Nursing

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After reading the article you should be able to:

1. Compare and contrast gastroplasty, gastric banding, and gastric bypass.
2. Discuss nursing and medical management for an overweight or obese patient.
3. Develop a plan of care for the patient undergoing surgery for treatment of morbid obesity.

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By ELIZABETH PETTIT, RN, BSN

ELIZABETH PETTIT is an assistant professor at Big Sandy Community and Technical College's Mayo Campus in Paintsville, KY. She also works as a critical care nurse at the Highlands Regional Medical Center in Prestonburg, KY. The author has no financial relationships to disclose. STAFF EDITOR: MARTHA K. RAYMOND, RN, BSN, BS

Obesity is defined as excess body fat determined by measurement of body mass index (BMI) of 30 kg/m² or more, usually due to an imbalance between intake and expenditure.¹ According to the 2003-2004 National Health and Nutrition Examination Survey (NHANES), an estimated 66% of adults in the United States are overweight or obese.² Overweight is defined as having a BMI of 25 kg/m² to 29.9 kg/m².¹ Costs of obesity in the U.S. are estimated at 5% to 8% of total healthcare spending, equal to approximately $90 billion annually.¹

People who are overweight or obese are more likely to develop health problems such as hypertension, hyperlipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, obstructive sleep apnea, and cancers, including endometrial, breast, prostate, and colon cancer. Weight loss can help reduce the chances of developing these health problems. Reducing body weight by even 5% to 10% can improve a person's health.³ If obesity can be effectively treated, quality of life can be improved with an improvement in comorbidities and reduction in mortality.⁴ Understanding how to identify, evaluate, and treat overweight and obese adult patients helps the nurse develop a plan of care and guide the patient towards wellness.

If a person has a parental history of obesity, history of high birth weight, or low socio-economic status, he or she is more at risk for becoming overweight or obese.⁵ Sleeping less than eight hours per day has been shown to increase BMI proportional to the sleep deficit.⁶ Other risk factors include coronary heart disease, type 2 diabetes, sleep apnea, osteoarthritis, gallstones, stress incontinence, cigarette smoking, hypertension high LDL-cholesterol, low HDL-cholesterol, impaired fasting glucose, family history of premature myocardial infarction or sudden death before age 55 in the father, or before age 65 in the mother.⁷ Other risk factors include high serum triglycerides and physical inactivity.⁷

Risk factors for adult obesity can start as early as childhood. Children and adolescents who consumed sugar beverages, didn't breastfeed, and watched television may be more likely to beome obese. Therefore, modifying these practices early may help prevent adult obesity.⁵

Discussing the patient's history of both successful and unsuccessful weight loss attempts may reveal a pattern of eating. Maybe the patient has an easier time sticking to a diet during times of stress or maybe it's more difficult. Also, evaluate the support system. Maybe family members continue a habit of before bedtime ice cream and offer some to your patient even though she's trying to lose weight. In addition, some people don't understand the causes of obesity and the problems it can lead to. Maybe a lack of education has thwarted weight loss. If the person is against physical activity or struggles to participate, weight loss will be more difficult. After assessing possible weight-loss obstacles, the healthcare provider can better explain the particular treatment prescribed by the practitioner. Explain what to expect, making sure that he or she understands the procedure.

DIAGNOSIS Waist circumference—at least 40 inches in men and 35 inches in women is often the first thing people notice. However, what's invisible are the comorbidities such as hypertension, joint pain, and swelling.¹ Obesity is mainly clinically diagnosed from BMI. However, ruling out other causes such as hypothyroidism, Cushing's syndrome, insulinoma, and chronic use of steroids is important.¹ Laboratory tests identify problems related to excess weight, such as hyperlipidemia and diabetes. The heathcare provider can use thyroid function tests, cortisol level, and insulin level with c-peptide measurements to rule out other causes of obesity.¹ The obese person's lipid profile and fasting glucose should be checked.⁵

TREATMENT AIMS The first goal is to prevent further weight gain. Next is to reduce body weight. The third goal is to maintain the weight loss over the long term.⁷ Risk factor modification is another goal.¹ Within the first year, reasonable expectations include weight loss of 1 to 2 pounds per week over a 6 to 12 month period and a loss of 10% of total body weight. Weight loss usually continues for up to five years. This should be followed by long-term maintenance of reduced weight.¹ Research shows that unless a weight maintenance program of diet therapy, physical activity, and behavior therapy is continued for life, lost weight will usually be regained.⁷ Interventions for weight loss include lifestyle changes ? diet, exercise, and behavior modification ? drug therapy, complementary or alternative therapy, and surgery.⁵ All obese patients with a BMI equal to 30 kg/m² or more should be counseled on lifestyle and behavioral modifications such as diet and exercise. Goals should be individually determined. For patients who have failed to achieve weight loss goals via diet and exercise, the heathcare provider can offer drug therapy. Before actually beginning the selected drug therapy, make sure to discuss drug side effects, lack of long-term safety data, and the fact that weight loss with medications is only temporary. Drug therapy options include sibutramine (Meridia), orlistat (Xenical), phentermine (Adipex, Zantryl), diethylpropion (Tenuate), fluoxetine (Prozac, Sarafem), and bupropion (Wellbutrin SR, Wellbutrin XL, Zyban). Choice will depend on side effects of the drug and the individual's tolerance of the side effects.

Surgery should be considered as a treatment option for morbidly obese patients. These patients have a BMI of 40 kg/m² or greater or a BMI of 35 kg/m² or greater plus a weight-related comorbid condition. These conditions include hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. The discussion of surgical options should include the long-term side effects, such as possible need for re-operation, gallbladder disease, and malabsorption. If the patient chooses surgery, refer to a high-volume center with surgeons experienced in bariatric surgery.⁸

SURGICAL OPTIONS Research has shown surgery to be the most beneficial for long-term successful results in the treatment of morbid obesity.⁹ The surgical procedures that will be discussed here include gastric bypass, gastroplasty, and gastric banding. The three most commonly performed worldwide are laparoscopic gastric bypass, laparoscopic adjustable banding, and open gastric bypass.⁹ The goal of surgery is to reduce weight and maintain the loss via restriction of intake or malabsorption of food, or a combination of both.⁹

GASTRIC BYPASS This procedure combines restrictive and malabsorption techniques, creating a small 30 ml gastric pouch¹⁰ and a bypass that prevents the patient from absorbing all they have consumed. The resectional bypass consists of a subtotal gastrectomy with a Roux-en-Y reconstruction. Typically, a specialist performs this major operation, which is irreversible.⁹ It guarantees weight loss, but does have complications, including leaks at the junction of the stomach and small intestine, failure of the stomach's staple partition, and acute gastric dilation, either spontaneously or due to a blockage at the Y shaped anastomosis.⁹ Other post-surgical complications include vomiting, hernias at the wound site, intestinal obstruction, anemia due to malabsorption of iron, vitamin B12, and calcium deficiency, and dumping syndrome.

The most serious complication and the most common cause of death is an anastomstic leak. Signs and symptoms include increasing pain in the left shoulder or back, substernal pressure, pelvic pain, and abdominal pain. Additional signs include restlessness and hiccups. Unexplained tachycardia—pulse rate greater than 120 beats per minute—after the first 12 hours of the operation can indicate gastric dilatation, a leak, or peritonitis. Unexplained oliguria can also point to an anastomotic leak.

Dumping syndrome is seen as postprandial diarrhea. It occurs because sugars enter the small intestine without being diluted by gastric secretions. It occurs in about 70% to 75% of patients who have had gastric bypass surgery. Rapid gastric emptying lets large volumes of hyperosmolar chyme into the small bowel. Eating small frequent meals and little or no refined sugar alleviates the syndrome. Assessment shows tachycardia, nausea, tremor, diarrhea, and faint feeling. It is thought to aid weight loss by conditioning the patient to avoid eating sweets.⁹

GASTROPLASTY In this procedure, the stomach is partitioned into two parts. A small segment at the top of the stomach is partially separated from the rest with only a small gap, a stoma, remaining. This can be done to the stomach either horizontally or vertically. The procedure works by causing a sensation of fullness from only eating a small amount of food.⁹ Vertical banding can be done laparoscopically. The advantage of vertical banded gastroplasty is that it is a restrictive procedure with no malabsorption component. Complications are rare with a low postoperative mortality rate. Other complications include bolus obstruction, suture line stenosis, esophageal and stomach ulceration, wound infection, and pouch dilation.⁹ This procedure is reversible.⁹

GASTRIC BANDING In this surgery, a constricting ring is placed completely around the fundus of the stomach, below the junction of the stomach and the esophagus. The band works by limiting the amount of food that can pass from the esophagus into the stomach. The bands now used are adjustable. They have an inflatable balloon in the lining of the band that can be adjusted to increase or decrease the amount of restriction and regulate food intake. Gastric banding can be done laparoscopically, decreasing the length of stay at the hospital. Band adjustment is be done in the office by adding or removing saline through a subcutaneous port connected to the band, making the band tighter or looser. Since this is a restrictive procedure, there are no complications of malabsorption.¹¹

Complications that do occur include accidental injury to the spleen, esophageal injury, slipping of the band, infection, leaking of the inflation system, vomiting, acid reflux, and failure to lose weight.⁹ The main advantage of laparoscopic adjustable gastric band is the ability to control the degree of restriction through intermittent adjustments of the device.

INTRAGASTRIC BALLOON This device is designed as a temporary aid that is passed into the stomach via endoscopy and reduces the stomach capacity by inflating a balloon at the end of the device. The use of the intragastric balloon (IGB) causes a sense of satiety with a smaller amount of food intake. There are some absolute contraindications for use of the IGB, these include the presence of a hiatal hernia, varicose veins in the esophagus, abnormalities of the pharynx and esophagus, use of anti-coagulants or anti-inflammatory drugs, pregnancy, or psychiatric disorders. Esophagitis and ulcers of gastric mucous membranes are relative contraindications. Complications of IGB are due to perforation, prolonged contact with mucous membranes or migration that can lead to esophageal or intestinal obstruction.¹² Patients after bariatric surgery are at increased risk for aspiration pneumonia and atelectasis. Soon after waking, patients should be encouraged to cough, take deep breaths, and use incentive spirometry. Also monitor the patient's blood pressure, arterially if possible; ventilator pressures, for compliance; peripheral pulses, with Doppler if necessary; arterial blood gases, to assess adequacy of oxygenation and for carbon dioxide retention. With IGB, patients usually demonstrate a maximum reduction in the amount of food consumed around the fourth week and return to normal intake after 12 weeks.¹²

GENERAL COMPLICATIONS Obese patients are at a higher risk for immobility complications, which can lead to deep vein thrombosis, pulmonary embolism, respiratory failure, and impaired skin integrity.¹² Following surgery, obese patients are more susceptible to clots and less able to break them down, which predisposes them to thrombus formation. Prophylactic anticoagulants are often subcutaneous low-molecular weight or unfractionated heparin.

In case of respiratory failure, endotracheal intubation requires body adjustments because of abdominal adiposity. Placing a patient in a reverse Trendelenburg position—head higher than the pelvis—may facilitate intubation.¹² Layering blankets under the upper body positions obese patients in a "ramped" rather than in a standard "sniff" position to ease airway insertion. In addition, hypoventilation and obstructive sleep apnea are often seen in bariatric patients. Anesthetics—as well as intraoperative—and postoperative medications may escalate these conditions, induce hypoxia, and increased arrhythmia risks.

Common cardiovascular problems are due to an increase in total blood volume and resting stroke volume, which increases the cardiac output. The more tissue a person has, the more blood vessels and blood volume. This increases the workload of the heart and places the post surgical pateint at risk for congestive heart failure, acute myocardial ischemia, and sudden cardiac death.¹³During the post-op period, it's essential to monitor central venous oxygen saturation, central venous pressure, cardiac rhythm and rate, respiratory rate, blood pressure, and oxygen saturation.¹³

Wound healing may be delayed because of decreased vascularity in adipose tissue. Patients with an open wound require dressing changes per a physician's order. Detailed documentation is necessary and should include assessment of wound bed and the type, color, and amount of drainage as well as the appearance of periwound tissue. Keep the areas clean and dry to minimize risk of skin ulceration and erosion, especially in skin folds.

Surgery results in 20 kg to 30 kg of weight loss that can be maintained up to 10 years or more. With less weight, several comorbid conditions improve such as hypertension, diabetes, and sleep apnea.¹⁰ No less important , is the weight loss improves the person's self esteem, social functioning, and sense of well-being.¹⁴

References

1. Ferri, F. F. (2008). Ferri's clinical advisor: instant diagnosis and treatment. Philadelphia: Mosby.

2. Centers for Disease Control. (Sept. 9, 2008). National Center for Health Statistics. Prevalence of overweight and obesity among adults: United States, 2003-2004. Retrieved Jan. 8, 2009. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_adult_03.htm

3. Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion (June 20, 2008). Healthy weight. What is healthy weight loss? Retrieved Jan. 6, 2009. http://www.cdc.gov/NCCdphp/dnpa/healthyweight/losing_weight/index.htm

4. Hainer, V., Toplak, H., & Mitrakou, A. (2008). Treatment modalities of obesity. Diabetes Care, 31, S269-S277.

5. Sheperd, T. M. (January 2003). Effective management of obesity. The Journal of Family Practice, 52(1), 34-41.

6. Bellar, A., Jarosz, P. A., & Bellar, D. (2008). Implications of the biology of weight regulation and obesity on the treatment of obesity. J Am Acad Nurse Pract, 20(3), 128-135.

7. National Heart, Blood and Lung Institute (Aug. 2005). U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Blood and Lung Institute. Aim for a Healthy Weight. Retrieved Jan. 20, 2009. http://www.nhlbi.nih.gov/health/public/heart/obesity/aim_hwt.pdf

8. Snow, V., Barry, P., et al. (2005). Pharmacologic and surgical management of obesity in primary care: A clinical guideline from the American College of Physicians. Annals of Internal Medicine, 142(7), 525-531.

9. Colquitt, J., Clegg, A., et al. (2005). Surgery for morbid obesity. Cochrane Database of Systematic Reviews 2005, Issue 4.

10. Maggard, M. A., Shugarman, L. R., et al. (2005). Meta-analysis: surgical treatment of obesity. Annals of Internal Medicine, 142(7), 547-557.

11. Cleveland Clinic. (2005). Cleveland Clinic Bariatric and Metabolic Institute. Surgical weight loss. Surgery overview. Laparoscopic adjustable gastric banding. Retrieved Jan. 6, 2009. http://my.clevelandclinic.org/bariatric_surgery/surgical_weight_loss/overview/default.aspx

12. Fernandes, M., Atallah, A. N., et al. (2007). Intragastric balloon for obesity. Cochrane Database of Systematic Reviews 2007, Issue 1.

13. Barth, M. M., & Jenson, C. E. (2006). Postoperative nursing care of gastric bypass patients. American Journal of Critical Care, 15(4), 378-387.

14. Shaw, K., O'Rourke, P., et al. (2005). Psychological interventions for overweight or obesity. Cochrane Database of Systematic Reviews 2005, 2.

COMPLICATIONS

Complications are possible in any bariatric surgery due to patients' comorbid conditions. Complications can be classified as early or late. Early postoperative complications occur within the first 30 days after the operation and late postoperative complications occur after the first 30 days.

EARLY COMPLICATIONS

• Wound infection/sepsis
• Anastomotic leak
• Immobility
• Embolism
• Deep vein thrombosis
• Respiratory failure
• Impaired skin integrity
• Vomiting and diarrhea
• Aspiration pneumonia
• Atelectasis

LATE COMPLICATIONS

• Nutritional deficiencies
• Anemia
• Dumping syndrome
• Incisional hernia
• Cholelithiasis
• Bolus obstruction
• Suture line stenosis
• Migration that can lead to esophageal or intestinal obstruction
• Esophageal and stomach ulceration
• Pouch dilation

Sources:

Barth, M. M., & Jenson, C. E. (2006). Postoperative nursing care of gastric bypass patients. American Journal of Critical Care, 15(4), 378-387.

Colquitt, J., Clegg, A., et al. (2005). Surgery for morbid obesity. Cochrane Database of Systematic Reviews 2005, Issue 4.

Fernandes, M., Atallah, A. N., et al. (2007). Intragastric balloon for obesity. Cochrane Database of Systematic Reviews 2007, Issue 1.

PSYCHOSOCIAL SUPPORT

PSYCHOLOGICAL SUPPORT is vital when caring for patients with morbid obesity. From the preoperative phase to long-term postoperative care patients need encouragement. Patients often have low self-esteem and feel fear, shame, and embarrassment.

Nonjudgmental supportive care includes behavioral therapy, education, support groups, and counseling. A professional attitude helps develop a therapeutic relationship, which is important when determining collaborative goals. These relationships enhance the outcomes for the patients.

Barth, M. M., & Jenson, C. E. (2006). Postoperative nursing care of gastric bypass patients. American Journal of Critical Care, 15(4), 378-387.

EQUIPMENT

SPECIAL EQUIPMENT TO CARE for the bariatric patient provides optimal patient management and care. Bariatric beds, mechanical patient lifts, trapezes on beds, air-assisted transfer devices, and other safety-promoting equipment is encouraged.

Chairs, beds, and commodes need to support patients weighing from 300 lb to 800 lb. In addition, transport carts and wheelchairs should be available for the bariatric patient. Specialized diagnostic imaging equipment for computed tomography, magnetic resonanceimaging, and radiography is required for these patients.

Source. Barth, M. M., & Jenson, C. E. (2006). Postoperative nursing care of gastric bypass patients. American Journal of Critical Care, 15(4), 378-387.