BAR IATRIC MANAGEMENT
mattress, seating, examination couches, patient handling equipment etc. For planned admissions, these requirements would be prepared for in advance.
Ward admission
The first item to consider for any inpatient setting is the bed frame and support surface. A bariatric bed offers an increased safe working load and a larger surface area. However, while a wider bed surface is ideal, it should not be so wide as to make it inconvenient for the carer to reach the patient, nor should it limit the individual’s ability to reposition. If the bed surface is not wide enough, the patient will not have sufficient space to reposition themselves or for the carers to assist.
Resuscitation A plus size person’s weight, neck circumference and body shape can have an impact on intubation; mechanical ventilation; circulatory assessment; vascular access; CPR and medication. Positioning the patient in a semi-recumbent or a sitting positioning may help to decrease atelectasis and improve oxygen saturation prior to intubation,32
with
head up or a ramped position to optimise the laryngoscopic view for intubation (Figure 6).33 Staff must also be aware of the increased
effort involved to perform chest compressions on the patient who has a larger than average body mass. The girth of the chest, size of arms etc. may necessitate a change in posture during chest compressions leading to the rescuer becoming fatigued quicker, requiring a rotation of staff to ensure effective CPR is undertaken.
Optimising skin management Excess adipose tissue and changes in skin physiology place plus size patients at risk for pressure ulcers, skin damage and infections. The immobile, obese patient can be at risk of atypical pressure ulcers, which can occur between skin folds, because of tubes or catheters, or from ill-fitting equipment.34 Many plus size patients present with a large pannus, where there is a higher risk of intertrigo, bacterial and fungal infections, which can show signs of inflammation, maceration, and erosion.35 management36
Moisture and skin fold repositioning,
due to the thick layers of subcutaneous fat, can potentially lead to skin breakdown due to the combined forces of moisture, gravity, torsion and a larger mass in motion.37 Proactive assessment using a care pathway, such as aSSKINg,38
can prompt
early identification and appropriate protective interventions that address the risks.39,40 Therapeutic surfaces and specialist seating are some of the preventative measures that can be used in conjunction with microclimate control, postural repositioning,
OCTOBER 2020 Figure 6
30º side lying, effective patient handling, off-loading and early detection through skin inspection.41 Furthermore, poor nutrition and hydration are recognised risks for developing pressure ulcers and international guidance42
recommends using a screening
tool to assess risk factors, including malnutrition. Obese patients are frequently malnourished since their weight may be due to increased ingestion of high-density energy foods that are high in fat and sugars but low in vitamins, minerals and other micronutrients.43
Wound healing involves
anabolic metabolism and will not occur without adequate protein stores.44
Early
detection and intervention provides an opportunity for timely intervention in the management of pressure ulcer prevention and the recovery process.
Interdepartmental transfers An interdepartmental risk assessment should consider the distance to travel, the number of staff required, the floor surface, gradients, corridor widths, equipment provision and turning circles throughout the transfer route. Depending on the patient’s clinical presentation, interdepartmental transfers can be via a powered wheelchair to transferring in a bed, with power drive and adjustable width for ease of passage through doorways etc.
Perioperative
There is a recognition that obese patients with metabolic syndrome, obstructive sleep apnoea syndrome, and obesity hypoventilation syndrome etc., require specific perioperative care45
considering
appropriate equipment and monitoring, anaesthetic management and a perioperative ventilation strategy to support postoperative outcomes.46
Post operatively they need to be
in an upright position to prevent the weight of the abdomen pressing against the diaphragm affecting their respiratory function.47
Seating A person’s body shape and size, the supporting surface, and even their health or emotional state can influence their seated posture. Evidence suggests that effective seating can help to reduce muscle atrophy, improve sitting balance, strength and conditioning with potential positive effects to improve patient flow.48
The principles of good seating consider:49 l Loading the body
– maximising the contact with the seating surface can provide good proprioceptive feedback;
– the chair must be adjusted to the individual’s body shape and size, ensuring the patient’s feet are on the footplate/floor to prevent any neurological complications;
l Provide postural support, targeting all body segments
– seat dimensions, safe working load, leg rests, footplate, head and armrests and seating time;
– provision of sufficient space for the patient’s hips and adipose tissue, easy access for applying patient slings;
l Allow effective repositioning – by using the tilt in space 30-45˚ functionality, where available; – off-loading anterior tilt to support standing with a stand aid and 24-hour care;
l Appropriate surface / cushion supporting immersion and envelopment – pressure ulcer prevention.50
A good posture, facilitates effective functional mobility, enables independence, encourages interaction, promotes physiological function and manages comfort levels and quality of life.
Hygiene
If the person is mobile or can weight bear, they may shower with the use of a hygiene chair, providing a toileting and showering solution that can help to maintain the individual’s dignity. As part of this solution, carers need to take into account the person’s weight, body shape and adipose tissue, which may be a complicating factor when undertaking hygiene routines.51
A large
abdominal pannus or skin folds can overheat due to the thick layers of subcutaneous fat, which increases the risk of friction and moisture.52,53
A mobile person who
can weight bear may stand and sit during the shower and may only require limited supervision or assistance, whereas a more dependent partially weight bearing patient is likely to remain seated throughout the shower – therefore needing assistance. Depending on their functional mobility, they may require a stand aid or a hoist and sling to transfer to the shower chair. When bathing is the preferred method, it is important to
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