Nutritional diseases

Bariatric Care

The field of medicine that offers treatment for the person who is overweight with a comprehensive program including: Diet and nutrition Exercise Behavior modification Lifestyle changes When indicated, the prescription of appetite

suppressants and other appropriate medications. Bariatric also includes research into

overweight, its causes, prevention, and treatment.

Weight Loss Surgery

Bariatric Procedures Gastric Sleeve procedure Roux-en-Y procedure Gastric banding

Gastric Sleeve Surgery / Roux-en-Y

Surgical Procedures

Risk factors for ICU admission after Bariatric Surgery

Male sex Age of 50 yearsBMI of 60 or greaterDiabetes mellitusCardiovascular diseaseObstructive sleep apnea syndromeVenous stasisIntraoperative complications

Medical & Surgical Management

PT Considerations Mobility Status & Complication Prevention

Pre-op mobility status is baseline Assess this well! Most of these patients will know their own ability. Get up from side because of cut abdominals.

Mobility will most likely improve w/wt loss Target weight changes take ≥ 2 years Immediately post-op

Observe NPO status (nothing by mouth)• May take 6 weeks to return to oral ingestion of food• Moist Cotton swabs for oral hydration/comfort

Frequent complications: depression, DVT, pneumonia, heat dissipation (too

hot) No lifting/strenuous activity for 6 weeks

Medical & Surgical Management

PT Interventions Deep breathing Positioning to minimize flexed postures

(abdom) Post surgical Pain

Mobility: log rolling transfers Most able to walk pushing IV pole by p/op days

1-3 Equipment post op:

Elastic stockings/TED Abdominal Binder-on with coughing or lung

clearance. Beds, Hoyer lift, overhead trapeze, chairs,

wheelchairs OT dressing/toileting equipment

Medical & Surgical Management

Exercise Prescription: Endurance: Intensity, duration, mode, frequency

Equipment, support group, safety issues Strength

Equipment, instructions, safety Flexibility

Instructions for safe stretching

Sleep Apnea

Obesity is strongly correlated with obstructive sleep apnea syndrome

Characterized by repetitive partial or complete obstruction of the upper airway that is associated with arterial blood oxygen desaturations and arousals from sleep

A decreased respiratory rate and ultimately periods of apnea occur frequently

Resultant self-limited periods of severe hypoxiaThink of positioning…

Social Impact

“There is also a stigma associated with being obese. Society views the obese as being fat, unkempt, lacking in self-control, and socially unacceptable. This is seen in restaurants, where seating is not adequate for someone who weighs 250 pounds. The seat is too small, and the chairs are usually made to hold up to 225 pounds. It is even something that happens in the theater. The seats are small and close together, and the obese individual is viewed as being "in the way."

In the airports before getting on a plane, obese individuals know to ask for a seat belt extender. They are constantly exposed to negative public response. This leads to psychological distress and other problems with coping which ultimately lead this type of person to eat more and become even more obese.”

Mary Ann Liebert; Bariatric Nursing and Surgical Patient Care  4.2 (June 2009): p91(4). 

Respect

The key to providing quality, patient-centered, sensitive care to the bariatric patient is R-E-S-P-E-C-T:

* R: rapport * E: environment=equipment * S: safety * P: privacy * E: encouragement * C: caring=compassion * T: tact

Mary Ann Liebert; Bariatric Nursing and Surgical Patient Care 4.2 (June 2009): p91(4). 

Bariatric Care

Most of the care of the bariatric patient is based on simple movements and transfer techniques

Have different body types and need different treatment and techniques for movement

Independence should be encouraged and use of trapeze

Mobility may take longer and it is important to give the patient the time needed to be independent

Bariatric mobility

Pear shaped Gluteal/femoral region adipose tissue Often move around quite well Get from sit stand by pushing their mass over their

legs, will lean forward. Apple shaped

Abdominal/ viscera adipose tissue Sit stand is more difficult Harder condition to work with

Bariatric Care

Ambulation Wide-walker

Personal care Patient independence is a must

Pre-planning Equipment Time

Washing under skin folds And drying To prevent fungal and bacterial growth

Shower Shower chair

Commode use

Care for the Bariatric Patient

Appropriate staffing to do the care appropriately and safely

Education Patient Equipment use

Communication documentation

Maintain handling tasks in a safe and dignified manner

Equipment

BedMechanical lifts (floor vs. ceiling)Non-friction sheets & Air assistive deviceTurn & position sheets/strapsCommode & bedpanChair, wheelchair & shower chairBlood pressure cuff & abdominal bindersID wristbands, gowns, slippers & linen

Medical & Surgical Management

PT Equipment Special

Needs Chairs/toilets

Width, height, depth, load,

Shape of body

Bariatric Equipment

Obesity rates from “HealthDay News”

Mississippi, where 34.4 percent of the people are obese, has the highest obesity rate.

Other states with obesity rates above 30 percent include: Alabama, Arkansas, Kentucky, Louisiana, Michigan (30.5), Missouri, Oklahoma, South Carolina, Tennessee, Texas and West Virginia.

Thirty-eight other states have obesity rates above 25 percent.

F as in Fat: How Obesity Threatens America's Future

Healthy People 2020

US Dept Health & Human Services Initiative

1. To increase the quality of life and years of healthy living for all individuals of all ages

2. To eliminate health disparities

Goal for physical activity 30 minutes per day > 5 days per week 2010 target is 50%

Role of PT

Health promotion or preventionPrevention activities

Obesity Develop exercise/fitness programs for overweight teens

and adults Discuss the advantages of weight loss

Advantages of Weight Loss

Increased energy levelLower your cholesterol levels Reduce your blood pressure Reduced aches and painsImproved mobilityImprove your breathingHelp you sleep better and wake more restedPrevention of angina, chest pain caused by

decreased oxygen to the heartDecreases your risk of sudden death from

heart disease or strokePrevention of Type 2 diabetesImproved blood sugar levels

Issues Affecting Exercise Adherence

Good Poor

Effective leadership Poor or limited leadership

Positive reinforcement Lack of value

Part of a regular routine Inconvenient time of class or program

No injury Injury

Enjoyment – fun – variety Boredom with exercise

Social support from a group Poor individual commitment

Regular updates on progress Unaware of any progress being made

Family approval Poor family support

Obesity Treatment Model/Mgmt

Assessment of health riskAssessment of readiness

Precontemplative vs other stages…. Is the patient eligible and interested in weight

reduction?Caloric Restriction and Exercise

DVT’s

PT considerations

See handoutEarly mobilization

For increased risk For prevention

Lit Search

Ciccone, PT Jan 2002 Ambulation activities should be resumed between 48-

72 hours if no distress Progressive ambulation activities after 72 hours

Lit Search

Blumenstein, Journal of Pediatric Oncology Nursing, 2007

Fear of dislodging thrombi has prompted many physicians to go against the advise of William Dock (1940’s Physician)

Bed rest has obviously more risk concerning thrombus propagation and life threatening complications, especially in old patients, and does not prevent PE

Lit Search

Schellong, Thromb Heamost -Sept 1999Bed rest as an additional measure in the

treatment of DVT is not able to substantially reduce the incidence of PE.

The discomfort and costs associated with the prescription of bed rest in DVT are obviously inappropriate

Lit Search

Partsch, Journal of Vascular Surgery, Nov 2000Study with 3 groups 45 patients with proximal

DVT’s; all patient were on Antithrombotics A: Compression bandages and gait B: Compression stockings and gait C: Bed rest no compression

Conclusion: Patients on Antithrombotics should be encouraged to

walk and wear compression. Pain and swelling had faster resolution No increased risk of PE

Lit Search

Trujillo-Santos et al, American College of Chest Physicians, 2005

2650 patients in studyNo significant difference between

bedridden and ambulatory patients in terms of new PE events, Fatal PE or bleeding complications

Lit Search

Overall consensus of the literature is:Early ambulation and PT/OT, as tolerated,

should be encouraged once anticoagulation is instituted