A

pproximately 127 million adults in the United States are overweight, 60 million are obese, and 9 million are severely obese. In recent years, obesity has increased at an alarming rate in the US (see Table 1). Currently, 64.5 percent of US adults age 20 and older are overweight, and 30.5 percent are obese.1
       Patients are considered obese when their body mass index (BMI) exceeds 30kg/m2 and extremely obese or “bariatric” when their BMI exceeds 40kg/m2.2 When the bariatric patient presents to the interdisciplinary team (IDT), the team must be prepared to provide unique assessment and treatment strategies. An interdisciplinary overview for professional practice and resource guide is offered in the following sections.

Activities
       Increased physical activity in the elderly can produce beneficial effects on muscle strength, endurance, and well being. However, getting sufficient exercise can be difficult for the bariatric patient. It is necessary for the activity staff to be innovative in helping bariatric patients develop ways to exercise. Stretching and flexibility exercises that involve the arms, trunk, and legs are a good starting routine. For ambulatory patients, walking is beneficial. If the facility has a pool available, either on site or in the community, water aerobics is an excellent exercise choice for the bariatric patient. Water aerobics allows the patient to exercise every muscle and joint in the body and is not stressful to the patient’s joints and muscles.3
       If the bariatric patient is also immobile, the person’s world grows smaller and smaller. A meaningful activity program based on individualized preferences and prior lifestyle is vital to prevent boredom, isolation, and depression. Activities, such as relaxation techniques, guided imagery, pet therapy, music, reading, playing cards, crafts, etc., can be enjoyable. Creativity and persistence by the activity staff will help these patients achieve a sense of well being and quality of life.

Social Services
       According to research findings, obese individuals in the general population have essentially normal psychological functioning. However, the risk of psychological distress does increase as the severity of the obesity increases. Obese patients with a BMI >= 40kg/m2 had significantly greater depressive symptoms and significantly lower self esteem than those with a BMI < 40kg/m2. The increased risk of medical complications and the greater likelihood of experiencing societal prejudice and discrimination may contribute to the person’s depressive symptoms.
       Obese patients and their healthcare team members may readily conclude that any anguish patients experience is solely attributable to their size and that they “just need to lose weight” to alleviate this distress. In fact, the opposite is recommended—if major depression is evident, the patient should be treated for depression before weight loss is undertaken. The symptoms of depression (e.g., low motivation, fatigue, withdrawal, etc.) can diminish the patient’s capacity to adhere to a weight loss program, leaving him or her vulnerable to attrition, unsatisfactory weight loss, and exacerbation of the mood disorder.4

Dietary
       It has been argued that there may be little benefit in encouraging weight loss in extreme old age (due to short life expectancy) especially when there are no obesity-related complications or biochemical risk factors and when strong resistance and distress arise from changes in lifelong habits of eating and exercise.5
       The decision to modify a patient’s diet must be made jointly between the IDT and the patient. Patient participation and willingness is crucial. If the patient is reluctant to change, suggest to the patient a goal of no further weight gain rather than a weight loss goal. If the patient chooses to lose weight, a reduction of 10 percent of the patient’s baseline weight within six months is a reasonable goal for the patient to set. The patient should lose weight at a rate of one to two pounds per week. To achieve this, caloric intake should be reduced by 500 to 1,000 calories per day from the current level.2

Nursing
       Obese patients have the same physical and psychological needs as most patients, but because of their size, the most basic nursing care can be challenging. Virtually every aspect of nursing care must be adapted to provide safe, high-quality care.

Physical Assessment
       The physical assessment process is identical to that of any adult patient except for measuring blood pressure and body weight. Facilities caring for bariatric patients should have scales with a weight capacity over 500 pounds. When measuring blood pressure, an appropriately fitting cuff should be used. If the bladder cuff is not the appropriate width for the patient’s arm circumference, a systematic error in blood pressure measurement can result; if the bladder is too narrow, the pressure will be overestimated and lead to a false diagnosis of hypertension. To avoid errors, the bladder width should be 40 to 50 percent of upper arm circumference. So, if the patient is mild to moderately obese, a large adult cuff (15cm wide) should be used; if the patient’s arm circumference is greater than 16 inches, a thigh cuff (18cm wide) should be chosen.6

Support Surfaces
       The bed must be safe for both the patient and the healthcare team. This is achieved by fitting the patient with the proper equipment. First, determine the manufacturer’s weight capacity for the bed. Standard bed weight capacities vary according to manufacturer and range from 250 to 400 lbs. Bariatric beds also vary according to manufacturer and range from 600 to 1,000 lbs.
       To determine whether the standard 35" bed is wide enough, measure the patient lying down in a supine position at the widest point. A wider size bed may be indicated; bariatric beds are available in 39", 48", 54", and 60" widths. A bed that is too wide may be comfortable for the patient, but will taunt the staff who must reach across the bed to provide care. When ordering a custom-size bed, assure the facility has access to bed linens that will fit the mattress.

Transfer
       The type of device needed for a safe transfer will depend on the overall strength and mobility of the patient. Many bariatric devices including ceiling lifts, lateral transfer aids, repositioning systems, power lifts, and standing assist aids are available to assist the bariatric patient and staff. When transferring patients, staff should seek adequate assistance and use correct body mechanics.

Seating
       The patient should be transferred to either a wheelchair or other chair suitable for the bariatric patient. Standard chairs are often not wide enough or structurally solid enough for the bariatric patient. A chair that accommodates the width needs and is structurally reliable should be used. Also, consider the width of doorframes when using bariatric wheelchairs. Doorframes must be wide enough to service the width of the wheelchair.

Ambulation
       For ambulatory bariatric patients with gait and balance disorders, canes and walkers can be used to maintain or improve mobility. Ambulation devices, such as a cane or a walker, increase the standing and walking base of support and provide stability. The devices offer feedback to the patient of where the body and its parts are in space (proprioception) through the handle, and it shifts the load on weight-bearing joints (such as hips, knees, ankles, and feet) to the upper limb. Furthermore, devices afford the user a visual presence of support that can instill confidence during ambulation and, thereby, may help to reduce the fear of instability and falls.7 Of course, these devices must meet the width and weight limits of the bariatric patient.

Dressing
       Clothing that is too snug is uncomfortable and can actually cause skin irritation and pressure ulcers. All items of clothing—bras, underwear, street clothing, gowns, and shoes—should be bariatric friendly. Loose-fitting clothing with high natural fiber content is recommended.

Toileting
       Urinary and fecal incontinence are more common in bariatric patients. Increased intra-abdominal pressure caused by excess weight in the abdomen places undue pressure on the internal structures, including the bowel and bladder. Limited mobility and certain medications may also contribute to the patient’s incontinence. Protecting the skin, preventing urinary tract infections, and enhancing dignity are the primary concerns. These complications occur primarily due to the patient’s inability to independently cleanse the perineum after episodes of elimination. No-rinse perineal cleansers, thorough drying, and moisture-barrier ointments are important.8
       If the patient uses the toilet, the environment must be fit to the patient and must be adequately equipped. Bathroom doorframes may need to be wider. Many wall-mounted toilets and grab bars are not bariatric friendly. Facilities should ascertain from the manufacturer the weight capacity of their wall-mounted toilets and grab bars to assure the equipment will meet the weight requirements of the bariatric patient. Floor-mounted toilets are recommended. If a bedside commode is used, the width and weight limits should meet the patient’s needs.

Bathing
       Bath time is often distressing for the bariatric patient. Frequently, the patient’s independence is limited requiring caregivers to provide physical assistance for bathing activities. This can be difficult and hazardous for caregivers. Weight combined with atypical body mass increases the risk for injury. Bathing approaches must be designed with safety in mind. For example, the caregiver must seek assistance from other staff members. Additionally, environmental issues, such as doorway, shower door, and tub clearance, and strength of equipment used in bathing the bariatric patient must be addressed.

Skin Care
       Due to immobility and decreased vascularity of adipose tissue, obese patients are at high risk for pressure ulcers. An aggressive preventative skin care protocol should be implemented. Assure pressure reduction devices used for the bed and chair are designed to provide pressure reduction for the bariatric patient.
       Skin folds of obese patients harbor microorganisms that thrive in moist areas and contribute to breakdown. Friction caused by skin-on-skin invites ulceration. Skin inspection should be conducted daily to rule out breakdown and infection. Skin should be cleansed with a no-rinse cleanser and dried thoroughly. Pad between skin folds with an absorbent material (e.g., ABD pad). Avoid using washcloths and towels, which keep the skin moist.

Resource Guide
       The task of finding a vendor that will assist you in meeting the many needs of the bariatric patient may seem overwhelming. This guide attempts to lessen that burden. Though not exhaustive, Table 2 provides an overview of what is available.

Conclusion
       With a virtual epidemic of obesity in the US, the number of bariatric patients receiving extended care is expected to sharply rise. These patients pose significant care challenges for facilities. More remains to be learned about the recognition and treatment of the special care needs of this patient population.