morbidly obese patients

[blackribbon]

I have been a nurse for almost a year and currently work on a women's gyn and med/surg floor at a major hospital. The last few weeks I have been assigned a couple patients who are very morbidly obese. I am working very hard at maintaining compassion for this special patient population but am already finding it frustrating. I am not a tiny person myself but am trying to find information on how a person becomes this obese. It seems like if eating was the only cause, the condition would be somewhat self limiting...if you can't walk to the kitchen or drive a car, then it would seem your calorie consumption should decrease and you would at least stop gaining weight. So what other metabolic situations are at play...or is it more a psychiatric eating disorder?

It may have just been these two patients but they seemed to believe the nursing staff was there to be their personal assistants for everything...I am not sure how they managed to readjust themselves in bed at home if they need constant help when in our specialized bariatric beds. One patient kept risking falling out of bed because she always wanted to be somewhere else...her biggest goal was a tiny chair that she never would have fit in. She didn't understand that couldn't just help her into the chair myself...that I needed help...and if she had managed to get in that chair, she didn't have the strength to stand up and get herself out. I finally got a hoyer lift so I could move her alone and she kept ignoring me and crawling out of the sling that we needed to leave under her so that we could lift her as needed. The minute she wiggled to somewhere else on the bed, she eliminated my ability to help her alone.

I also have a problem with these patients being considered "one" on our patient load...to care for a severely obese patient takes the time of caring for at least two regular patients. Just assessing skin takes a long time and these patients usually have a lot of skin care needs. I had a confrontational patient last night (I wouldn't assist her to the little wooden chair that she was so obsessed by) so I didn't have time to clean the skin folds and change the dry flo sheets like I should have...and she was pissed so she wouldn't let me assess her coccyx pressure ulcer.

Another patient told me about something she wanted to do at home but her husband told her if she sat on the floor, they would never get her up. Her "solution" was that they would call the EMTs because they would lift her. I am working hard to not let that entitled mentality to not harden my heart against her because I have been told she is a frequent visitor to our unit. She was also a very informed patient which I admire but at the same time, I think being a medical patient has almost become her "career". She like to come to the hospital. She has "isolation history" so always gets a nice private room...and the nursing staff means guaranteed "visitors" and a social circle.

Does anyone have any resources that they can suggest so that I can read to understand this special patient population better. I hope to not become hardened to their plight because I know it can't be easy...but every thing I have found so far concerning the morbidly obese focuses on those doing bariatric surgery and not just general medical patient needs. My heart bleeds for the one woman who started to freak out as she realized that this time her cellulitis and vascular problems were not probably going to heal all the way and she may be facing permanent damage (related to a crushed vascular system) and she was still relatively young.

I am also interested in info on just general care of the very obese...like trying to place a foley or dealing with stools that are so large they clogged the plumbing if you try to empty the bedside commode in there.

Before anyone criticizes me and my attitude, I am just being honest about the conflicted feelings I am having. I never gave subpar treatment. I always smiled when I went into their rooms. And concerning the obnoxious pt, I know she was just a difficult person and her weight issues just complicated it. I even did most of my charting in her room so I could allow her the freedom to sit on the side of her bed and at least watch her for safety (she was going to sit on the side of the bed with or without me but at least when I was aware, I could get her a foot stool so she didn't slide out onto the floor and I could lift her legs back in when she got tired. It was a safety risk but I couldn't legally force her to stay in the bed either. I really do want to be an advocate to all my patients regardless of their personal lives. I may have just been a bit mentally worn out by another patient earlier this week who was attempting to get her narcotic addiction needs met by our hospital...but that is a different story.

[thenightnurse456]

Oh how I do not miss med surg. Your post brings back horrible memories!

[ixchel]

PCOS and hypothyroid can contribute. Metabolic disorder.

I can feel your strong level of repulsion through your post. Please be careful with this when you're with the patient. I believe you when you say you are good to your patients. I believe very much that you do try hard to remain compassionate. Even just your "vibe" in the patient's presence can reveal that repulsion, though. As hard as it is to care for her (them), even the one who behaved with entitlement - underneath her deflection is probably humiliation. I've come to the conclusion that there must be underlying mental illness to allow it to become so severe. They know what they look like. They know how they smell. They know what judgments you have. They know it more than you do, probably.

The physical aspects of patient care, as you noted, are complicated. Absolutely everything you do should be done with help. They likely have special beds, right? These will be helpful for preserving skin. Be sure to engage in frequent and thorough skin assessment/care. Nystatin will be your BFF. Make sure you call pharmacy and let them know that you'll need multiple of it because of the patient size. Massage will increase/improve lymph flow and drainage, which these ladies desperately need. Be present for bed baths because interventions for skin care that are outside CNA's scope will always be necessary and clustering as much as possible will save you time, will save them from humiliation, and will decrease their overall discomfort.

Beg the MD if you have to for a foley. Skin issues and prolonged immobility, in addition to strict I&Os should qualify her. This foley will save you from the pain and her from the humiliation of using a bedpan. Insertion of the foley will not be a dignified experience. It is vital that you, and all those helping, treat this woman with total respect and dignity. Keep her talking about unimportant things to ease her mind, and frequently assess her comfort.

Recruit every helper available. You will need at least one person to stand with each leg, assisting her to prop them up (think gyn stirrups here). Use the widest tape on your unit to help lift/splint her belly. If you've ever seen bariatric surgery, you may have seen this done before. You essentially splint the porifice with the tape, attaching the ends of the tape to the bed rails, lifting her belly off her pelvis. Have 1-2 people available to ensure this stays secure as you work.

Use a bright flash light to see your working space better. Don clean gloves and assess for the urethra. If you need another person to hold the labia back, this is the time to determine that. Once you know you can safely work while preserving a sterile work space and urethra, the rest is just like normal foley insertion. The only time I've needed to be the one inserting the foley on a morbidly obese female, I needed to actually get up on her bed so that I could see and reach better. I am a very small person, though, so for me, it made sense to do it this way. This is honestly not going to be comfortable for anyone in the room; least of all the patient. Consider wearing contact gowns to protect your scrubs. No sense in getting stained with iodine.urethrabetter.

[ixchel]

It seems I'm completely unable to get the words "urethra.better" off the end of that post. Grrrrr I wish they'd fix the words disappearing off the bottom of the app issue.

[TheCommuter, BSN, RN]

Overeating frequently has an emotional component attached. Overeating can be used as a self-destructive technique of numbing emotional pain for some people, similar to the way many people turn to heroin or other drugs to soothe emotional pain.

Also, people who experienced certain childhood traumas (abuse, parental domestic violence, parental alcoholism, etc) are at risk of becoming obese adults: Adult Obesity Linked with Traumatic Childhood Experiences - TIME

So although the obese person knows he is eating himself to death, the highly palatable large pizza and dozen of chicken wings distracts him from the psychological pains of his past (his former spouse, his abusive parents, etc).

Obesity is a complex issue with no simple solution.

[blackribbon]

I think my frustration with this situation comes across as repulsion. Maybe it is a bit related to being verbally abused and shouted at for two nights straight by the last patient. Like I said, i realize that this is not a weight issue but it sure complicated my ability to care for her. Trust me, I feel nothing but compassion but don't know how to help and am constantly being surprised by things nobody covered in nursing school (ie, the sheer quantity of stool). I am searching for information on how to be a better nurse for these patients...doesn't that say something.

I don't know where you work that you can find that many assistants to do normal daily care and to get nystatin requires a doctor's order...being night shift, I put in the request and only hope it gets filled during the day shift hours unless it is a severe condition that needs immediate intervention. I only have the amount of time that i have for my other patients...I wish I could make the time suddenly increase but I can't. I even stayed over the last night to assist the next shift's nurse tech to move the patient after she refused to move when I could have found help on my shift (she picked shift change to insist that she needed to be moved again). I gave up my lunch break both days to make more time...but I can't do that very often if I don't want to burn completely out. I was also caring for a dying woman who was in the process of being transferred to hospice care. A very young woman who was dealing with severe congential birth defects and had spent the last two weeks of her senior year of high school on our floor while they were trying to decide how to proceed. And another patient decided to have an allergic reaction to yet another antibiotic on my shift. And I was given two new admissions. One was very lonely and hadn't been in a hospital for 10 years in spite of a severe medical condition, and the other was upset that she didn't get a private room this visit (chronic condition that brought her back often). The charge nurse apologized as she gave me the last admit but she was already caring for as many patients as I was on top of being charge. I was the only one left to assign the last admit too. It was the weekend from hell.

Maybe I can request the nurse manager compile a list of bariatric related supplies that we can request since we don't stock them on our floor. I was amazed when I realized that there were specialty bedpans and special bedside commode available. I would never have known to even ask for them and would have struggled with trying to make what we have work.

I really do want to understand what causes this condition because I don't believe the answer is simply to "eat less"....but I don't understand the dynamics. I don't want to see these women die young. And my heart goes out to people who are completely crippled by their weight.

[FolksBtrippin, BSN, RN]

For what it's worth, I see your compassion and it's stronger than your revulsion.

[ixchel]

Big hugs to you, love. It sounds to me like it's been a terrible patient load for you. My one large lady with the foley start.... She had me baffled as well. I just couldn't wrap my mind around her story at all. She hurt her back before her one and only pregnancy, and she just never tried to get better.

Now, at something like 600 lbs, she doesn't try to do anything for herself. She's still married to a man who weighs her food. WEIGHS IT. They have a little scale in the kitchen and he puts every portion on it. Her now adult child skipped town. She was admitted for some kind of GI bleed, but this massive person had a HR in the 40s. Very mild Circumoral cyanosis. Alert, oriented. If you were to speak with her on the phone, you would have absolutely no idea that she was in the shape she is in. It was just bazaar. No other word for it. Then my third night with her, she flipped into afib in the 140s. I had literally just received a sepsis patient who was circling the drain. I was pretty fresh off orientation, it was my first night ever having one extra patient, and the only shift I've ever had with two people crashing at the same time as each other. It was quite a night.

Do you have a night shift MD for her? We use hospitalists and we have a pharmacist on the grounds 24/7. Makes it easier to get those less urgent med orders that day shift may not think of or get time to ask for. I'm on an ICU step down with a 4:1 ratio. 20 patients, so we'll have 2 techs, charge, and then 5 floor nurses. We waited until after our 2200 med passes and vitals were all done. We left one nurse to "man" the call bell, and all of the rest of us got the job done on that foley. So glad to work on a unit that does value working together!

My theory in life is you can wait for opportunities to get things done, or you can MAKE opportunities. I'm not good at waiting for anything!

[ixchel]

For what it's worth, I see your compassion and it's stronger than your revulsion.

^^^ this, too. I especially see it all over your response to my comment. We can save our patients from so much, but not from themselves. (((Hugs))) I can tell you are a very compassionate and caring person, and I apologize if my comment regarding repulsion was harsh.

[blackribbon]

We tend to be a 1:6 ratio on the night shift by the end of the shift. This was a Friday and Saturday night and my experience has been that Friday nights tend to be lighter nights so the staff we had that first night should have been enough but instead we were almost a full house. Our charge nurse usually only carries 2-3 patients so she can be available to jump in when needed...but she had 5 both nights. We had 4 techs but one had to sit with a patient the first night...the 4th was a salvation the second night because she did all the new admits. I know I had 2 new new admits and she had at least 3 in between those and one before. I could find people if needed for something like a foley but that would leave the rest of the floor with very little nursing coverage especially if one nurse and one tech were on lunch break so I couldn't do that very often. I believe the problem is that our very large hospital (1070 pt beds) has been almost full the entire time I have been working there and we get the overflow of the specialty floors when they don't have a bed available. I believe the hospital census was at 1016 that night and I know at least 15 of the empty beds were in our next pod which only takes postpartum patients (we overflow clean gyn patients into that pod but we staff the overflow rooms). My dying patient should have been triaged straight to the hospice floor...her family was open to it from day one and she was very frail. I thought the severely overweight went to the bariatric floor but I need to check and see if they only do patients getting weight reduction surgeries and related cases. I really don't know what they do. Either way, I suspect both floors were full. The hardest part about our floor is that we get everything...so almost every shift I see something I have never had to take care of before. Walking into each room for the first time is a crap shoot.

Our gyn patients have residents that are available 24 hours. Many of our other patients have private doctors and I am either contacting a night service or directly paging the doctor on the night shift. I have learned it is often hard enough to get desperate needs like pain management met that I don't have the time to hunt down a doctor for a minor condition on the night shift. It is faster to just make a note and hand it off to the day shift that actually sees doctors. For a change of condition, we just call a rapid response. I was told after the fact that my patient's behavior might have warranted a rapid response to get a sedative prescribed...but since not even the night charge suggested it, I am not convinced. I will send a message to the manager and ask.

OT gave up on my patient...she wouldn't learn or participate...I don't know how long she had been that obese since she was an amazing 77 years old but she wasn't making any friends on my floor. You should have seen the faces fall when they found out that Room XX was theirs. I kept her for both my nights. I figured I already knew her and there was no need to dump her on someone else. If I had a third night, I would have had to pass her to someone else though. It takes a lot to make me cry but she said things that made he have to take a short break to gather myself back up. I have never had to do that on the floor except when I was new and going through some sort of secret staff hazing (let's overload the new nurse with the worse cases an see if she breaks down).

[Mavrick, BSN, RN]

If you were to speak with her on the phone, you would have absolutely no idea that she was in the shape she is in. It was just bazaar. No other word for it.

May I suggest "bizarre" as another word.

If I didn't enjoy your posts so much I would have just clicked "like" but I have my own compulsions to deal with.

[Mavrick, BSN, RN]

Good on you OP for your strength and compassion to these special patients. Obviously when they hit the 600 lb level it takes plenty of assistance from the manipulated family to keep those calories coming. There is a whole system of illness/manipulation/enabling that one little nurse cannot cope with alone. I agree these people are enough work to count as two patients for assignment purposes.