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Assessment Resource (Phillips, 2013)

Assessment Resource (Phillips, 2013) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines, Related

Care of the
Patient in A
j JoAnne Phillips, MS
The cost of obesity-related medical conditions
many of
r, and
on, hy-
nto the
olik, &
Copyright� 2013 by the Association for Radiologic & Imaging Nursing.
Matwiyoff, 2010).
To understand the impact of obesity on lung function,
it is helpful to consider three different yet related
effects, which are as follows:
1. Restrictive dysfunction
2. Metabolic differences between an obese and non-
obese person in relation to oxygen consumption
JoAnne Phillips, MSN, RN, CCRN, CCNS, is a Clinical Nurse
Specialist at The Hospital of the University of Pennsylvania,
Philadelphia, PA.
Presented at Nursing 2011 Conference.
Corresponding author: JoAnne Phillips, The Hospital of the University
of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104. E-mail:
de is estimated to be $147 billion annually
n, 2011). The burden of illness from obesity-
comorbidities is staggering. Overweight and
account for significant disease burden for
the associated comorbidities: diabetes (44%),
heart disease (23%), and certain cancers
with higher rates of all-cause mortality, cardiov
(CV) disease, diabetes mellitus, breast cance
stroke. Central obesity is also characterized by e
triglycerides, increased incidence of hypertensi
perinsulinemia (elevated circulating insulin), in
insulin resistance (inability to move insulin i
cell), and glucose intolerance (Amundson, Svet
sion of obesity among US adults since 1990.
droid obesity, a distribution of adipose tissue predom-
inantly around the abdominal area, which is associated
ABSTRACT: Obesity has become a health care crisis ac
tions for obesity. This article will review the physiol
endocrine, and integumentary systems. It will also h
provides care throughout the patient’s imaging exper
tion priorities for managing the bariatric patient in
KEYWORDS: Obesity; Bariatric patient; Imaging; Radi
The increasing prevalence of obesity is a global health
care crisis. Since 1980, the obesity rate for adults has dou-
bled, and the rate for children has tripled (Peavy, 2009).
Overweight, obese, and extreme or morbidly obese are
defined by body mass index (BMI), expressed as weight
in kilograms divided by height in meters squared
). Table 1 delineates definitions of each from the
World Health Organization (WHO). Globally, over-
weight and obesity are the fifth leading risk for death in
adults, resulting 2.8 million deaths annually. In the
United States, an estimated 300,000 deaths per year are
associated with overweight and obesity. Based on the
WHO criteria, in the United States, 34.2% of adults
who were 20 years and older were defined as overweight,
33.8% obese, and 5.7% extremely obese (“Obesity and
Overweight”; “Overweight and Obesity: Health
Consequence”; “Overweight and Obesity: US Obesity
Trends”). Figure 1 demonstrates the startling progres-
32 ISSUE 1 www.radiologyn
cute Care
the world. There are significant physiologic implica-
impact of obesity on the pulmonary, cardiovascular,
ight concepts important to the radiology nurse who
. The appendices describe assessment and interven-
e care. (J Radiol Nurs 2013;32:21-31.)
(7e41%)(Obesity and Overweight). There are signifi-
cant physiologic implications associated with obesity.
The purpose of this article is as follows:
1. To apply the concepts of restrictive, metabolic,
and compliance to the understanding of respira-
tory dysfunction in the obese patient.
2. To identify assessment challenges of the obese
patient as they relate to the pulmonary, cardiac,
and skin integumentary systems.
3. To differentiate the drug dosing guidelines for
drugs that are fat and water soluble as they relate
to the obese patient.
There are significant medical comorbidities associated
with obesity, listed in Table 2. The presence of simple
obesity can be further complicated by central or an-
and carbon dioxide (CO
) production, and

3. The role of decreased compliance in pulmonary
The first component in pulmonary dysfunction is the
restrictive element. Adipose tissue, which is nonelastic,
surrounds the thorax and ribs, creating an effect anal-
ogous to a bungee cord around the patient’s chest. In
attempting to increase the depth of respiration, the
obese person attempts to work against this restrictive
force. The confounding restrictive force relates to dia-
The second effect relates to the difference in oxygen
consumption and CO
production between the obese
and nonobese. Oxygen consumption may increase four-
fold or more in obese versus nonobese persons
(Honiden & McArdle, 2009; Sood & Ortiz-Cantillo,
2011). Oxygen consumption increases linearly with
weight, in an attempt to support the metabolic activity
of the excess tissue mass (adipose tissue). Increased ox-
ygen consumption is associated with a marked increase
in CO
production. CO
production may increase by as
much as 40% (Siela, 2009). The elimination of CO
be facilitated by an increase in minute ventilation,
a function of respiratory rate (RR) and depth. Because
the restrictive factors associated with pulmonary dys-
function in the obese prevent the patient from increas-
ing the depth of their respirations, an increase in
minute ventilation is achieved by an increase in RR
(Honiden & McArdle, 2009; Honiden, 2011). The RR
may increase by as much as 40% (Siela, 2009).
The third factor is compliance. An increased BMI is
associated with an exponential decrease in respiratory
Table 1. World Health Organization (WHO) definitions
Terminology BMI Risk of comorbidities
Normal BMI 18.5e24.9 Average
Preobese 25.0e29.9 Increased
Obesity class I 30.0e34.9 Moderate
Obesity class II 35.0e39.9 Severe
Obesity class III R40 Very severe
BMI, body mass index.
Reference: The Global Challenge of Obesity and the International
Obesity Task Force.
Phillips Care of the Bariatric Patient in Acute CareJOURNAL OF RADIOLOGY NURSING
phragm descent. During normal inspiration, the dia-
phragm descends into the abdomen. People with
central obesity have abnormal diaphragm descent re-
lated to the obstruction created by excess adipose tissue
in the abdomen. As the obese person attempts to in-
crease the depth of their respirations, the chest cannot
expand because of the adipose tissue on the chest
wall, and the diaphragm cannot descend because of
the obstruction of the adipose tissue in the abdomen
(Salome, King, & Berend, 2010; Siela, 2009).
Figure 1. Obesity trends among US adults, 1990-2010. BMI, body mas
22 www.radiologyn
compliance. Adipose tissue on the chest wall plays
a role, but the overriding decrease in compliance in
the lung tissue is because of an increase in pulmonary
blood volume (Honiden & McArdle, 2009; Salome
et al., 2010; Siela, 2009; Sood & Ortiz-Cantillo, 2011).
Compliance may be reduced by as much as 25% in sim-
ple obesity (Honiden & McArdle, 2009).
Figure 2 is a summary of the three key factors that
lead to pulmonary dysfunction in the severely obese
person. The ensuing atelectasis and decrease in func-
tional residual capacity widens the ventilation/
s index.
MARCH 2013ursing.org

perfusion mismatch with resulting hypoxemia
(Honiden, 2011; Honiden & McArdle, 2009; Salome
et al., 2010; Siela, 2009).
A thorough assessment of the patient’s medical history
Table 2. Comorbidities related to obesity
System Dysfu
Cardiovascular Sudden cardiac death, obesity cardiomyopathy, h
cerebrovascular disease, peripheral vascular dis
Respiratory Restrictive lung disease (asthma), obstructive slee
Endocrine Diabetes mellitus, Cushing syndrome, hypothyroi
Gastrointestinal Hiatus hernia, gallstones, inguinal hernia, fatty liv
Genitourinary Menstrual abnormalities, female urinary incontin
Malignancies Postmenopausal breast cancer, prostate, colorecta
Musculoskeletal Osteoarthritis of weight-bearing joints, carpal tun
Dermatologic Dermatitis, cellulitis, panniculitis, pressure ulcers
Ophthalmologic Cataracts and glaucoma
Neuropsychiatric Idiopathic intracranial hypertension, stroke, depr
References: Amundson et al., 2010; Craft & Reed, 2010; Honiden, 2011;
Care of the Bariatric Patient in Acute Care PhillipsJOURNAL OF RADIOLOGY NURSING
provides the foundation for an accurate pulmonary as-
sessment. Important questions in assessing the patient’s
history include asking the patient what position they
sleep in, if they snore, and if they have a history of sleep
apnea. If they have been diagnosed with sleep apnea,
do they use CPAP or BiPAP at night? A history of
sleep apnea may impact the patient’s response to proce-
dural sedation (King & Velmahos, 2010). Auscultation
of the lung sounds may be impaired by excess adipose
tissue or folds of the skin on the chest wall. It may be
necessary to physically spread the folds of skin to
enable positioning of a stethoscope onto the chest
wall, particularly to auscultate the posterior lung fields.
Figure 2. Pulmonary dysfunction related to obesity. References:
Honiden, 2011; Honiden & McArdle, 2009; Salome et al., 2010;
Siela, 2009; Sood & Ortiz-Cantillo, 2011.
VOLUME 32 ISSUE 1 www.radiologyn
As with nonobese people, it is essential to auscultate all
lung fields, in particular over the dependent areas of the
lung where fluid may collect and lung tissue is close to
the chest wall (Siela, 2009).
The breathing pattern of obese persons may reflect
an increased work of breathing as a result of abnormal
chest elasticity, abnormal diaphragm position, in-
creased chest wall resistance, and an increased upper
airway resistance. Work of breathing may increase by
as much as 60% in the obese and 250% in the morbidly
obese. Persons with obesity-related pulmonary dys-
function will desaturate more easily, related to
a decrease in functional residual capacity. The greatest
decline in lung volumes occurs in the supine position;
thus, it is important to avoid supine, lithotomy,
and Trendelenberg positions. The use of reverse
Trendelenberg, semifowlers, or side-lying position
may result in an increase in tidal volume with a corre-
sponding decrease in respiratory rate (RR). Signs of
hypoxia, including altered level of consciousness, ar-
rhythmias, cyanosis, or changes in rate, depth, or qual-
ity of respirations should be assessed. RR should be
counted for a full minute to account for abnormalities
in respiratory rhythm. Pulse oximetry value may be dis-
torted as the signal may be obscured by the adipose tis-
sue in the finger. The presence of adipose tissue on the
nction related to obesity
ypertension, ischemic heart disease, hyperlipidemia, cor pulmonale,
ease, deep vein thrombosis, and pulmonary embolism
p apnea, obesity hypoventilation syndrome, aspiration pneumonia
dism, infertility, hyperlipidemia, metabolic syndrome
er, irritable bowel syndrome, liver and gallbladder disease
ence, renal calculi, polycystic ovarian syndrome
l, cervical, ovarian, uterine, endometrial, gallbladder, and pancreatic
nel, low back pain, bone demineralization
Lowe, 2009; Mathier & Ramanathan, 2007.
face and cheeks can create a challenge in providing bag-
valve-mask ventilation. Obese persons will often
present with a short neck, large tongue, and excessive
palatal and pharyngeal soft tissues, a high and anterior
larynx, and restricted mouth opening (Garrett, Lauer,
& Christopher, 2004). Appendix A provides guidelines
for pulmonary assessment and nursing interventions to
optimize the care of the obese person with obesity-
related pulmonary dysfunction.
CV disease, including hypertension, ischemic heart dis-
ease, and cardiomyopathy, dominates morbidity and
mortality in the obese. Mild to moderate hypertension

Phillips Care of the Bariatric Patient in Acute CareJOURNAL OF RADIOLOGY NURSING
is present in 50% to 60% of obese individuals and se-
vere hypertension in 5% to 10% (Garrett et al.,
2004). A key aspect of blood pressure (BP) assessment
is consistency in the cuff size and measurement site.
Monitoring trends in BP with the correct cuff size
and from the same site will enable the practitioner to
manage an obese person’s BP more accurately. The
cuff used to measure the BP manually should exceed
the circumference of the extremity by 20%, and the
width of the cuff should be greater than or equal to
40% of the circumference of the arm (Peavy, 2009).
The physiology of hypertension is complex. Hyper-
insulinemia activates the sympathetic nervous system,
resulting in the expansion of extracellular volume
through sodium and water retention. Volume overload
can lead to concentric left ventricular hypertrophy
(Honiden & McArdle, 2009) and increase in cardiac
output. Insulin resistance may be responsible for in-
creased activity of norepinephrine and angiotensin II,
with resulting vasoconstriction (Garrett et al., 2004).
Although the exact mechanism is unknown, hyperten-
sion is believed to be an interaction among genetic,
hormonal, renal, and hemodynamic factors.
An increase in BMI results in a linear increase in blood
volume. Increased blood volume leads to an increase in
preload, with a resulting increase in stroke volume. The
increased stroke volume supports the increase in car-
diac output necessary to meet the metabolic demands
of the excess adipose tissue. As the left ventricular
workload increases and contractility becomes less effi-
cient, left ventricular hypertrophy develops, evidenced
by increase in left ventricular mass and wall thickness,
an increase in left ventricular end diastolic volume, and
a decrease in ejection fraction. An increase in wall
thickness will decrease chamber size, resulting in sys-
tolic and diastolic compromises or obesity cardiomyop-
athy. Obesity cardiomyopathy develops in less than
10% of people with BMI O40 kg/m
2011). Patients with left ventricular failure from obesity
cardiomyopathy do not tolerate large volume shifts
or aggressive volume resuscitation (Honiden, 2011;
Pieracci, Barie, & Pomp, 2006).
Obesity increases the risk for cardiac dysrhythmias, in-
cluding atrial fibrillation, ventricular ectopy, and sud-
den cardiac death. Premature ventricular ectopy is
seen in patients with concentric left ventricular hyper-
trophy. Atrial fibrillation occurs in the obese secondary
to volume overload and dilation of the atria. Condi-
tions that lead to cardiac arrhythmias include hypoxia,
hypercapnea, electrolyte disturbances, increased cate-
24 www.radiologyn
cholamine concentrations, and fatty infiltration of the
conduction system (Garrett et al., 2004; Mathier and
Ramanathan, 2007; Peavy, 2009; Siela, 2009).
Assessment of the CV system presents challenges as clas-
sic symptoms of heart failure are unreliable. Excess
adipose tissue makes the auscultation of heart sounds
difficult, especially when listening for murmurs. Strate-
gies such as minimizing extraneous noise may help facil-
itate assessment of heart sounds. It may also help to
position the patient in the left lateral position or sitting
up at a 45

angle (Peavy, 2009). Signs of cardiac failure,
such as jugular venous distension, hepatomegaly, and
peripheral edema may be masked by body habitus. In
addition to understanding the challenges of ausculta-
tion, nursing care priorities for patients with cardiac
failure include vigilant intake and output, cautious re-
placement of volume, and selection of the appropriate
size of BP cuff to facilitate consistent measurements for
BP. Appendix B establishes priorities for assessment
and intervention of obesity-related cardiac dysfunction.
Facilitating venous access on the obese can be difficult.
For inpatients, the use of central venous access is be-
coming more common. In attempting to insert a central
venous catheter, the practitioner must be mindful that
the obese do not tolerate Trendelenburg positioning
and may have obscure landmarks and short necks.
There may be a distorted angle and depth of insertion
because of the greater skin-to-vessel distance; therefore,
the length of the needle must be considered as well. The
use of ultrasound can improve success and decrease
complications in the obese. Nursing care after insertion
includes daily assessment of the ongoing need for cen-
tral access, meticulous inspection of the intertriginous
folds around the insertion site, and site care as per in-
stitutional policy to prevent infection. Whether central
or peripheral, the presence of an intravenous infiltra-
tion may be obscured by excess tissue, requiring vigi-
lance with thorough and frequent site inspections.
Appendix C delineates care strategies for obese patients
with central or peripheral venous access (Garrett et al.,
2004; Honiden, 2011; Honiden & McArdle, 2009;
McAtee & Personett, 2009; Pieracci et al., 2006).
The incidence of deep vein thrombosis (DVT) and pul-
monary embolism (PE) is often underestimated. Obe-
sity is an independent risk factor for the development
of DVT/PE. Although rare, PE is the leading cause
of death after bariatric surgery (Craft & Reed, 2010;
Honiden & McArdle, 2009). The National Hospital
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Reed, 2010; Liebman, 2011; Mathier & Ramanathan,
2007). The clinical presentation of metabolic syndrome
is presented in Table 3 and includes increased waist cir-
cumference, elevated triglycerides, reduced high-density
lipoproteins, hypertension, and elevated fasting blood
sugar. Patient characteristics commonly seen in meta-
bolic syndrome include sedentary lifestyle, atherogenic
diet, and smoking. The incidence of metabolic syndrome
increases after menopause (Paul & Smith, 2005). Other
physiologic characteristics associated with metabolic
syndrome include increased insulin resistance (inability
to move insulin into the cell), hyperinsulinemia, hyper-
glycemia, elevated triglycerides, and hypertension. Hy-
perinsulinemia activates the sympathetic nervous
Care of the Bariatric Patient in Acute Care PhillipsJOURNAL OF RADIOLOGY NURSING
Discharge Survey (Craft & Reed, 2010) reported a rela-
tive risk ratio for nonobese versus obese for DVT of
2.5 versus 5.2 and for PE 2.21 versus 5.19. There is
an incremental risk for recurrent venous thromboem-
bolism with increasing BMI (Craft & Reed, 2010).
Risks for the development of DVT and PE in the obese
include decreased ambulation, inadequate mechanical
prophylaxis, and pulmonary hypertension. The patho-
physiology associated with the development of DVT/
PE in the obese includes increased blood viscosity, de-
creased levels of antithrombin III, and an increased
concentration of fibrinogen and plasminogen activator
inhibitor 1 (PAI-1). PAI-1 is produced by adipose tis-
sue and disrupts the conversion of plasminogen to plas-
min, thus decreasing fibrinolytic activity. Tissue-type
plasminogen activator (t-PA), another key enzyme in
the fibrinolytic response, is also decreased in the obese
(Craft & Reed, 2010; Honiden, 2011; Pieracci et al.,
2006). The decrease in PAI-1 and t-PA leads to an in-
crease in clot formation without the ability to destroy
the clot, leading to the development of DVT and PE.
Prevention of DVT and PE should be facilitated
through a multimodal prevention program, including
mechanical and pharmacologic strategies. Limited
data are available on pharmacologic prophylaxis. In
one study (Honiden & McArdle, 2009), pharmacologic
prevention with enoxaparin (40 mg) every 12 to 24 hr in
postoperative patients resulted in very low rates of
DVT/PE. Mechanical prevention with compression
boots carries concerns of appropriate fit and compli-
ance. Surgical patients who are at very high risk may
benefit from a retrievable inferior vena cava (IVC) fil-
ter. Characteristics of very high risk include BMI
, central obesity, venous stasis disease, or
a history of DVT/PE (King & Velmahos, 2010;
Pieracci et al., 2006). An IVC filter is not without risk
as one study (Vaziri, Bhanot, & Hungness, 2009) re-
ported DVTs in 21% of the patients and filter thrombo-
sis in 14% of the patients. Complications with removal
are rare but include filter breakage, caval perforation,
and retroperitoneal hemorrhage. Despite the initial
plan to explant the IVC filters, several studies reported
that 4% to 17% of the filters are not explanted (Mehran
& Ruggiero, 2010). Other prevention strategies include
early ambulation and adequate hydration. Appendix D
describes risk factors and prevention strategies for
DVT/PE prophylaxis.
Metabolic syndrome is a myriad of systemic dysfunc-
tions that develops over several years. It is estimated
that two in five Americans have metabolic syndrome,
raising their risk of coronary artery disease, type II diabe-
tes, stroke, and peripheral vascular disease (Ashburn &
VOLUME 32 ISSUE 1 www.radiologyn
system, causing sodium andwater retention, a contribut-
ing factor in hypertension (Amundson et al., 2010;
McAtee & Personett, 2009).
Another important aspect of endocrine dysfunction
in the obese is the active role of adipose tissue. As
a multifunctional organ, adipose tissue creates a proin-
flammatory state through the secretion of proinflam-
matory mediators, including interleukins 1, 6, and 8,
C-reactive protein, tumor necrosis factor alpha, and
angiotensin II. The state of inflammation created by
these substances produces plaque that narrows arteries
(atherosclerosis). Ongoing inflammation can cause
a rupture of unstable plaque, resulting in clot forma-
tion (Ashburn & Reed, 2010; Liebman, 2011).
The pharmacokinetics associated with obesity is com-
plex. There are marked changes in distribution, binding,
and elimination of medications. An increase in body
mass combined with a decrease in percentage of lean
mass and bodywater changes the volume of distribution.
Dosing ofmedications is based on their affinity for water
or adipose tissue (Honiden, 2011; Honiden & McArdle,
2009; Pieracci et al., 2006). The volume of distribution
of hydrophilic medications (water soluble) relates better
Table 3. Metabolic syndrome
Measure Value
Elevated waist circumference (cm)
Men R102
Women R88
Elevated triglycerides R150 mg/dL
Reduced high-density lipoprotein cholesterol
Men !40 mg/dL
Women !50 mg/dL
Elevated blood pressure Systolic R130 and/or
diastolic R85 mm Hg
Elevated fasting glucose R100 mg/dL
References: Alberti et al., 2009; McAtee & Personett, 2009.
Values are different in different ethnicities and different parts of
the world.

to lean tissue because of the poor penetration into adi-
pose tissue (McAtee & Personett, 2009; Pieracci et al.,
2006). Thus, dosing of hydrophilic medications is based
on actual body weight (ABW). Lipophilic medications
(fat soluble) have more of an affinity for adipose tissue;
therefore, dosing is based on ideal body weight (IBW).
Obese people with normal renal function will have ele-
vated glomerular filtration rate and increased clearance
of medications. Consequently, a calculated creatinine
clearance does not correlate well with measured creati-
nine clearance. If creatinine clearance is needed to dose
medications, a measured creatinine clearance is needed.
Phillips Care of the Bariatric Patient in Acute CareJOURNAL OF RADIOLOGY NURSING
Overdosing or underdosing may occur related to the
changes in total blood volume, cardiac output, changes
in renal and hepatic functions, and plasma protein bind-
ing (Honiden, 2011). Unfortunately, pharmacokinetic
data in obese patients do not exist for most drugs. Clini-
cians should design treatment regimens that account for
any significant differences in the clearance and volume of
distribution in the obese (Hanley, Abernethy, &
Greenblatt, 2010).
Table 4 provides examples of commonly adminis-
tered lipophilic and hydrophilic medications. In addi-
tion to IBW and ABW, certain medications are dosed
based on an adjusted or dosing weight, which is calcu-
lated as follows: IBWD (0.4 � [ABW � IBW]). Many
medications are initially dosed on IBW but adminis-
tered based on clinical response. For example, opioids
and benzodiazipines are generally lipophilic, thus are
initially dosed based on IBW, with subsequent dosing
based on clinical response (Honiden & McArdle,
2009). Certain medications must be administered based
on serum levels. For example, aminoglycosides carry an
increased risk of nephrotoxicity, thus require careful
monitoring of serum levels (Pieracci et al., 2006).
Transdermal patches must be used with caution.
Placing patches on different parts of the body may
lead to inconsistent absorption. For example, there
may be different absorption of medication from the up-
per arm and abdomen. When giving injections, it is
important to ensure that the needle is the appropriate
Table 4. Medication dosing guidelines
Ideal body weight Actual body weight Dosing weight
Opioids Low-molecular-weight
(continuous infusion)
Thrombolytics Aminoglycosides
Beta-blockers Vancomycin
Histamine 2 blockers Benzodiazepine (single
References: Honiden, 2011; Honiden & McArdle, 2009; Pieracci
et al., 2006.
26 www.radiologyn
length, and sites must be observed for inflammation/
fat necrosis.
Obese people struggle with a myriad of skin integrity is-
sues, including risk for pressure ulcers, venous insuffi-
ciency ulcers, diabetic foot ulcers, perineal dermatitis,
intertrigo, and others. Comorbidities associated with
obesity, such as diabetes mellitus, hypertension, CV
disease, and pulmonary dysfunction, increase the risk
of skin complications. The body habitus of an obese
or morbidly obese person may interfere with the ability
to assess hypotension, hypoxia, and hypoperfusion, all
of which contribute to skin breakdown. No risk assess-
ment scales have been validated for the obese. Pressure
ulcers or intertrigo (erythema of skin caused by friction
between two surfaces) often occur in unusual places,
such as under the breasts, in the gluteal folds, under
the pannus, in the perineal area, or in the lumbar/mid-
back area. It is essential to examine all the intertrigi-
nous folds everyday to inspect for intertrigo or yeast
infections. The use of appropriate equipment to move
and position the obese person will keep the patient
and radiology staff safe, by preventing not only muscu-
loskeletal injuries but also skin injuries as well. When
taping skin folds to access a procedure site, care should
be taken to carefully pad the skin to prevent abrasions
when the tape is removed. When taping the breasts, for
example, with insertion of a portacath (implantable
port device), always it is necessary that the tape does
not restrict the chest movement. Appendix E describes
risk factors and strategies for skin maintenance and
pressure ulcer prevention for the obese (Lowe, 2009).
When an obese person is hospitalized, providing equip-
ment that is designed and built to accommodate their
weight is essential to creating a safe environment for
the patient and caregiver.An accurateweight is essential,
as most standard hospital beds can safely accommodate
patients up to 500 pounds. Patients who are ofmore than
500 pounds or have a body habitus that does not allow
safe repositioning of the patient in a bed should be placed
in a bed designed especially for obese patients. Other
important equipment designed for the obese patients in-
clude chairs, walkers, commodes, gowns, and stretchers.
Certain radiology diagnostic areas in the hospital may
not be able to accommodate patients with a certain
weight or body habitus. Before accepting obese patients
to areas such as radiology or the cardiac catheterization
laboratory, it is best to ensure that the patient’s weight
can be accommodated (Lowe, 2009). This will prevent
an embarrassing situation for the patient. If the patient
MARCH 2013ursing.org

requires sedation, consideration should be taken to con-
sult an anesthesia provider as opioid-related respiratory
depression may occur at a higher rate because of under-
lying respiratory compromise (King & Velmahos, 2010).
Another safety factor to consider during radiology pro-
cedures is positioning. The supine position may
increase the risk for aspiration; therefore, the patient
must be closely monitored (Siela, 2009).
The prevalence of obese and morbid obesity will no
Honiden, S., & McArdle, J.R. (2009). Obesity in the intensive
care unit. Clinics in Chest Medicine, 30, 581-599.
King, D.R., & Velmahos, G.C. (2010). Difficulties in managing
the surgical patient who is morbidly obese. Critical Care
Medicine, 38, S478-S482.
Liebman, B. (2011). Fighting inflammation. Nutrition Action
Health Letter, 38,1.
Lowe, J.R. (2009). Skin integrity in critically ill obese patients.
Critical Care Nursing Clinics of North America, 21,
Mathier, M.A., & Ramanathan, R.C. (2007). Impact of obesity
and bariatric surgery on cardiovascular disease. Medical
Clinics of North America, 91, 1-12.
McAtee, M., & Personett, R.J. (2009). Obesity-related risks and
Care of the Bariatric Patient in Acute Care PhillipsJOURNAL OF RADIOLOGY NURSING
doubt continue to increase for the foreseeable future.
Understanding the physiologic impact that obesity has
on the pulmonary, CV, endocrine, and integumentary
systems will help the radiology nurse and staff to identify
risk factors and to plan and carry out essential nursing
interventions necessary to prevent complications.
Alberti, M.G.M.M., Eckel, R.H., Grundy, S.M., Zimmet, P.Z.,
Cleeman, J.I., & Donato, K.A., et al. (2009). Harmonizing
themetabolic syndrome: A joint interim statement of the Inter-
national Diabetes Federation Task Force on Epidemiology
and Prevention; National Heart, Lung, and Blood Institute;
American Heart Association; World Heart Federation; Inter-
national Atherosclerosis Society; and International Associa-
tion for the Study of Obesity. Circulation, 120, 1640-1645.
Amundson, D.E., Svetolik, D., & Matwiyoff, G.N. (2010). The
obesity paradox. Critical Care Clinics, 26, 583-596.
Ashburn, D.D., & Reed, M.J. (2010). Endocrine system and
obesity. Critical Care Clinics, 26, 633-636.
Craft, M.K., & Reed, M.J. (2010). Venous thromboembolic dis-
ease and hematologic considerations in obesity. Critical Care
Clinics, 637-640.
Garrett, K., Lauer, K., & Christopher, B. (2004). The effects of
obesity on the cardiopulmonary system: Implications for crit-
ical care nursing. Progressive Cardiovascular Nursing. Re-
trieved from, http://www.medscape.com/viewarticle/495041.
November 1, 2011.
Hanley, M.J., Abernethy, D.R., & Greenblatt, D.J. (2010). Effect
of obesity on the pharmacokinetics of drugs in humans. Clin-
ical Pharmacokinetics, 49, 71-87.
Honiden, S. (2011). Caring for the critically ill obese patient. Pulmo-
nary critical care sleep update. Retrieved from, http://www.
pageZ0,3. November 1, 2011.
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obesity/tabfig.htm. November 1, 2011.

Deficit Pulmonary assessment Nursing interventions
Obesity-related pulmonary
� Auscultate all lung fields
� May be necessary to reposition folds of
skin to have stethoscope on the anterior
and posterior chest walls
� Count RR for a full minute and observe
for changes in rate or pattern
� Assess for increased work of breathing
� Assess saturation of peripheral oxygen
B Value may be obscured by excess tissue
and inability of light to reflect
� Assess for clinical signs of hypoxia
B Altered level of consciousness
B Dysrhythmias
� Assess the patient and document:
B Breath sounds
B RR and pattern
B Heart rate
B Pulse oximetry
(if available)
� Additional findings: color, orientation
� Avoid lithotomy, supine, or Trendelenburg position
� Position in reverse Trendelenburg, side lying, or high
fowlers position. Frequent repositioning will facilitate
full lung ventilation
� If the patient has previously diagnosed sleep apnea, ob-
tain information on continuous positive airway pressure
or BiPAP settings
B Stimulate and provide supplemental oxygen
B Evaluate BiPAP settings if applicable
B Assess for possible mask/circuit leak
B Evaluate medications
B Consider low-dose naloxone
B Consider arterial blood gas
B Suspect hypoxia/hypercarbia
B Evaluate for relaxation of airway
� Call triggers: If the patient exhibits any of the following
clinical signs, a call must be immediately placed to the
physician or nurse practitioner:
B Increase/decrease in RR
B Change in respiratory pattern
B Change in level of consciousness or orientation
B Decrease in pulse oximetry !90% for 5 min
B Increase in ETCO
B Nasal flaring or use of accessory muscles to breath
RR, respiratory rate; ETCO
, end-tidal CO
; BiPAP, bilevel positive airway pressure.
Goal: Prevent pulmonary complications and optimize respiratory function.
Reference: Siela, 2009.
Phillips Care of the Bariatric Patient in Acute CareJOURNAL OF RADIOLOGY NURSING
B Cyanosis
(if available)
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Deficit Assessment Nursing interventions
Risk for cardiovascular
disease associated with
hypertension and diabetes
� Vital signs
- BP cuff should exceed the circumference
of the extremity by 20%, and the width
of the cuff should be greater than or
equal to 40%of the arm circumference
- Consistently use same extremity to mea-
sure BP
B Auscultate heart sounds:
- Minimize extraneous noise
- Displace tissue to place stethoscope on
chest wall
- Position on left side or sitting up at 45

B Doppler may be required
� Normal signs of heart failure are not reliable:
B Jugular venous distension
B Hepatomegaly
B Peripheral edema
B Heart murmur
� Be vigilant in monitoring intake and output
� Fluid resuscitate cautiously
� Be prepared to use invasive hemodynamic
� BP monitoring
B Obtain and use appropriate size cuff
B Measure BP in the same extremity with each
assessment to provide trending data
BP, blood pressure.
Goal: Assess and stabilize vital signs.
References: Garrett et al., 2004; Honiden & McArdle, 2009; Peavy, 2009; Pieracci et al., 2006.
Deficit Assessment Nursing interventions
Infiltration of IV line
Baseline puffy appearance to skin
Veins lying deeper underneath skin, resulting
in more difficult assessment IV site
� IV site assessment every 8 hr, including
the intertriginous skin folds at the cen-
tral or peripheral site
� IV site assessment with shift change
activities to confirm changes/baseline
with next shift registered nurse
� Daily assessment for ongoing need for
� Monitor patient to ensure desired out-
come of IV therapy
� Pain assessment every 4 hr, and after
additional pain, medicine given to en-
sure desired effect
� When patient complains of pain at IV
site assess for signs of infiltration
(warmth, redness, swelling) recognize
that lack of these signs may still repre-
sent an infiltration, and consider con-
sult with clinical nurse specialist/
charge nurse
IV, intravenous.
Goal: Safe acquisition and maintenance of venous access.
References: Garrett et al., 2004; Honiden, 2011; Honiden & McArdle, 2009; Pieracci et al., 2006.
Care of the Bariatric Patient in Acute Care PhillipsJOURNAL OF RADIOLOGY NURSING
� Pulses
B Respiratory ratedcount for 1 full minute
B Pulse oximetry
- Values may be obscured by adipose
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Deficit Assessment Nursing interventions
The bariatric patient is at higher risk for the
development of DVT/PE:
IVC filter candidate
� Venous stasis disease
� BMI O50 kg/m
� Truncal obesity
� Previous PE
� History of DVT (patient), and family
history of blood disorder
� Clinical signs of DVT are often absent
� Assess patient for sudden onset of ta-
chypnea, acute desaturation, increased
work of breathing
� All patients will have two forms of DVT
prophylaxis (mechanical and
� Assure proper fit of compression boots
or foot pumps
B Assure compliance with wearing
� Ambulate as tolerated based on preill-
ness mobility status
B Obtain bariatric walker
� Administer pharmacologic prevention
as ordered
B Provide patient education in prepa-
ration for discharge
DVT/PE, deep vein thrombosis/pulmonary embolism; IVC, inferior vena cava; BMI, body mass index.
Goal: Prevent the development of DVT and PE.
Reference: Pieracci et al., 2006.
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Deficit Assessment Nursing interventions
Atypical pressure ulcers
Found between intertriginous skin folds,
around catheters and tubes that burrow into
the body, and any other area of the body that
has been exposed to unrelieved pressure
� Poor vascularization associated with
adipose tissue places the morbidly
obese patient at a high risk for pressure
ulcer formation at these skin folds and
tubes site
� Moisture contributes to skinbreak-
down in skin folds
� Fungal infections thrive in dark, moist
areas frequently seen in the perineal
� Morbidly obese patients are frequently
unable to visualize or reach distal skin
� Capillary size and number, slower red
blood cell velocity, thus it takes longer
for skin to recover after pressure is
� Systematic skin assessment/inspection
every 12 hr
� Focus should be on skin folds and
catheters and tube placement. Skin
areas near catheters should be assessed
with each turn
� Target skin areas include abdomen,
breasts, back folds, thighs, posterior
neck, and perineal area
� Observe for progression of any fungal
� Provide the appropriate size bed to fa-
cilitate the repositioning of patient and
drains at frequent intervals, at least ev-
ery 2 hr
� Use appropriate size lifts when avail-
able for repositioning to prevent shear,
friction, and injury. If lifts are not
available, plan with appropriate num-
bers of staff to reposition patient on
a schedule. Engage the patient in the
plan and operaiton of turning schedule
� Catheters, tubes, and skin folds should
be assessed frequently and cleaned and
dried as necessary
� Reduce pressure within skin folds.
Position patient on side with pannus
(abdomen) positioned away from un-
derlying skin
� Apply antifungal powder to areas
affected with candidiasis. Use skin seal-
ants and protective ointments tomain-
tain skin integrity
� Provide nutrition to prevent catabolic
Poor wound healing � Assess oxygen status to assure ade-
quate oxygenation on a 24-hr basis
� Assess wound edges for signs of stress
on the incision including patient pain
or obvious separation of the incision
� Evaluate for a current nutrition plan
� Recommend pulmonary consult for
ventilation deficits (obesity hypoventi-
lation syndrome and sleep apnea)
� Use the appropriate size of surgical
binder to support abdomen
� Recommend nutrition consult to assur-
eadequate caloric intake
� Tubular mesh or mesh panties may be
used to keep dressing in place
Urinary incontinence � Frequent assessment of bed linen and
patient gown for presence of urine
� Obtain information from patient on
voiding strategy before hospitalization
� Promote frequent toileting by offering
thebedpan/urinal frequently
� Cleanse perineal area, and apply mois-
ture barriers especially within the peri-
neal folds.
� Consult occupational therapy for
equipment to enable patient to perform
self-perineal care
Goal: Provide skin maintenance and pressure ulcer prevention.
References: Lowe, 2009; Honiden & McArdle, 2009.
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