morbidly obese patients

blackribbon · Jun 14, 2015

Patients who don't seem to care about their health is another complication. If there are any psych nurses reading my nonsense, I would love suggestions on how to approach the problem of preparing a patient for discharge when possible underlying psychiatric issues are present. Sadly, I see some patients' faces entirely too much for the same or similar reasons--specifically, substance abuse, depression, and obesity. Had anyone had success with programs that incorporate behavioral therapy alongside medical therapy post-discharge? I just feel like the current "patch the hole" take on patient care isn't enough. I would greatly like to utilize such a program at my new place of employment.

I am also a contingent psych nurse and I get so frustrated by the attitude on the medical floor by the nurses who "don't do psych diagnoses"? In my mind, that is like saying the patient is here for COPD so I "dont' do diabetes diagnoses". How do you separate them out? When I see a diagnosis for anxiety or depression or bipolar or schizophrenia...that makes the top of my "significant history list". I know that seeing "anxiety" or "panic attacks" means I am going to have to spend a little bit extra time helping this patient reduce their anxiety...it may be explaining what to expect when they are sent down for an ultrasound...or saving a xanax for bedtime...or holding their hand while another nurse puts in an IV or lab does a blood draw. In the hospital, we are compounding their psych diagnoses with stress and removing their normal coping rituals...which can be a simple as taking a hot shower (try to do that in a hurry in the hospital with an IV) or even just petting their cat.

I look forward to the day when the medical side recognizes that psych issues are simply another organ that is not functioning as it is supposed to and something that is treatable even if it isn't curable. They often are not "non-compliant" or "difficult" so much as their disease or disorder actually is expressing symptoms. For me, the jury is still out if my last patient was just mean and self-centered (quite possible) or if she was suffering from such severe anxiety related to her COPD issues being complicated by her obesity that she really couldn't think straight and was living in a constant state of panic. This all was complicated by my inability to meet her needs because of my limited time and manpower issues.

SubSippi · Jun 14, 2015

I am also a contingent psych nurse and I get so frustrated by the attitude on the medical floor by the nurses who "don't do psych diagnoses"? In my mind, that is like saying the patient is here for COPD so I "dont' do diabetes diagnoses". How do you separate them out? When I see a diagnosis for anxiety or depression or bipolar or schizophrenia...that makes the top of my "significant history list". I know that seeing "anxiety" or "panic attacks" means I am going to have to spend a little bit extra time helping this patient reduce their anxiety...it may be explaining what to expect when they are sent down for an ultrasound...or saving a xanax for bedtime...or holding their hand while another nurse puts in an IV or lab does a blood draw. In the hospital, we are compounding their psych diagnoses with stress and removing their normal coping rituals...which can be a simple as taking a hot shower (try to do that in a hurry in the hospital with an IV) or even just petting their cat.
I look forward to the day when the medical side recognizes that psych issues are simply another organ that is not functioning as it is supposed to and something that is treatable even if it isn't curable. They often are not "non-compliant" or "difficult" so much as their disease or disorder actually is expressing symptoms. For me, the jury is still out if my last patient was just mean and self-centered (quite possible) or if she was suffering from such severe anxiety related to her COPD issues being complicated by her obesity that she really couldn't think straight and was living in a constant state of panic. This all was complicated by my inability to meet her needs because of my limited time and manpower issues.

It's not so much that we don't "do" them, it's that these patients can be much more difficult to deal with. Definitely not always, some are reasonable people who happen to have a psych diagnosis. A little extra hand-holding or explaining is fine, that's why I'm here. It just gets hard to remain compassionate when a patient who is really only still in the hospital because we are working on placing them takes up 75% of your time. The other patients are the ones who lose in the end, I still have to be there for 12 hours regardless.

I don't deal with this too often where I'm at now, but when I worked tele, it was CONSTANT. It gets touch.

I hate to say it, but it would take all of my concentration and energy to keep being nice when it was both an emotional and a physical challenge to take care of someone!

canigraduate · Jun 14, 2015

I'm fat now, and I wasn't two years ago.

In my case, it's a psych issue and an emotional problem. I eat when I'm stressed, upset, or emotional. I eat when I am depressed or anxious.

I eat when I'm happy, I eat when I'm sad, I eat when I don't physically feel well. I eat to calm myself down, to psych myself up. In my mind, food is safer than drugs (legal or not).

Over the last two years, my mom's breast cancer came back, she became homeless, had to fight to get on disability, had brain surgery, had chemo, and ultimately died from secondary complications from pneumonia. She was my best friend and I tried to support her emotionally and financially throughout all of this. My grieving process has been complicated by guilt and shame because I didn't help her enough and I'm pretty sure if I had been more aggressive she would still be alive.

My husband had a lot of problems at work and we had to transfer to another city to get away from a boss that was bullying him. The new boss was much better, but the work situation was much worse, so he ended up transferring to another department in another state. He is really good at his job and has been promoted twice since then, each time with another move to another state. So, four moves since Sept '13.

During all this, my ADHD has been managed inappropriately because each new provider thinks it's a different type and is comorbid with something different each time. I have been on stimulants, antipsychotics, anxiolytics, and antidepressants. I also have gained eighty pounds. Now I have sleep apnea, GERD, minor heart failure, yadda, yadda, yadda. Each new treatment ends up gaining me pounds and another physical ailment. I have also changed jobs a ridiculous number of times, and each time I have been faced with the anxiety of not being well enough to perform my job. I have done agency work and been thrown in the deep end on unfamiliar units with whacked out assignments more times than I could relate. I tried teaching clinicals, and had to deal with a bunch of really bad students with entitled attitudes. To cope, I ate. The sugar and dopamine highs I got from a comfort meal binge have trained me to keep doing the same thing.

I swim, I run, I work out. Some. Probably not as much as I should. They say exercise makes you feel better and I keep trying.

My husband is not a health nut and is obese himself. Whenever we try to eat better, we sabotage ourselves or each other, thinking one pizza or one burger won't hurt (this week). We both come from cultures that celebrate food.

I am not making excuses. I know I can do better. I just wanted to let you know that obese people do not exist in a vacuum and just decide to get fat. Sometimes it is a part of the culture, sometimes it is psych, sometimes it is a crappy run in life and food is the most attractive way to deal with it.

ixchel · Jun 14, 2015

I reached a limit this week. A morbidly obese patient with a ton of psychosocial issues who was incredibly non-compliant and dealing with an injury to his limb secondary to lymphedema. Did I leave out that he's only in his 50s? The only thing I could see which might contribute to his obesity initially was hypothyroid. Otherwise, his health issues were secondary to weight.

I was soft, gentle, nice nurse. I did everything for him that he requested, because I genuinely subscribe to the notion that until I've lived it, I'll try like hell to not judge it. But then after meeting his home health aid and learning from PT (this guy has been a frequent flyer for the better part of a decade) that he's one of those people who walks everywhere and is way more capable of doing things than he lets on.... I hit a proverbial wall. This apparently walkie/talkie person killed my back soaking up the extra attention he was getting.

What I don't understand.... If he loves the extra attention and doting, why not be compliant with lymphedema visits? Get the extra attention. I guess maybe a decrease in health status means loss of his aid???? I don't know. After learning this stuff about him, I made him be more functional. I wasn't going to tuck him in and hold his straw anymore. (I wish that was all he expected.) Once he realized I was done doting on him, he got pouty and quiet the rest of the day, making me have to repeat simple things over and over as though he didn't understand the first time. (There was no deficit in understanding anything before that point.)

The worst part of it all was late in my last shift with him, I absolutely had to change that bandage on him. This was not our first rodeo, not even on that day. But suddenly he couldn't lay on his side for me to get to it. This sucker was putting out enough drainage to soak through 2 ABD pads in only a few hours, and the smell resembled rotting meat. I explained to him that if we didn't get control of this wound, he was going to lose the leg. I certainly wasn't the first to say it, either. But even still, would not do a thing to help me turn him. I know he was able because he'd done it before, but he pretended he couldn't.

I was (and still am) angry at this man for wasting my time, expecting me to do unneeded heavy lifting (look, I'm 5'2", 115-120 lbs), playing this helpless soul when in fact he had far more ability to function than he let on. There HAS to be something not right emotionally, psychologically to allow that kind of physical growth and deterioration to occur. This man is why these terrible stereotypes exist. I'm mad at him for contributing to them. I'm mad at me for being suckered in (my back still hurts!), I'm also mad at me for feeling repulsion by him because I thought I was better than that, and really, I'm once again finding my Pollyanna self being surprised by the way people can behave.

Anyway, please forgive that rant. Felt good to let go of it.

On another related story, I have an ex friend who got bariatric surgery. It was incredibly successful for her. Very proud of her progress and commitment to success. That is, until her husband deployed and she started bar hopping to pick up men. She posted often on social media of the guys she was meeting. She kept bragging to me of her sexual conquests. It made me so sad for her husband. They had their problems on occasion, but ultimately he was the best kind of man. Always put her first, helped take care of her and her daughters (from a prior relationship) like they were his own. He was so good to her. I finally gathered the courage to ask her what was going on, or if maybe she was going through something I didn't understand or know about. Turns out that since she's hot now, she doesn't need him. She can do better then him. *sigh* She left him while he was deployed. Hopefully he's realized he can do so much better than her.

Red Kryptonite · Jun 15, 2015

Turns out that since she's hot now, she doesn't need him. She can do better then him. *sigh* She left him while he was deployed. Hopefully he's realized he can do so much better than her.

Jesus. As the wife of a veteran, who deployed overseas without me twice, that kind of b**** was unfortunately common. I always wanted to find them and beat their asses. How dare you do that to a man while he's in harm's way? Please tell me they don't have kids.

I hate people. There are several important exceptions, but in general, I hate people. :mad:

ajohn2015 · Jun 15, 2015

As a CNA in a SNF, I cared for an obese woman who got more care out of me than any other patient got from any staff in that facility. She refused to sit on the shower chair for a proper shower, so I had to manage washing her hair with shampoo and conditioner in bed which was a nightmare. Would refuse to get out of bed with assistance and demanded the hoyer lift which forced me to find help, impossible on day shift, and then grab her as she was being lowered into her giant wheelchair which would then smash my arms and break off all my (natural) nails. My arms were always sore and bruised. Then she would demand to go back to bed immediately after I returned from lunch break even though residents lunch was on it's way, which would of course involve an incontinence change and would cause me to be late for tray pass and coworkers always pissed at me for being late (she would cry if forced to stay up through lunch). Oh and for the giant BMs..... it was like she was delivering a baby every time, my god! Nothing could have prepared me for that. I found it was best to try and bag it rather than ruin the plumbing. I also found out that she was lying to me and the other staff about being married, having sons, and generally having a happy normal life. What I learned from this particular patient is that morbid obesity is a disease that comes with its own set of symptoms; selfishness, victimization, false realities and many other things that are just too strange to name. They don't get that big over night, it takes years of self destructive behavior which leads to a very damaged personality.

blackribbon · Jun 26, 2015

I had another one this week. The patient everyone gives up after one night. I volunteered to keep her both my nights since I already knew her and where all her "wounds" were and her odd way of getting in and out of bed (put your hand on my toe and heel and lift...DAMN, don't bend my knee!) She had told the new nurse on the floor that it was a nurse's job to rub her back ... for 30 minutes. I threw away a whole handful of meds because she wouldn't stop talking when I was opening them (I usually announce each pill before I open it) and then when given the pill cup, she made me identify each pill while she refused half of the meds in there "because she didn't need them". I didn't pass her pills until almost midnight because she "had to eat before taking her meds" and her tray sat in front of her untouched from 6pm to after 11pm. The med schedule was so messed up that we just handed off .... to look at the actual timing before giving a med because it was impossible to keep retiming everything she wanted later. The second day, she was pissed that I didn't bring her meds before 8pm...when actually, I did stick my head in her room and ask if she was "ready" or should I come back "later"...she said "after my son comes" - and he came at 10pm. The highlight was listening to her refuse her statin because she was going to control her cholesterol with her diet...as she ate fried chicken out a kentucky fried chicken box that her son and brought her (her second dinner of the night). She refuse to allow us to use the hospital glucometer but wouldn't test herself with her own...she wanted the tech to use it (and I was told it was dangerous looking). She refused dialysis and to talk to the nephrologist because she "didn't have a problem with her kidneys"....never mind her legs were now 3+ w/edema, her skin itched all over (put some more of that benedryl cream on my back please), and her BUN was 111. But she wasn't going to have us "experiment on her", we just needed to get the fluid out of her legs! (I did have a sit down talk with her about why her legs were so swollen and how dialysis would help resolve that....and at 11pm at night she said she might actually be willing to talk to the nephrologist after all...but only if I told her who was the best one we had...???....I documented this conversation but don't know if she was still willing come morning (minus needing THE BEST comments.)

I want to be sympathetic but I almost feel like I am enabling some of the patients who seem to use their weight to get extra attention while denying the consequences of their choices....pouting if I have to go take care of my "dying patient" or the woman who just miscarried because they have to sit in the chair longer than they want to.

TheCommuter, BSN, RN · Jun 26, 2015

This latest patient sounded manipulative. If I were her nurse, I would have laid down some rigid boundaries and not permitted her to fritter away my limited time. I suspect she knew what she was doing and perhaps did it on purpose.

I had another one this week. The patient everyone gives up after one night. I volunteered to keep her both my nights since I already knew her and where all her "wounds" were and her odd way of getting in and out of bed (put your hand on my toe and heel and lift...DAMN, don't bend my knee!) She had told the new nurse on the floor that it was a nurse's job to rub her back ... for 30 minutes. I threw away a whole handful of meds because she wouldn't stop talking when I was opening them (I usually announce each pill before I open it) and then when given the pill cup, she made me identify each pill while she refused half of the meds in there "because she didn't need them". I didn't pass her pills until almost midnight because she "had to eat before taking her meds" and her tray sat in front of her untouched from 6pm to after 11pm. The med schedule was so messed up that we just handed off .... to look at the actual timing before giving a med because it was impossible to keep retiming everything she wanted later. The second day, she was pissed that I didn't bring her meds before 8pm...when actually, I did stick my head in her room and ask if she was "ready" or should I come back "later"...she said "after my son comes" - and he came at 10pm. The highlight was listening to her refuse her statin because she was going to control her cholesterol with her diet...as she ate fried chicken out a kentucky fried chicken box that her son and brought her (her second dinner of the night). She refuse to allow us to use the hospital glucometer but wouldn't test herself with her own...she wanted the tech to use it (and I was told it was dangerous looking). She refused dialysis and to talk to the nephrologist because she "didn't have a problem with her kidneys"....never mind her legs were now 3+ w/edema, her skin itched all over (put some more of that benedryl cream on my back please), and her BUN was 111. But she wasn't going to have us "experiment on her", we just needed to get the fluid out of her legs! (I did have a sit down talk with her about why her legs were so swollen and how dialysis would help resolve that....and at 11pm at night she said she might actually be willing to talk to the nephrologist after all...but only if I told her who was the best one we had...???....I documented this conversation but don't know if she was still willing come morning (minus needing THE BEST comments.)
I want to be sympathetic but I almost feel like I am enabling some of the patients who seem to use their weight to get extra attention while denying the consequences of their choices....pouting if I have to go take care of my "dying patient" or the woman who just miscarried because they have to sit in the chair longer than they want to.

blackribbon · Jul 31, 2015

She was lonely and had significant medical issues (I have no doubt she is in the early stages of dying). I don't know that I consider it "manipulating" so much as being legitimately needy. Time and sympathy are also elements of caring for a patient. The problem is that we don't always have much to offer.

Here.I.Stand, BSN, RN · Aug 2, 2015

Hugs!! For what it's worth, I didn't sense revulsion in your post; I sensed frustration and a true desire to provide the best care for these women. That was confirmed by your response here.

I really do want to understand what causes this condition because I don't believe the answer is simply to "eat less"

This issue is multifactorial. You're right that it's not a matter of just eating less. As PPs pointed out, it's a coping mechanism for people, oftentimes in response to childhood trauma. I haven't read a lot of research on it, but anecdotally I've heard some molestaion victims say that they believed that somehow if they were less attractive, their abuser would lose interest in them.

Their is an addiction component; eating generally us pleasurable. You've heard the phrase "comfort food," right? It usually refers to foods that feel indulgent and nostalgic, e.g. in America a gooey homemade mac'n'cheese, pot pie, bread pudding. These foods also happen to be high in carbs and fat. So anyway, we eat delicious foods, and our brain responds. It's similar to our (general) physiological/psychological response to sex, opioids, etc.

Genetics plays a role. Have you heard of Prader Willi Syndrome? It's a genetic condition that causes a complete lack of satiety, along with a degree of MR and social/emotional immaturity. These people are always hungry because they physiologically cannot feel full. If it is possible to be born this way, perhaps others are born with impaired satiety to a lesser degree?

Some people have slower metabolism than others. I can (and have) gone weeks with eating whatever the heck I want -- mac'n'cheese with bacon and a salad with croutons and creamy dressing for dinner and leftover pizza for a bedtime snack, munch on candy throughout the day, hit Starbucks every day...you get the idea. I'll put on maybe 10 lbs, and then lose it when I discipline myself again. Others will put on 10 lbs even with healthy eating -- but no exercise.

And then metabolism can get into a vicious cycle -- the heavier a person gets, the harder activity becomes. Less activity --> slower metabolism --> faster wt gain --> less activity......

And then, we're looking at some serious enabling and codependency issues. Watch any episode of shows like "My 600 Pound Life," and you'll see what I mean. 20 yr old son is too obese to get out of bed much less drive, but Mama will go to BK for him and order a couple supersized Whopper combos with an extra side of onion rings, large milk shake, and one of each pie on the dessert menu.

I'm sure this is where the entitlement comes in; someone who has her family at her beck and call has become accustomed.

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.

Fantastic idea! Good for you, taking the initiative for procuring needed resources! I'm all about working smarter, not harder. Your idea is a perfect example of working smarter. It will benefit all involved -- pts and staff.

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..........description of your beyond-challenging shift truncated for ease of reading

Wow. That's enough to stress out the best of us. You sound like a really good nurse to me -- you truly desire and bust your tail to provide the best nursing care possible. Some of these things take teamwork -- there is no getting around that. I have a friend who works L&D and has very morbidly obese pts sometimes. She says Foley placement always requires extra help because it is simply impossible to maintain sterile technique for a woman that big.

Bariatric chairs are a necessity. Pts need to get OOB; even in the ICU where I am, unless contraindicated the goal is OOB TID. That said, if the pt won't hold still in the Hoyer, she cannot be in it. 9.81 m/s2 times 400 lbs is going to be one dangerous fall!! Actually one of my first patients I cared for on orientation on my current job, was an elderly lady who fell from a Hoyer and hit her head on a piece of furniture on her way down. She died after a week in the ICU. We both would hate that for your patient, and I would really hate for you to live with that memory.

Entitled beliefs or no, you need to be kind but matter-of-fact that you will need help. You don't owe her an explanation, nor do you need permission from the pt; just say "Let me grab some extra hands, and we'll be glad to help you." And then exit to find help. If she persists in the "no, just help me now," there is no need to bring up her size. Just tell her that we all need to be safe, especially her.

Here.I.Stand, BSN, RN · Aug 2, 2015

I was administered massive doses of Solu-Medrol (prednisone to reverse the effects of the status asthmaticus. I got enormously heavy from the injections, and even suffered steroid induced myopathy

Corticoteroids -- a factor I left out! A well-loved AN moderator has discussed the effects of need for large, long-term doses of prednisone on her body...it's heartbreaking. One of her posts literally had me in tears a while back. Thank you for sharing, Fran.

I was pondering how someone makes it to 77 with these kind of weight issues

Some people are like that. I had a great-aunt who was probably 300 lbs and had CHF, and died at age 96. My husband's grandpa also lived into his 90s smoking 3 packs/day and driving a motorcycle.

adding quote--
This latest patient sounded manipulative. If I were her nurse, I would have laid down some rigid boundaries and not permitted her to fritter away my limited time. I suspect she knew what she was doing and perhaps did it on purpose.
She was lonely and had significant medical issues (I have no doubt she is in the early stages of dying). I don't know that I consider it "manipulating" so much as being legitimately needy. Time and sympathy are also elements of caring for a patient. The problem is that we don't always have much to offer.

I hear you, but regardless if needy vs. manipulative, you still need to set boundaries. Pouting is her choice; you cannot neglect your other pts' needs for prompt meal service (if you are to help with tray pass), incontinence care, and perinatal bereavement, just because this pt chose to pout.

I'll usually tell someone who wants to get back in bed very soon after getting OOB that s/he needs to stay in the chair at least one hour, so we will help them at such-and-such time. Then right away, find the CNA/fellow RN and make a plan for said time.

blackribbon · Aug 2, 2015

I think you and I agree on this thing. I did set boundaries but I put her last so I could address more of her "needs". The charge nurse would help me ... we went in as a group and dressed her wounds as a team while the NA took vitals. When I went in alone, it was after everyone else was cared for.