THIS.

That is the main issue; the advocating for a "no lift" facility...

I found max assist pts more of an issue than bariatric pts. I also have worked in "no lift" facilities; this should be the rule, not the exception.

[Ruby Vee, BSN]

I have to give you credit for providing an article for your point, but I should say, I still don't buy this. The reason being, if one changes a life style and sticks with it, then until death bed, he/she will not be obese. Also I don't think this article clearly reports the method by which the subjects were tried. If you want to prove your argument, then there has to be a scientific proof that even though the subjects were obligated, monitored and enforced to exercise x amount of minutes/day and given calculated amount of calories less than what was required of each individual's BMR, AND still gained weight, then yes that would back your argument that no matter how much one works out or eats less than required BMR, still human beings are bound to weight gain and can't do much about it, but it does not clearly say anything remotely close to that. It seems like it says "we followed them around 2 yrs, gave them advices on exercises and nutrition, and they were still obese." I don't see the record of how much subjects ate or how much calories they burned during each workout session and what their individual BMRs were and if they devotedly stuck to the program.

I will bet my dollars that given any person, if we can make that person dedicate to exercise regularly, eat less than their BMR and do that consistently everyday and stick with it, they will lose weight and not gain it back.

Why do you think 2.1 billion people are fatter than the past like the article says? Because the lifestyle has changed, because the eating habits changed for the worse turn. US alone increased in obesity from 1950s by about 214%. Doesn't that tell us something? Japan has 3.6% obesity rate whereas US has 32%. If the article suggests that humans are evolved to be fat and stay fat, why are there so much discrepancies between countries? Well for one thing, we can find that answer in lifestyle. I have an article link to this if you want. Again, if someone starts a different lifestyle and sticks with it, I surely believe they will lose weight and stay that way. I have seen way to many cases for it to be only 5%.

I'm fat. I started Weight Watcher's and faithfully followed the program to the letter, at the same time training to walk a marathon. I was walking 25 miles a week at a pace of abot 4 mph and sticking faithfully to the WW program. In 3 months, I lost 2 pounds.

Tell me again that I would have lost weight if I'd just eaten less or exercised more.

After 8 months, I'd lost three pounds. I have strong legs, but I'm still fat.

[BuckyBadgerRN, ASN, RN]

Tarotale: Wow. Really? Just really.

[fetch, BSN, RN]

But in the end, what does it really matter? They are a human being who needs your help, and it's your job to help them.

THIS!!! So much!

[1wellnessnurse]

For my daughters (and myself), I posted a picture on the bathroom scale that says,

"you are more important than this number".

[Clementia]

I admit that the obese are not my favorite patients. I'm not going to label someone as "bad" or "irresponsible" or "lazy" because they happen to weigh 350 pounds. But when you work on an ortho floor, as I did, then a 350-lb patient who's just had joint surgery means a lot of heavy lifting for the nurses.

And no, you cannot always round up 4 or 5 more people to help with a lift or turn, change dressings on ulcers, or clean up C.diff for the fifth time. I worked nights on a 24-bed unit. There were weekend nights when we only had 3 or 4 staff on the floor. The floor beneath us couldn't spare anyone either. When two or three call lights are going off and the larger patient needs something, you end up turning him yourself because there just aren't any other staff members around to help you. This is why I never liked dealing with morbidly obese patients -- because of the high risk of doing a permanent injury to my back.

[pooh1258]

JasBSN - I TOTALLY AGREE WITH YOU! I finally had to tell one of my doctors the same thing. Once I said it, our relationship totally changed for the better. The PA still blamed everything on "well if you'd just lose some weight" but the MD finally treated me as a person.

[brandy1017, ASN, RN]

JasBSN - I TOTALLY AGREE WITH YOU! I finally had to tell one of my doctors the same thing. Once I said it, our relationship totally changed for the better. The PA still blamed everything on "well if you'd just lose some weight" but the MD finally treated me as a person.

I had a dear friend who was treated that way by her dr and of course avoided going to the dr as much as possible because of his poor bedside manner. Finally she was able to get her old dr back who had gone back to school to specialize in geriatric medicine and he was always kind and treated her with respect. This dear lady had to have an epidural after falling on spilled grease while she was volunteering at a church and a very mean nurse was laughing at her because of her weight! It makes me so mad, frankly if I was there I might have smacked her! Even years later she was in tears when she related what happened! Also she would receive cruel comments from members of a church group on how she had a pretty face, but her legs looked bad. She had five children and had bad varicose veins. It makes me so sad to hear how she was treated and how Esme's been treated! How dare you treat someone that way! Anyone that treats others so cruel and mean doesn't deserve to have a job taking care of others! That type of person should be doing paperwork away from people!

Surely all of us or most of us have a friend or family member or even ourselves that is overweight or obese. Would you want any one of your dear loved ones to be mistreated as Delicate FLower and Esme have experienced. I sure wouldn't! It makes me cringe to hear nurses speaking that way and yes I do remember a mean old nurse who once sang a polka song "She's too fat for me" to another overweight coworker just to be cruel. That same nurse hung out with the clique of the moment, trying to be popular, but guess what, she was not! For her retirement party, they were begging people to attend and I would not! Very few people came!

I remember watching an Extreme Loser show that had a nurse that lost a lot of weight and was promised a tummy tuck if she reached goal. She was successful, but it was not easy and at one point she had a relapse and regained a lot of weight in a short time. The way the trainer and Dr treated her was so rude and I was just appalled. Frankly I would not let someone talk to me the way they talked to her! I would have quit if I was her. She apologized for her weight gain, humbled herself, admitted her stress and financial problems and was able to please them and lose the weight. Finally she did succeed and I guess got her tummy tuck, but I still think the way they treated her was shaming. Good for the professional trainer that he was so fit, but frankly I don't think a person that has been thin and fit all their lives can comprehend how someone with a real weight problem feels. What is easy for them is not for the obese people they treat.

Shaming behavior usually just leads to low self esteem and avoidance of medical care. We as nurses need to treat our patients kindly with love we would show to our own dear loved ones! When my dear friend was dying of cancer I didn't worry about hurting my back when I was helping her. I would do anything for her. I love her and miss her so much! She was truly a living saint!

[calivianya, BSN, RN]

THIS.

That is the main issue; the advocating for a "no lift" facility...

I found max assist pts more of an issue than bariatric pts. I also have worked in "no lift" facilities; this should be the rule, not the exception.

Just playing devil's advocate - when the max assist patient is a tiny dementia patient that has gone septic at the nursing home and weighs less than 80 pounds, total care can still be easier than dealing with even partially mobile bariatric patients. I can turn an emaciated end-stage Alzheimer's patient by myself; I cannot turn someone over 300 pounds by myself.

There was one week that I was working 5 12s and they had me in the back corner with two extremely bariatric patients, both sedated and on the ventilator, both over 400 pounds. I am not going to lie, by my last night those two patients were lucky to get turned twice a shift, if they even got turned that often. We have no techs on my floor. Every nurse has two ICU patients and even our charge nurses have two patients. There is no help, and both of my patients took at least four nurses to turn. If you're talking about four nurses being monopolized in one room for a bath/dressing change that takes at least 45 minutes because of the size of the patient, you are talking about leaving SEVEN critically ill patients without nursing care for almost an hour, and that's just wrong.

I feel for the bariatric patients; I really do, but when I think about those other seven patients, I get a little resentful. Morbidly obese patients just cause problems with allocation of resources. That's my main gripe. The patients in the above scenario for that week I worked both needed to be turned 12 times a day for weeks. That is a LOT of nurses and many hours spent on just two patients, and it's just not fair to the rest of the patients on the floor. Even patients who are coding are not as resource-intensive as bariatric patients who spend weeks on the ventilator. It's not like we are allowed to have more FTEs working based on the number of bariatric patients on the unit. Staffing is based on census, not average patient weight.

I really try not to judge people, I really, really do, but by the end of that week I was just glad neither of my patients was alert and oriented, because they would have read a lot of judgment in my body language if nothing else.