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!

[Esme12, ASN, BSN, RN]

Playing the devils advocate.....Lets change your scenario to race, religion, sexual preference, or color in place of bariactric.

Not a petty picture is it?

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.

I hear what you are saying...but that doesn't make it right. What makes them less deserving of good respectful care.

[Crazed]

For the very obese it is also important to remember that there is also a psychological component involved. It is theorized that creating the physical barrier of obesity is a way to ensure others stay away for emotional protection. Now while this is not the case all the time it does happen.

When I lost a lot of weight the world at large looked at me differently. I stopped being treated as if I was invisible because I was finally an acceptable member of society, but I was personally far more miserable thinner than I was fatter. This had everything to do with why I lost weight. Then I gained it all back. Five years to take it off a year to put it back on. It was very disheartening but it forced me to figure out how I felt about myself and what I wanted to do with my life.

Unless you've lived that struggle it's very hard to know how it affects a person esp when others feel entitled to tell you how you should feel about your weight. Why should I feel ashamed of myself because my body is larger than someone else's? We are reminded daily that we are not the ideal and never will be in our society.

Now I say things like, "Oh I'm not fat it's just my personality is too large to fit into a smaller body."

If I had any other chronic illness no one would be outwardly cruel to me but we've decided that in the interest of health that it's okay to fat shame.

Funny enough though I had a very thin instructor and her experience and mine were almost the same. Society tells her too that there is something wrong with her body because she's too thin.

[CrunchRN, ADN, RN]

If you haven't been there you just have no idea.

I used to weigh 235. I have fought hard to keep my weight in the 155-165 range for 25 years. It takes an amazing amount of work.

The issue is that hospitals need to provide more resources to their staff. If the staff had the proper resources tthey would not resent obese patients.

[ceccia]

Playing the devils advocate.....Lets change your scenario to race, religion, sexual preference, or color in place of bariactric.

that doesn't make any sense. Differences in religion/race/sexual orientation don't require 5-6 workers to accomplish even the simplest care task.

[calivianya, BSN, RN]

that doesn't make any sense. Differences in religion/race/sexual orientation don't require 5-6 workers to accomplish even the simplest care task.

You beat me to it!

Also, if I have a coworker that has a problem with their patient's race, religion, sexual orientation, or color, I could switch with them and take that patient for them. No harm, no foul. But... when we are talking about morbidly obese patients, there is no one that can safely care for them alone. None of our nurses are bodybuilders, and even if they were, there's a difference between bench pressing 400+ pounds of a stable, solid bar and rolling a sedated 400+ person adequately and somehow holding them up and bathing them alone. It's just not possible for one person to do.

The ultimate problem is staffing, not the patient, but I really don't see upper management letting us redo our staffing based on daily average patient weight instead of HPPD. They should, but there's no way anyone will approve that.

[Delicate Flower]

Our responsibility as health care providers is to provide the standard of care for the patients in our care. Period.

If you CANNOT provide the standard of care to ALL patients, because your staffing/environment/lack of equipment does not allow you to safely do so, then that is an issue that should immediately be taken up the chain.

Unit management - Facility Management - Risk Management - TJC - OSHA

Who does it help to stand around rolling your eyes, sighing, and thinking angry thoughts about your fat patients? It certainly doesn't help the patient.

I'm curious....when you only managed to turn your patient twice during the shift, did your charting reflect that? Did you document that you failed to meet the standard of care?

[Delicate Flower]

that doesn't make any sense. Differences in religion/race/sexual orientation don't require 5-6 workers to accomplish even the simplest care task.

You can argue that for a very, very heavy patient you may need 5-6 workers to turn and position, IF you do not have a turn assist bed or reliable safe lift equipment. If you do have those things, the number of people needed will be considerably fewer.

But for the "simplest" care task? Really? How many people does it take to give meds, do oral care, check vital signs, talk to your patient, perform neuro checks, manage pain, feed your patient, assess and monitor everything other the back side?

Turning, bathing, bathroom care, yes. Everything else, you can (generally) do by yourself.

[aeris99]

Honestly I am at the other end of the spectrum. I am small 5'6 and 120lbs. I can not gain weight. Even with increased calories and protein drinks (ensure high cal) I hover. I get weird looks because I'm bony. My doc lectures me about my intake. Truth be told that doesn't help at all. I would guess that it's the same for those on the other end.

In my work experience I have had some clients who were much larger than me. I don't think I ever made their weight an issue except when I physically could not lift/roll/assist without putting us both at risk. In that case it was as simple as letting the client know "I'm going to need your help"

I worked with geriatric clients and those who are carrying extra weight need MORE caring and MORE empathy. Not only are they hurt, weak or ill, they also have many more places which they can not access that can break down. If it's a problem just ask yourself how would I behave if this were my mother or father?

It is not ok to tear someone else down no matter what your reason is.

[CrunchRN, ADN, RN]

Honestly I am at the other end of the spectrum. I am small 5'6 and 120lbs. I can not gain weight. Even with increased calories and protein drinks (ensure high cal) I hover. I get weird looks because I'm bony. My doc lectures me about my intake. Truth be told that doesn't help at all. I would guess that it's the same for those on the other end.

In my work experience I have had some clients who were much larger than me. I don't think I ever made their weight an issue except when I physically could not lift/roll/assist without putting us both at risk. In that case it was as simple as letting the client know "I'm going to need your help"

I worked with geriatric clients and those who are carrying extra weight need MORE caring and MORE empathy. Not only are they hurt, weak or ill, they also have many more places which they can not access that can break down. If it's a problem just ask yourself how would I behave if this were my mother or father?

It is not ok to tear someone else down no matter what your reason is.

Love this!

[BuckyBadgerRN, ASN, RN]

My level of care does not change based on the size of a client. BUT, my empathy level does when an obese resident in my facility does NOTHING to help himself. Non-compliant with medications, non-compliant with the special diet that he requested to be on. Refuses to do the minimal exercises that therapy has instructed him on. Dictates his own personal cares and treatments to areas of skin breakdown. Because, you know, its his RIGHT to do so. He will make demands as far as which staff is "allowed" to be in his room (for ANYTHIHG: meal delivery, cares, toileting, passing linens/waters) and then gets furious when he has to wait for his call light to be answered because his favorites are completing other tasks.

All at the courtesy of Medicaid, BTW.

[JasBSN]

My level of care does not change based on the size of a client. BUT, my empathy level does when an obese resident in my facility does NOTHING to help himself. Non-compliant with medications, non-compliant with the special diet that he requested to be on. Refuses to do the minimal exercises that therapy has instructed him on. Dictates his own personal cares and treatments to areas of skin breakdown. Because, you know, its his RIGHT to do so. He will make demands as far as which staff is "allowed" to be in his room (for ANYTHIHG: meal delivery, cares, toileting, passing linens/waters) and then gets furious when he has to wait for his call light to be answered because his favorites are completing other tasks.

All at the courtesy of Medicaid, BTW.

Do we work at the same place? You just described one of my residents perfectly! No one has an issue with his weight. We are lucky enough to usually have the necessary staff available, and since we are a no lift facility we have plenty of mechanical lifts around that are a godsend. What we have issues with his attitude!

[CrunchRN, ADN, RN]

I don't think anyone could fault you for complaining about that particular type of patient. obese or not.