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Obesity Full Guideline

Obesity Full Guideline - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines, Related


Intended Users
ξ Registered Nurses
ξ Any direct care providers who care for this patient population
Target Population
Obese patients, including those undergoing bariatric surgery, cared for within the UW
Health system.
Nursing Practice Guideline Objective(s)
To describe best practices surrounding the care of obese patients. Specifically, this
guideline addresses:
ξ Nursing assessment
ξ Safe patient handling
ξ Bias
ξ Nursing considerations related to bariatric surgery
Clinical Questions Considered
When caring for obese patients:
ξ How does knowledge of a modified nursing assessment influence the nurses’
ability to optimize care and proficiency in this specialty population?
University of Wisc onsin
Hosp ita ls and Clinic s
Nursing Practice Guidelines
September 2013
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

ξ How does a safe patient handling program and related equipment influence staff
or patient injuries and patient’s perception of care?
ξ How does awareness of bias affect healthcare interventions and patient
perception of care?
ξ What nursing considerations are needed to optimize care for bariatric surgical
Major Outcomes Considered
Registered Nurses have evidence-based resources to improve the quality of care
through improved assessment, use of safe patient handling equipment, recognition
and reduction of bias, and interventions specific to the bariatric surgery population.
Description Of Methods Used To Collect/Select the Evidence
The literature search began with a search for external, pre-existing guidelines utilizing
AHRQ’s National Guideline Clearinghouse searching for “obesity” and “bariatric.” Nine
(9) guidelines were reviewed and determined to not meet the needs of the intended
users. In a search for individual studies to guide our practice recommendations, the
guideline development group conducted a literature review in both CINAHL and PubMed
for each clinical question. These terms were searched individually and in combination:
nursing care, Bariatric surgery, weight loss surgery, standards of care, complications,
assessment, postoperative, nurse, nursing, obesity, physical assessment, assessment,
Bariatric, nursing assessment, safe patient handling, patient handling, mobility, bias,
healthcare, stigma, and stereotype.
Methods Used To Assess The Quality And Strength Of The Evidence
The following rating scheme was utilized to identify to strength of each individual study.
Rating Scheme For The Strength Of The Evidence
Strongest (I) – Weakest (VII) as follows:
A systematic review of meta-analysis of all relevant Randomized Clinical
Trials (RCT) or Evidence Based Practice (EBP) Clinical Guidelines on
systematic reviews of RCTs
II At least one properly designed RCT of appropriate size
III Well designed trials without randomization
IV Well designed single group pre-post cohort, time series, or matched
case-control studies
V Systematic review of well-designed descriptive and qualitative studies
VI Single experimental, quasi-experimental, non-experimental (descriptive
or qualitative) study
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

VII Opinion of respected authorities, based on clinical evidence, descriptive
studies or reports of expert committees.
Description Of Methods Used To Formulate The Recommendations
Guideline developers reviewed the tables of evidence developed by individual
workgroup members. These tables of evidence guided the writing of recommendations
based on the best available evidence. Guideline recommendations addressed
assessment, bias, safe patient handling and bariatric surgery. The guideline group
reviewed the evidence and developed recommendations by consensus.
Rating Scheme For The Strength Of The Recommendations
Category Description
for Practice:
Interventions for which effectiveness has been demonstrated by strong
evidence from rigorously designed studies, meta-analysis, or systematic
reviews, and for which expectation of harm is small compared to the
Likely to be
Interventions for which effectiveness has been demonstrated from single
rigorously conducted controlled trial, consistent supportive evidence from
well-designed controlled trials using small samples, or guidelines
developed from evidence and supported by expert opinion.
Balanced with
Interventions for which clinicians and patients should weight the beneficial
and harmful effects according to individual circumstances and priorities.
Not Established:
Interventions for which insufficient or conflicting data or data of
inadequate quality currently exist, with no clear indication of harm.
Interventions for which lack of effectiveness has been demonstrated by
negative evidence from a single rigorously conducted controlled trial,
consistent negative evidence from well-designed controlled trials using
small samples, or guidelines developed from evidence and supported by
expert opinion.
for Practice:
Interventions for which lack of effectiveness or harmfulness has been
demonstrated by strong evidence from rigorously conducted studies,
meta-analyses, or systematic reviews, or interventions where the costs,
burden, or harm associated with the intervention exceed anticipated
Description Of Method Of Guideline Validation
Content of this guideline has been validated by the Nursing Practice Guideline
Committee. Additionally, external reviewers representing non-nursing disciplines in adult
and pediatric practice areas provided feedback on the guideline to ensure content
validity. The Nursing Practice Council reviewed and approved the guideline.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

The Centers for Disease Control and Prevention (CDC) defines both overweight and
obesity as “labels for ranges of weight that are greater than what is generally considered
healthy for a given height. The terms also identify ranges of weight that have been
shown to increase the likelihood of certain disease and other health problems (CDC,
2012).” Overweight and obesity are determined by calculating the body mass index, or
BMI. For adults, a BMI between 25 and 29.9 is considered overweight and a BMI of
greater than 30 is considered obese. In children, a percentile is utilized to classify a
child as overweight (85th to less than 95th percentile) or obese (95th percentile or higher)
when compared to children of the same age and sex (CDC, 2012).
Over the last 20 years the rates of obesity have dramatically increased in the United
States. “More than one-third of U.S. adults (35.7%) and approximately 17% (or 12.5
million) of children and adolescents aged 2 - 19 years are obese” (Ogden, Carroll, Kit, &
Flegal, 2012). Some of the leading causes of preventable death are associated with
obesity including, “heart disease, stroke, type 2 diabetes and certain types of cancer”
(CDC, 2012). As the prevalence of Americans who meet the overweight and obese
criteria increase, so do the associated health conditions. The combination of these two
factors will increase the number of people who are seeking healthcare in both the clinics
and in the hospital.
This Nursing Practice Guideline is a revision of the 2008 Care of the Bariatric Patient
Guideline. It describes the best practices surrounding the care of obese patients,
specifically addressing nursing assessment, safe patient handling, bias, and nursing
considerations related to bariatric surgery. These topics were chosen based on
discussion with content experts, the guideline development group, and members of the
UWHC Nursing Practice Council.
1. Nurses should modify assessment techniques when caring for obese patients.2,13,23,25,27
o Altered assessment techniques are needed to properly assess each system given
the potential physiologic and structural changes that occur with obesity. (Phillips,
2013; Rush & Muir, 2012; Sherwood, Bauman, & Shephard, 2012; Bahamman &
Al-Jawder, 2012; Honiden & McArdle, 2009). The pulmonary, cardiovascular,
endocrine, and integumentary systems are most affected by increased body mass
causing such complications as pulmonary dysfunction, increased deep vein
thrombosis (DVT)/pulmonary embolism (PE) risk, infiltration of intraveneous lines,
atypical pressure ulcers, poor wound healing, urinary incontinence, hypertention
and dysrhythmias (Phillips, 2013). Specific assessment techniques are detailed in
the companion document (Phillips, 2013).
Likely to be effective:
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

2. Appropriate safe patient handling equipment should be available and education provided
for all staff members who care for obese patients to prevent staff and patient injury during
o There is strong empirical evidence specific to safe patient handling but little
evidence specific to obesity (Galinsky, Hudock & Streit, 2010). The available
literature suggests that the use of established plans and/or protocols across the
continuum can facilitate safe patient handling (Lautz et al, 2009; McGinley &
Bunke, 2008; Muir & Archer-Heese, 2009; Muir, Heese, McLean, Bodnar & Rock,
2007; Safe Bariatric Patient Handling Toolkit, 2007). Additionally, education needs
to be provided to staff addressing proper utilization of available equipment and
resources (McGinley & Bunke, 2008; Muir & Archer-Heese, 2009).
3. Nurses should identify biases in providing care for obese patients.7,17,24,29,30
o Teixeira, Pais-Ribeiro, and Maia (2012) reported in a systematic review of beliefs
and practices of health care providers that biases and stereotypes held by
healthcare providers toward obese people are similar to those that are held by the
general public. Inconsistent practices among healthcare providers result from these
biases and stereotypes, as there is skepticism toward efficacy of interventions with
this population (Teixeira, Pais-Ribeiro, & Maia, 2012). Other studies report the
need for healthcare workers to reflect on and recognize their own attitudes toward
the weight of their patients and how these attitudes may affect the care they
provide (Teixeira & Budd, 2010). It is important for healthcare professionals to
understand that their own bias toward this population can lead to low self-worth
and self-esteem in their patients which can result in patients being hesitant or
resistant to participating in activities to improve their health and well-being (Lewis
et al, 2011). While there is limited evidence of how to help healthcare
professionals decrease their bias (Puhl & Heuer, 2009), one study does suggest
that comparing one’s own values and stigmas can be efficacious in decreasing
bias (Ciao & Latner, 2011).
4. Nurses should be knowledgeable about the various approaches to bariatric surgery and
resulting anatomical changes.1,3,4,8,9,11,12,14,22
o Multiple authors (Petit, 2009; Green, 2012; Gagnon & Karwacki, 2012; Harrington,
2006; Clutts, 2009; Ide, 2008; Baird et al, 2012; Apau & Whiteing, 2011; Barth &
Jenson, 2006) review the various bariatric surgical approaches as the foundation
for discussing appropriate assessments and interventions for this patient
population. To this end, it is important for nurses to understand the surgical
approaches utilized and the resulting anatomical changes in order to successfully
and comprehensively care for this patient population.
5. Nurse should be aware of potential post-operative complications of bariatric surgery to
guide assessment and care.1,8,9,12,22
o Complications of bariatric surgery are included in the companion document. While
these complications are similar to those of other abdominal surgery, the
presentation of the complication may be altered in this patient population; for
example, unexplained tachycardia, dyspnea, and restlessness may be the only
signs and symptoms of an anastomotic leak (Apau & Whiteing, 2011; Harrington,
2006). Additionally, obese patients are at greater risk for postoperative
complications such as deep vein thrombosis, respiratory failure and impaired skin
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

integrity (Apau & Whiteing, 2011; Clutts, 2009; Petit, 2009). In addition to
immediate postoperative complications, nurses should be aware of complications
such as dumping syndrome, nutritional and psychosocial complications (Apau &
Whiteing, 2011; Clutts, 2009; Gagnon & Karwacki, 2012; Petit, 2009).
6. Nurses should be aware of the unique pre-and post-operative psychosocial needs of those
undergoing bariatric surgery. Assessment and advocacy for appropriate referrals should
be made by the nurse across the continuum of care.15,28
o Following patients one year postoperatively, qualitative studies capture the lived
experiences of those undergoing bariatric surgery. Patients describe the
experience as “life changing” (Sutton, Murphy & Raines, 2009) and as a “paradox”
(LePage, 2010). Patients report a variety of experiences, including “surgery as
renewed hope, finding balance, filling the void, and transformation of self-image”
(LePage, 2010, p. 57). These studies highlight the importance of following patients’
psychosocial needs, along with medical and physical needs, in the postoperative
period and at least one year after surgery.
o Nurses should understand that these patients report alterations in coping
mechanisms after surgery. Nurses could be instrumental in providing or advocating
for resources that would assist with the development of healthy coping strategies.
Studies show that for many, food was utilized as a coping mechanism before
surgery; postoperatively the replacement coping mechanisms were unhealthy,
such as bulimia, illicit drug use, and excessive shopping (LePage, 2010).
7. Nurses should provide patient education to bariatric surgery patients relevant to their
unique self-management needs (such as dietary progression, potential for nutritional
deficits, medication regimen, incisional care, signs and symptoms to report that could
indicate complications, importance of physical activity, and information about support
o Effective patient education contributes to successful patient self-management.
Patients must be able to recognize signs and symptoms of possible post-operative
complications in order to seek care in a timely way. Patients must also be
knowledgeable enough to be able to advocate for themselves when interacting with
clinicians who are not as familiar with post-operative surgical complications.
Patients who do not understand or adhere to specific self-management needs after
surgery will be less successful in maintaining optimal health. (Gagnon & Karwacki,
2012; Harrington, 2006; Ide, 2008).
Companion Documents and Resources
ξ Assessment Resource (Phillips, 2013)
ξ Safe Movement and Repositioning Techniques (SMART) Resources and Tips (U-
Connect: https://uconnect.wisc.edu/clinical/patient-safety/quality-safety/smart-
ξ BMI (Body Mass Index) Chart
ξ Bed Use Algorithm (Adult)
ξ Bed Use Algorithm (Pediatrics)
o Selection of Therapeutic Pressure Redistribution Support Surfaces for
Patients with BMI < 55 – Pediatrics
o Selection of Therapeutic Pressure Redistribution Support Surfaces for
Patients with BMI > 55 – Pediatrics
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

ξ Bariatric Resource Grid
ξ Wound and Skin Resources (U-Connect: https://uconnect.wisc.edu/clinical/nursing-
ξ Bariatric Surgery Complications Resource
Availability Of Companion Documents
U-Connect, Nursing Practice Guidelines webpage will link to available resources and
companion documents.
Patient Resources
Health Facts for You #7750: The Roux-en-Y Gastric Bypass Surgery
Health Facts for You #7751: Laparoscopic Adjustable Gastric Band Surgery
Health Facts for You #327: Eating after Gastric Bypass or Sleeve Surgery
Bariatric Surgery Support Group
References Supporting The Recommendations
NOTE: Level of evidence appears after the reference.
1. Apau, D., & Whiteing, N. (2011). Pre- and post-operative nursing considerations of
bariatric surgery. Gastrointestinal Nursing, 9(3), 44-48. VII
2. Bahammam, A. S., & Al-Jawder, S. E. (2012). Managing acute respiratory
decompensation in the morbidly obese. Respirology, 17(5), 759-771. doi: 10.1111/j.1440-
1843.2011.02099.x VII
3. Baird, G., McGuire, J., Dahlby, M., Kaehler, B., & Wood, L. (2012). Overview of bariatric
surgeries and related complications. Med-Surg Matters, 21(3-4), 20-23. VII
4. Barth, M. M., & Jenson, C. E. (2006). Postoperative nursing care of gastric bypass
patients. American Journal of Critical Care, 15(4), 378-388. VII
5. Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity and
Obesity, National Center for Chronic Disease Prevention and Health Promotion. (2012).
Defining Overweight and Obesity. Retrieved from
http://www.cdc.gov/obesity/adult/defining.html. VII
6. Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity and
Obesity, National Center for Chronic Disease Prevention and Health Promotion. (2012).
Basics About Childhood Obesity. Retrieved from
http://www.cdc.gov/obesity/childhood/basics.html. VII
7. Ciao, A. C., & Latner, J. D. (2011). Reducing obesity stigma: the effectiveness of cognitive
dissonance and social consensus interventions. Obesity (19307381), 19(9), 1768-1774.
doi: 10.1038/oby.2011.106 II
8. Clutts, B. J. (2009). Recognition and management of complications following Roux-en-Y
gastric bypass: a guide for health care workers in non-bariatric hospitals. Medsurg Nurs,
18(6), 335-341. VII
9. Gagnon, L. E., & Karwacki Sheff, E. J. (2012). Outcomes and complications after bariatric
surgery. Am J Nurs, 112(9), 26-36, quiz 51, 37. doi:
10.1097/01.NAJ.0000418920.45600.7a VII
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

10. Galinsky, T., Hudock, S., & Streit, J. (2010). Addressing the need for research on bariatric
patient handling. Rehabilitation Nursing, 35(6), 242-247. VII
11. Green, N. (2012). Bariatric surgery: an overview. Nursing Standard, 26(36), 48-56. VII
12. Harrington, L. (2006). Postoperative care of patients undergoing bariatric surgery.
MEDSURG Nursing, 15(6), 357-363. VII
13. Honiden, S., & McArdle, J. R. (2009). Obesity in the intensive care unit. Clinics in Chest
Medicine, 30(3), 581-+. doi: 10.1016/j.ccm.2009.05.007 VII
14. Ide, P., Farber, E. S., & Lautz, D. (2008). Perioperative nursing care of the bariatric
surgical patient. AORN Journal, 88(1), 30-58. doi: 10.1016/j.aorn.2008.02.015 VII
15. LePage, C. T. (2010). The lived experience of individuals following Roux-en-Y gastric
bypass surgery: a phenomenological study. Bariatric Nursing & Surgical Patient Care,
5(1), 57-64. doi: 10.1089/bar.2009.9938 VI
16. Lautz, D. B., Jiser, M. E., Kelly, J. J., Shikora, S. A., Partridge, S. K., Romanelli, J. R., . . .
Ryan, J. P. (2009). An update on best practice guidelines for specialized facilities and
resources necessary for weight loss surgical programs. Obesity (19307381), 17(5), 911-
917. doi: 10.1038/oby.2008.581 V
17. Lewis, S., Thomas, S. L., Blood, R. W., Castle, D. J., Hyde, J., & Komesaroff, P. A. (2011).
How do obese individuals perceive and respond to the different types of obesity stigma
that they encounter in their daily lives? A qualitative study. Social Science & Medicine,
73(9), 1349-1356. doi: 10.1016/j.socscimed.2011.08.021 VI
18. McGinley, L. D., & Bunke, J. (2008). Best practices for safe handling of the morbidly obese
patient. Bariatric Nursing & Surgical Patient Care, 3(4), 255-260. VII
19. Muir, M., & Archer-Heese, G. (2009). Essentials of a bariatric patient handling program.
Online Journal of Issues in Nursing, 14(1), 1-1. VII
20. Muir, M., Heese, G. A., McLean, D., Bodnar, S., & Rock, B. L. (2007). Handling of the
bariatric patient in critical care: a case study of lessons learned. Crit Care Nurs Clin North
Am, 19, 223-240. United States. VII
21. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prevalence of obesity in the
United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD: National Center for
Health Statistics. VII
22. Pettit, E. (2009). Treating morbid obesity: surgery is often a last resort, but can be a life-
saving choice that improves self-esteem and overall quality of life. RN, 72(2), 30-35. VII
23. Phillips, J. (2013). Care of the bariatric patient in acute care. Journal of Radiology Nursing,
32(1), 21-31. doi: 10.1016/j.jradnu.2012.07.002 VII
24. Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: a review and update. Obesity
(Silver Spring), 17, 941-964. United States. V
25. Rush, A., & Muir, M. (2012). Maintaining skin integrity bariatric patients. Br J Community
Nurs, 17(4), 154, 156-159. VII
26. Safe bariatric patient handling toolkit. (2007). Bariatric Nursing & Surgical Patient Care,
2(1), 17-45. VII
27. Sherwood, S. F., Bauman, M., & Shephard, A. (2012). Pulmonary considerations and
management of the morbidly obese patient. Bariatric Nursing and Surgical Patient Care,
7(4), 160-166. doi: 10.1089/bar.2012.9962 VII
28. Sutton, D. H., Murphy, N., & Raines, D. A. (2009). Transformation: the "life-changing"
experience of women who undergo a surgical weight loss intervention. Bariatric Nursing &
Surgical Patient Care, 4(4), 299-306. doi: 10.1089/bar.2009.9948 VI
29. Teixeira, F. V., Pais-Ribeiro, J. L., & Pinho da Costa Maia, A. R. (2012). Beliefs and
practices of healthcare providers regarding obesity: a systematic review. Revista Da
Associacao Medica Brasileira, 58(2), 254-262. V
30. Teixeira, M. E., & Budd, G. M. (2010). Obesity stigma: a newly recognized barrier to
comprehensive and effective type 2 diabetes management. Journal of the American
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

Academy of Nurse Practitioners, 22(10), 527-533. doi: 10.1111/j.1745-
7599.2010.00551.x V
Type Of Evidence Supporting The Recommendations (the type of supporting evidence is
identified and graded for each recommendation)
Describes the type of evidence supporting the recommendations.
Category Number of references (used in recommendations) in each category
I 0
II 1
IV 0
V 4
VI 3
VII 22
Potential Benefits
By implementing this guideline, nursing will further improve patient care which should
lead to optimal patient outcomes.
Potential Harms
There are no potential harms associated with implementing this guideline.
Description Of Implementation Strategy
Implementation strategies will vary based on practice improvement needs of individual
units/clinics using this guideline. Clinicians involved with implementation should evaluate
practice related to the guideline recommendations in order to identify gaps and prioritize
improvement plans.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org

Implementation Tools
Utilization of the Evidence-Based Practice Implementation Model from the University of
Iowa Hospital & Clincs (Cullen, L. & Adams, S., In review) is recommended.
Date Released (Revised)
2008 (revised 2013)
Guideline Sponsor
UWHC Nursing
Guideline Authors
Members of the Nursing Practice Guideline Committee
Guideline Availability
Guideline is available on UWHC intranet (i.e., U-Connect).
Guidelines are designed to assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Last Revised: 09/2013EArsenaultknudsen@uwhealth.org