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Preplanning With Protocols for Skin and Wound Care in Obese Patients

Posted on: Friday, 29 October 2004, 03:00 CDT

PURPOSE

To provide physicians and nurses with an overview of the impact of obesity on postoperative wound healing and how preplanning protocols can minimize skin and wound care problems in this patient population.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in reducing skin and wound care problems in their patients who are obese.

OBJECTIVES

After reading the article and taking the test, the participant will be able to:

1. Identify obesity-related changes in body systems and how these impede wound healing.

2. Identify complications of postoperative wound healing in obese patients and the assessments and intervention strategies that can reduce these complications.

3. Identify skin and wound care considerations for obese patients and the role of preplanning protocols in avoiding problems.

ADV SKIN WOUND CARE 2004;17:436-41; QUIZ 442-3.

According to the World Health Organization, the United States ranks fifth among the top 100 countries for obesity-related deaths.1 Two-thirds of Americans are overweight, defined as having a body mass index (BMI) greater than 25 (Table 1). As the number of larger patients increases, so do the health problems related to obesity, including diabetes, sleep disorders, lipedema, hypertension, soft tissue infection, some cancers, and impaired circulation, each of which interferes with the patient's level of health in general, and skin care in particular.

Many authors contend that from the onset, the obese patient is more challenging because diagnosis is difficult and treatment and procedures are technically more complicated and time-consuming.2 In the health care setting, the skin-the largest body organ-is at particular risk for injury in obese patients. Many wound care clinicians report concerns about inadequate equipment, education, and personnel to accommodate the needs of these patients, which leads to issues of skin and wound care. In addition, economic costs related to caring for this population are skyrocketing.3

Table 1.

BODY MASS INDEX CATEGORIES

DEFINING OBESITY

Morbid obesity, a term described by the American Society for Bariatric Surgery (ASBS) as synonymous with clinically severe obesity, is a disease of excess energy stored in the form of fat. The term bariatrics, derived from the Greek word baros,4 refers to the practice of health care relating to the treatment of obesity and associated conditions. The ASBS more specifically defines obesity as a lifelong, progressive, life-threatening, genetically related, multifactorial disease of excess fat storage with multiple comorbidities.5 In one sense, the cause of obesity seems straightforward, but in another, the etiologies of obesity are elusive and are more accurately thought to involve a complex and individual regulation of body weight, specifically body fat. This individual regulation is the unknown factor in weight management.6 Regardless, obesity, according to the National Institutes of Health, is simply a diagnostic category that represents a complex and multifactorial disease that has just recently been recognized by the Medicare programs.7

CHANGING DEMOGRAPHICS

Sixty-seven percent of Americans are overweight, 10% to 15% are considered obese, and 1 in 20 are categorized as morbidly obese.8 Morbid obesity, defined as a BMI greater than 40, was once thought to be rare. This is rapidly changing: The number of morbidly obese Americans has quadrupled since the 1980s to 6 million. Studies suggest a substantial increase in obesity among all age, ethnic, racial, and socioeconomic groups.9 In the early 1960s, only one- quarter of Americans were overweight; today, over two-thirds of adults are overweight, as are one-quarter of children.

Despite efforts at weight loss, Americans continue to gain weight. Obesity is a factor in 5 of the 10 leading causes of death.6 This chronic condition is considered the most common cause of early and preventable death in the United States.10 Besides the physiologic costs, the morbidly obese patient is at risk for emotional problems, such as situational depression; altered self- esteem; social isolation; and affective, anxiety, and, substance abuse disorders.11 Experts argue that it is likely society's response to the obese person that places the patient at risk for these emotional conditions.12

BARRIERS TO CHANGE

A survey of severely obese individuals found that nearly 80% reported disrespectful treatment from the medical community.13 The failure to ensure respect for, and understanding of, the bariatric patient (or obese people in general) is a significant concern.5 Obese Americans neither chose to be overweight nor chose to experience widespread prejudice and discrimination.14 Failure to provide equal or fair accommodation is often related to the lack of inadequate policies and procedures, which may be justified by blaming the patient's body weight for the condition he or she is in. This attitude transcends age, gender, and ethnicity.15'16 It is even observed among obese persons themselves.17'18 For example, a recent study reported that many obese people consider their weight a handicap greater than dyslexia, blindness, or deafness.19

In a culture that prizes thinness, obese people experience discrimination in schools, the workplace, and heath care settings.20 The general bias against obese people creates a barrier to change.21

The overwhelming misunderstanding of obesity is likely to interfere with preplanning efforts, access to services, and resource allocation. Although this misunderstanding is not universal, it is pervasive enough to pose obstacles, and clinicians interested in making changes will need to recognize the barriers.

ECONOMIC COST

The prevalence of obesity differs from region to region, and thus the costs vary. However, most research suggests that nationwide, Americans spend close to $117 billion on obesity related health care, with another $33 billion spent annually in attempts to control or lose weight.22 Nearly half the costs of obesity are paid out of tax-supported health insurance.3 Preplanning for care is thought to prevent some of the costly complications associated with caring for obese patients.

SKIN AND WOUND CONSIDERATIONS

Timely, appropriate assessment that leads to prevention of skin and wound complications is a cost-effective alternative to treatment- especially among heavier, more complex patients (see Skin Care Considerations). Preplanning provides for this early assessment and action. For example, pressure ulcers are related to pressure, friction, and shear; pressure seems to be a dominant factor in many cases. They generally develop over a bony prominence where soft tissue is damaged from external pressure exerted over the hard surface of the skeletal structure. Typically, they form over the back of the head, sacrum, heels, or any other area where prolonged pressure exists. In the obese patient, however, atypical pressure ulcers can occur within skin folds, where a catheter has burrowed into the skin surface, or over the hips bilaterally when the patient spends extended periods of time in a chair or wheelchair that is too narrow. Each of these situations can be prevented or controlled through early and knowledgeable skin assessment and by having correctly sized equipment for the patient. In the acute setting, the clinician must evaluate the skin surface in such a way that skin changes that could lead to atypical pressure ulcers are identified in a timely manner. A preplanning document for care is designed to outline appropriate care once the condition is assessed. In addition to having this plan for care, it is essential for the clinician to understand the pathophysiology of skin changes to make a knowledgeable assessment, such as redness or discoloration indicating changes occurring beneath the skin surface that put the patient at risk for skin breakdown.

MAKING CHANGES

In managing the skin care needs of the bariatric patient, preplanning for equipment has been thought to be the first step for intervention. Although this is an important step, it is simply not enough on its own. A comprehensive, interdisciplinary patient care approach is necessary, and should include a 1) bariatric task force; 2) a criteria-based protocol, which includes preplanning for size- appropriate equipment; 3) competencies/skill sets; and 4) outcome measurement efforts (see Development of a Bariatric Care Protocol).

The value of an interdisciplinary bariatric task force as the initial phase of planning cannot be overlooked. The bariatric task force is an interdisciplinary quality-improvement effort comprised of interested and diverse parties from a variety of disciplines. The task force is designed to address ongoing issues and ideas, and could include pharmacists; physical, occupational, and respiratory therapists; physicians; nurse practitioners; clinical nurse specialists; wound, ostomy, and continence nurses; and others. The inclusion of a patient representative is essential in that he or she understands the lived experience of being a larger, heavier patient.4

A criteria-based protocol is simply preplanning based on specifically designated criteria. These criteria can include the patient's weight, BMI, body width, and clinical condition.23 Actual weight is an important consideration with the equipment; if \the weight limit is exceeded, breakage, failure to function properly, or patient/caregiver injury can occur. Body width is described as the patient's body at its widest point, which could be at the patient's hips, shoulders, or across the belly when side-lying. Any clinical condition that interferes with mobility, such as pain, sedation, fear, or resistance to participate in care, places the patient at risk. Criteria-based protocols should be designed to meet the needs of the patient by ensuring access to resources, such as specialty equipment and clinical experts, in a timely, cost-effective manner.

Part of the preplanning effort must include provision for communication. Although sometimes difficult to arrange, a face-to- face interdisciplinary conference (planned within 24 hours of admission) may prevent costly intervention later.24 Consider including the patient and/or his or her significant other, as this offers insight into the patient's special needs. Documentation of meetings, individual patient care goals, and corresponding interventions improves consistency and accountability. This level of accountability more fully defines each clinician's responsibilities.

Education provided to ensure basic skills or competencies is imperative, and has become a critical part of any care plan. Consider conducting a survey to determine the actual learning needs of clinicians. The value of a diverse, interdisciplinary bariatric task force is that it serves to provide a pool of experts to develop educational efforts addressing clinical needs. For example, suppose clinicians are seeking information pertaining to sensitivity. A social worker, chaplain, nurse expert, and patient member of the task force could develop a module to teach these skills.

Outcomes studies are essential to ensure long-term success of a comprehensive bariatric program. Cost, clinical, and satisfaction research can be conducted to measure the value of an organizational improvement effort. Studies examining time from admission to equipment availability and incidence of skin injury, among others, will document (from a quality perspective) the value of a comprehensive bariatric care plan.

CONCLUSION

With obesity on the rise, wound care clinicians are increasingly responsible for managing the needs of this complex patient population. Although preplanning for equipment is a helpful adjunct to care, it is never a substitute for care. Numerous resources are available to clinicians across practice settings, and use of resources in a timely and appropriate manner are thought to measurably improve cost, clinical, and satisfaction outcomes. Coordinating these resources in the form of a comprehensive bariatric care plan may ensure the most favorable outcome. The obese patient holds numerous care challenges, and it is in the interest of health care organizations to meet these skin and wound care challenges in a clinically, ethically, and legally sound manner.

DEVELOPMENT OF A BARIATRIC CARE PROTOCOL

Suppose a 450-pound patient is admitted through the emergency department. Is the facility ready to meet the needs of this patient at every point of entry and every encounter within the facility? Consider these questions:

* Will the hospital bed on the unit accommodate the person's weight?

* Can the person fit into the magnetic resonance imaging scanner?

* Are appropriate respiratory supplies available in case of an airway emergency?

* Does confusion stemming from uncertainty with the plan of care cause fear and stress for the patient and the staff?

* How is patient and staff safety accomplished?

Clearly, a plan that will provide optimal care for the bariatric patient is needed.

University Medical Center, an acute care hospital with a Level 1 trauma center, is affiliated with the University of Arizona College of Medicine, Tucson, AZ. Although bariatric surgery is not performed at the hospital, the increasing number of bariatric patients being hospitalized there for various medical and surgical conditions prompted the development of a comprehensive bariatric care plan.

With support from hospital administration, a task force was convened. The task force began by having members draft content sections related to their specialty. All drafts were reviewed by the entire team and resulted in a final document that provided a seamless process of care among disciplines. The final draft was approved via the appropriate channels. Next, preprinted physician order forms were developed to reflect the protocol. Finally, the task force provided in-service education to clinical staff. Due to hospital policy, specific interventions were not included in the protocol. Instead, these points became "clinical pearls," accessible via a separate clinical Web site

The protocol was designed to accommodate the needs of inpatients with a BMI greater than 40, or if the patient is 100 pounds overweight and at risk for skin or pulmonary complications, has difficulty with movement, or needs special equipment. The paramount requirement was addressed: safety for the patient and staff. The staff is now empowered with information and resources to provide optimal care to the bariatric patient.

The following preprinted orders are applied for any patient meeting the above criteria.

BARIATRIC PRE-PRINTED ORDERS

Mark all areas that apply:

* A private room is to be assigned to the patient and is considered medically necessary.

* Skin consultation within 24 hours of admission

* Assess and document skin condition every 12 hours

* Nutrition consult

* Pharmacy consult

* Physical/occupational therapy consult

* Respiratory consult

* Endocrine consult for pediatrie patient

* Notify radiology 1 hour before any in-department procedure

* case management/social service consult for discharge planning needs

* Properly sized equipment

* 39'' if BMI < 50

* 48'' if BMI > 50

* Optional rotation therapy for skin or pulmonary complications

* Bed trapeze

* Lift and transfer system

* Wheelchair

* Regular back

* Reclining wheelchair

* Walker

* Commode

* Gown

All consultations are to be done and documented on the interdisciplinary flow sheet within 36 hours unless otherwise indicated.

SKIN CARE CONSIDERATIONS

The ratio of skin area to body mass is lower in the patient who is obese than it is in patients who are normal weight. The larger body mass, combined with smaller relative skin area, leads to increased perspiration and difficulty controlling body temperature.1 The persistent moisture from perspiration collects in skin folds and can lead to skin irritation, body odor, or candidiasis.2 More frequent linen and gown changes may be necessary, and the use of a fan may increase patient comfort.1 Increased perspiration also creates the need for increased fluid intake.1 Inspection of the skin should target the abdomen, breasts, back folds, thighs, posterior neck, and perineal areas, as well as any surgical incision site.

Surgical wounds in the patient who is obese are more prone to dehiscence because of excessive tension on the wound edges. Additionally, hypoperfusion increases the risk for infection and delayed healing.3 Tubular mesh, mesh panties, or even the weight of a skin fold might be used to secure dressings instead of tape. Adhesives may not stick on moist skin or may need to be changed more frequently, therefore creating an increased risk for skin tears.

The patient who is obese is at higher risk for skin breakdown resulting from impaired mobility, increased pressure created by his or her weight, and increased shear during movement.4 Standard support surfaces are typically effective only for patients weighing less than 300 pounds. Specialized support surfaces are available to accommodate the patient who is obese. The patient's bony prominences may be padded by adipose tissue, but additional skin folds can present significant pressure risks. Capillary closure pressures within these folds can be sufficient to create pressure necrosis, especially if tubes or catheters run through them. Tubes should be repositioned every 2 hours to prevent this complication.5 Skin breakdown may also be caused by shearing or prolonged contact with bedside rails or chair arms.6 Specific bariatric equipment, such as special beds and chairs, may be necessary for the patient who is obese.

Urinary management is difficult for patients who are obese. Increased intra-abdominal pressure secondary to adipose tissue predisposes them to urinary incontinence.1,7 Stress incontinence when laughing, coughing, or simply assuming an upright posture creates the potential for excess moisture in the perineal area. This increases the risk for candidiasis and other skin problems. More frequent skin inspection, linen changes, and the use of moisture barriers, especially within perineal folds, may reduce skin problems.8

For female patients, insertion of a urinary catheter is complicated by the twin difficulties of patient positioning and decreased visualization of the urethral opening. Additional physical assistance and an introducer may be needed to get past the additional skin folds. In male patients, the penis may be retracted, making catheterization or even the use of a standard urinal more difficult. Patients of both genders have likely developed compensatory measures to address these problems at home and should be encouraged to openly discuss their needs so that good hygiene can be maintained during their hospital stay. Nurses should be ready to assist patients who cannot reach their own perineal areas to position a catch container for a urine specimen.

Whenever possible, normal toilet use should be encouraged. The goal is to prevent skin breakdown and maintain the patient's self- esteem.9

References

1. Green SM, Gillett A. Caring for patients with morbid obesity in hospital. Br J Nurs 1998;7:785-92.

2. Gallagher SM. Morbid obesity: a chronic disease with an impact on wounds and related problems. Ostomy Wound Manage 1997;43(5):18\- 24, 26-17.

3. Browne N, Thompson G. Wound healing/product selection for a critically ill obese patient. Br J Nurs 2002:11:998.

4. Gallagher SM. Tailoring care for obese patients. RN 1999;62(5):43-6, 48, 50.

5.Troia C. Promoting positive outcomes in obese patients. Plast Surg Nurs 2002;22:10-8,28.

6. Dionne M. One size does not fit all. Rehab Manage 2002;15(8):16-54.

7. Gallagher SM. Restructuring the therapeutic environment to promote care and safety for the obese patient. J Wound Ostomy Continence Nurs 2000:26:292-7.

8. Holland DE, Krulish YA, Reich HK, Roche JD. Expanding the care plan for a morbidly obese patient. Nursing2000 2000;30:(12):32.

9. Holland DE, Krulish YA, Reich HK, Roche JD. How to creatively meet care needs of the morbidly obese. Nurs Manage 2001 ;32(6):39- 41.

Adapted from Taggart HM, Mincer AB, Thompson AW. Caring for the orthopaedic patient who is obese. Orthopaedic Nursing 2004;23:204- 10.

REFERENCES

1. Mortality: obesity per capita. Available at http:// www.nationmaster.com/graph-T/mor_obe_cap; accessed July 14, 2004.

2. Krai JG, Strauss RJ, Wise L. Perioperative risk management in obese patients. In: Deitl M, editor. Surgery for the Morbidly Obese Patient. Toronto, Ontario, Canada: FD Communications, lnc; 2000. ''

3. Magee M. The cost of obesity in America. Health Politics. Available at http://www.health-politics.com/ programjnfo.asp?p=prog_474; accessed July 14, 2004.

4. Gallagher S. Bariatrics: considering mobility, patient safety, and caregiver injury. In: Charney W, Hudson A, editors. Back Injury Among Healthcare Workers. Boca Raton, FL: CRC Press; 2004.

5. American Society of Bariatric Surgery. Rationale for the surgical treatment of morbid obesity, November 29, 2001. Available at http://www.asbs.org/html/rationale/rationale.html; accessed April 1, 2004.

6. Knudsen AM, Gallagher S. Care of the obese patient with pressure ulcers. J Wound Ostomy Continence Nurs 2003;30:111-8.

7. Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults. The National Health and Nutrition Examination surveys, 1960 to 1991. JAMA. 1994;272:20511.

8. Gallagher S. Panniculectomy, documentation, reimbursement and the WOC Nurse. J Wound Ostomy Continence Nurs 2003;30:72-7.

9. Lantz P, House J, Lepowski J, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behavior and mortality: results from the Nationally Representative Prospective Study of US Adults. JAMA 1998;279:1703-8.

10. Fox SR. Discrimination: alive and well in the United States. Obesity Surgery. 1995;5:352.

11. Charles S. Psychiatric evaluation of morbidly obese patients. Gastroenterol Clin North Am 1987:16:415-32.

12. Thomas A. Frontline 1708, Fat, Public Broadcasting Service. Aired November 3, 1998. Script available at http://www.pbs.org/wabh/ pages/frontline/programs; accessed August 26, 2004.

13. Rand CS, Macgregor AM. Morbidly obese patients' perception of social discrimination before and after surgery for obesity. South Med J 1990;83:1390-5.

14. Gustafson NJ. Managing Obesity and Eating Disorders. South Easton, MA: Western Schools Press;1997.

15. Staffiert JR. A study of social stereotype of body image in children. J Pers Soc Psychol 1967;7:1014.

16. Thone RR. Fat: A Fate Worse than Death? Women, Weight, and Appearance. New York: Harrington Park Press; 1997.

17. Maiman LA, Wang VL, Becker MH, Finlay J, Simonson M. Attitudes toward obesity and the obese among professionals. J Am Diet Assoc 1979;74:3316.

18. Schwartz MB, Chambliss HO, Brownell KD, Blairs Billington C. Weight bias, bias among health professionals specializing in obesity. Obes Res 2003; 11:1033-76.

19. Rand CS, Macgregor AM. Successful weight loss following obesity surgery and the perceived liability of morbid obesity, lnt J Obes 1991 ;15:577-9.

20. Puhl R, Brownell JD. Bias, discrimination, and obesity. Obes Res 2001 ;9:788-805.

21. Gallagher SM. Morbid obesity: a chronic disease with an impact on wounds and related problems. Ostomy Wound Manage 1997;43(5):1824, 26-7.

22. Mazur F. Health cost control: prevention. Legislative Update. Available online at http://user.adelphia.net/frankmazur/ prevention_10_3.htm; accessed August 26, 2004.

23. Gallagher S. Restructuring the therapeutic environment to promote care and safety for the obese patient. J Wound Ostomy Continence Nurs 1999;26:292-97.

24. Mayes DP, Patterson CH. A fresh approach to workplace safety: an executive summary. Journal of Healthcare Safety 2003,1 (2):43-6.

Susan Gallagher, PhD, RN, CWOCN * Clinical Affairs Coordinator * SIZEWise Rentals * Kansas City, MO

Charlotte Langlois, BS, RN, CWOCN * Clinical Educator * Holyoke Hospital * Holyoke, MA

David W. Spacht, MHA * Director of Bariatric Services and Wellness Pavilion Holy Cross *; Fort Lauderdale, FL

Annie Blackett, MSN, RN, CWOCN * Clinical Nurse Specialist * University Medical Center * Tucson, AZ

Therese Henns, BSN, RN, G/ANP-CS * Nurse Practitioner * Pima Health Service * Tucson, AZ

Susan Gallagher, PhD, RN, CWOCN, has disclosed that she is an employee of SIZEWise Rentals. The other authors have disclosed that they have no significant relationships or financial interests in any commercial companies that pertain to this education activity.

Copyright Springhouse Corporation Oct 2004

Source: Advances in Skin & Wound Care

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