The following article is written by Anne Dean, RN, BSN, LRM, CEO and co-founder of The ADA Group.
As America's waistband expands more and more, we are seeing patients who qualify for the classification of the morbidly obese being admitted to the surgery centers for their procedures. This practice will, most probably, not go away, but will become even more popular. The question emerges as to whether or not the average ambulatory surgery center is prepared to take care of such patients. From what this author has seen, unless the center performs bariatric surgery, neither the available equipment nor the staff/staffing are usually adequate to provide safe care of the patient.
In the past, leaders in the surgery centers designated a pound limit for admission to the center (e.g., patients over 350 pounds would not be admitted for procedures). This figure was primarily selected based upon the poundage limit of stretchers and OR tables. There was not, on the whole, a conversation about other equipment (exception being a lift) needed in order to care for this type of patient. There was an assumption that any patient weighing 350 pounds was obese; however, just as America's waistband has expanded, so has our height. We are seeing many more patients in ASCs who are 6'6" tall and taller. Those patients may not, in fact, be classified as obese. This distinction has forced us to begin evaluating a patient's level of obesity based on his body mass index. Today the designation of obesity can only be made by performing a BMI.
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In many centers, neither the patient's weight nor BMI is made known until the day before the procedure when the schedule is sent to the operating room supervisor. This practice does not allow adequate preparatory time to plan for a safe environment for these patients. Rather, this information must be collected at the time the patient is scheduled. Collect the patient's height and weight as a matter of course during the scheduling process, then calculate the BMI. Calculation of the BMI is accomplished by taking the weight in kilograms divided by height in millimeters squared (kg/m2). The following classifications should be followed:
- < 18.5 — Underweight
- 18.5-24.9 — Normal
- 25.0-29.9 — Overweight
- 30.0-39.9 — Obese
- >40.0 — Morbidly obese
Instruct the scheduling secretary to notify the OR supervisor of any BMI greater than 35 immediately so that proper preparatory actions and processes can be put in place.
For preoperative care:
- The scheduling secretary calculates the BMI and alerts the OR supervisor if BMI is > 35
- The BMI is posted on the surgery schedule if >35.
- The preoperative RN completes the nursing assessment following the nursing care plan for patients who are morbidly obese and the assessment tool for patients who are morbidly obese.
- The preoperative nurse places the inflatable patient transfer pad on the preop bed and collects the appropriate sized blood pressure cuff, patient gown bed linens and extra large sequential compression devices for each leg.
- The anesthesia providers assess the patient in the preoperative area to include the lungs, oral airway and history of obstructive sleep apnea. The anesthesia provider determines the presence of all required specialty equipment to meet the special needs of the morbidly obese to include intubation equipment and CPAP or BIPAP, as appropriate, head cradle and elevation wedge.
- The preoperative RN assesses lung sounds, vital signs, oxygen saturation, presence of edema and information regarding sleep habits such as snoring, daytime sleepiness and other symptoms of OSA,
- The preoperative RN performs postoperative teaching in the preop area, teaching the patient regarding deep breathing, leg exercises, incentive spirometry, CPAP or BIPAP (bileval positive airway pressure).
Note: The preoperative RN should interview the patient regarding reflux/GERD and should alert anesthesia where the patient admits to this condition. Determine with the patient to what degree he is able to lay flat. Advise anesthesia of this response.
- The anesthesia provider pre-oxygenates the patient. Provide two anesthesia providers where a difficult airway is anticipated.
- The anesthesia provider positions the patient's head using a head cradle and an elevation wedge being especially aware of the patient's needs regarding the presence of GERD/reflux while awake and the impact of this condition on the patient's comfort as well as the hazard it imposes regarding the possibility of aspiration. The need for the elevation wedge is evident.
- The circulator procures extra drapes to adequately create the sterile field while protecting the patient from the possibility of "pooling" of prep and/or irrigation solutions especially in skin folds.
- The circulator gathers extra large equipment as needed, such as bariatric instrumentation for retractors.
- Extra large stepstools are provided for additional staff to prevent leaning across or onto the patient.
- Provide pads, positioning and protective devices to prevent pressure points and assess these areas frequently.
- Position hands such that maximum protection is allowed.
- If patient is to be in the lithotomy position, check prior to the day of surgery with the surgeon to determine the acceptability of available stirrups (e.g., candy cane vs. boot)..
- The patient in lithotomy position will require special attention to fluid volume shifts and ventilation changes presenting in this position.
- Select anesthesia based on procedure to be performed utilizing regional or local whenever possible. Ketorolac is recommended.
- Deflate the inflatable patient transfer device once the patient is on the table.
- Prior to draping, check again for pooling making sure crevices are dry.
- If intubated, following the procedure the anesthesia provider should delay extubation as long as possible.
- Reinflate the patient transfer device for transferring the patient from the OR table to the stretcher bed.
- Advise the PACU that the patient is about to be transported from the OR.
- The anesthesia provider and circulating RN transport the patient to the PACU with oxygen.
- If possible due to the procedure performed, transport the patient with the head of the bed elevated to 30-45 degrees in order to relieve the intra-abdominal pressure on the lungs.
- If extubated, transport the patient with a nasal or oral airway in place.
- Maintenance of the airway is a special challenge in the post-anesthetic morbidly obese patient and should be monitored closely.
- Have CPAP or BIPAP ready for immediate use in the PACU.
- Maintain the elevation of the head of the recovery bed.
- Make sure emergency airway equipment is immediately available.
- Limit narcotic and sedative use and use ketorolac when possible.
- Use nebulized breathing treatments as needed.
- Observe patient for conditions and complications associated with severe obesity after surgery to include:
- congestive heart failure
- deep vein thrombosis
- myocardial infarction
- pulmonary embolism
- respiratory depression
- rhabdomyolysis (deep muscle damage)
- skin breakdown
- Initiate standard postoperative care
Care of the morbidly obese in the PACU and discharge area requires a one-on-one staffing ratio until the patient is ready for discharge. It is crucial that this patient be rigorously monitored. Deep breathing/breathing treatments and leg exercises are crucial. Getting the patient up and out of the recovery bed to a chair as quickly as his condition allows is vital to his successful recovery. Repetitive education regarding breathing and leg exercises at home is critical. Provide demonstrations and demand the patient return the demonstration. Make sure he or she applies his CPAP device properly. Solicit the patient's return explanation regarding the prevention of DVT (and the care person's explanation, too). Remember that this patient's size in of itself is an obstacle in moving his or her body to the extent needed. The nurse providing postoperative instructions must ensure the patient's level of understanding is such that the patient will "move the mountain" in order to best provide the best outcome possible for his or her care. The need to limit pain medication may further inhibit activity and limit compliance. Be firm. Explain possible complications and the degree that inadequate ventilation and exercise contribute to these even to the point of pneumonia and blood clots that could, potentially, be fatal.
In providing the best possible patient education, the nurse caring for these patients must be aware of the underlying emotional needs as well as the obvious physical that are present. The patient may be defensive about his or her weight. The patient may, even, be in denial of the extent of the problem. The patient may be embarrassed, but, certainly sensitive about the issue. Protect his or her privacy. Provide as much privacy during the assessment and teaching phases of his care as the physical plant restrictions allow. Plan this out prior to the patient's admission. Is there space anywhere that can be commandeered to provide these special needs? This patient needs staff support.
How do you provide staff support of the morbidly obese patient when literature and studies abound regarding the stigma and bigotry that exists regarding such patients? Start now with providing staff education. Have round table discussions on the subject. Contact local eating disorder clinics or bariatric centers for expert guest speakers. Given the staffing constraints that exist in most surgery centers, nevertheless, select and assign staff members carefully when planning the patient's care. Just as there are considerations in making other staffing assignments due to religious beliefs, etc., so these may exist among your staff members regarding weight and the morbidly obese. Staff members should be assessed as to whether such pre-conceived convictions can be set aside to provide the degree of support these patients need.
Care of the staff person must also be planned and implemented when caring for the morbidly obese. Injury is a very real hazard, whether a back injury from moving the patient or an injury sustained trying to prevent a patient from falling or working with lifting devices, etc. Determine how best to mitigate such circumstances.
Finally, calculate the costs of providing care to the morbidly obese patient in the ASC. If your center does not routinely provide care to bariatric patients, what are all the direct and indirect costs you will be incurring compared to the reimbursement you will be receiving?
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