Bariatric Care: Acute
Occupational
Therapy Role
Robin Huesca MOTR/L
Bariatric Care
• Issue: the care of bariatric clients often is riddled
with decreased familiarity in bariatric care: ranging
from sub-optimal equipment and environmental
barriers, personal bias and significant caregiver
burden.
• Goal: to broaden understanding of realistic evidencebased solutions for therapist to improve client
independence and decreased burden of daily care to
interdisciplinary team members
Session Objectives
1) Understand barriers and identify solutions to achieve
independent self-care performance of the bariatric
client in the acute setting
2) Understand barriers and identify solutions to
achieve an optimal disposition for bariatric clients in
the acute setting.
3) Familiarize and expand knowledge of bariatric
equipment for both acute and home setting
Body Mass Index (BMI)
Categorizing Bariatric Weight
Distribution
1.
2.
3.
4.
Anasarea
Apple
Pear
Bulbous
Apple Ascites Distribution
Apple Pannus Distribution
Bulbous Gluteal Region
Proportionate
Stigma
• A stigmatized trait can lead to experiences of
discrimination and the feeling of being stigmatized
can put one at risk for low self esteem, depression
and lower quality if life.
• Weight bias and stigma is often referred to as the
“last socially acceptable form of racism”
• The negative attitudes underlying the enacted stigma
can be explicit or implicit (conscious or automatic)
Healthcare provider/patient
relationships
Patient Obesity
Provider Stereotype of patient
Provider attitudes(enacted stigma)
Threatening environmental cues
Provider biased decision making
Patient avoidance of care
Patient Stress
Patient mistrust of Provider
Patient Poor Compliance
Poor communication in pt/provider interaction
Poor Outcomes
Perceived Attitudes in the Care of
the Obese patients
• Nursing study: 70 percent of nurses reported they
felt that morbidly obese patients are more demanding
in interpersonal relationships than on obese patients
• They reported high levels of dependency in ADL’s (8
areas), the highest need in bathing, dressing toileting
and self care (greater than 80% patients required
assist)
Factors contributing to perceptions
• Baseline barriers in household structures (bathrooms
unable to accommodate obese patient and/or equipment)
• Baseline inability to get in/out of bed (both home and in
hospital)
• High degree of assist required for hygiene care (clothing,
skin challenges, lifting skin folds)
• Safety issues- falls, CG injuries, proper equipment
• Psychosocial issues related to resulting from obesity
The Reality of Care Needs
(Porkorny, 2009)
Activity
% of Assistance
Required
Bathing
90
Dressing
87
Toileting
84
Skin Care
82
Feeding/food (shopping or prep)
66
Getting out of Bed
54
Feeding/food (eating)
25
Oral Hygiene
11
Physiological consequences of
weight gain
• Increases the demands for insulin  pancreatic
failureDM
• Hyperinsulinemia sodium retention hypertension
• Increased triiodothyronine (T3 T4) metabolic rate
increased cardia output heart failure
• Increased need for oxygenation and alveolar ventilation to
maintain adequate tissue perfusion placing them high
risk of Pickwickian syndrome and sleep apnea (especially
when their weight is primarily adnominal girth-resting on
chest
Mobilizing – why is this so complex?
• Human loads are heavy, highly dependent and
unpredictable
• Self mobilization of the bariatric patient is often
complex as the medical treatment the patient is
receiving is often a health related consequence
resulting from their weight
Systematic steps for safe
mobilization of the bariatric patient
1. Bariatric risk assessment
2. Moving and handling assessment
3. Equipment provision
Pitfalls of “Weight” and “Equipment
Capacities”
• Appropriate equipment should be picked based on
the needs of the specific patient, not just weight and
capacity. Should consider:
• Physical limitations of patients (limited ROM, panus)
• Physical characteristics i.e. weight distribution, girth, width
• Cognition
• Psychosocial Status
The Bariatric Triad
1. Expandable support surface bariatric bed
2. Weight-rated portable bedside lifts
3. Weight-rated wheel chair
What if?
Ideal Bariatric Suite
• 5 feet service area around the bed
• Double entry door
• Eliminate bathroom replace with
foldaway/rectactible wall separating the bathroom
area from a regular room
Why Does This Equipment “fit”
The patient?
Positioning in Chair
• Some bariatric clients cannot keep their legs together
enough to even get them on the footplates on a w/c
or within the frame of the walker  wider walker,
uneven depth seating, expanded foot plates
• May not be strong enough if the client needs to push
themselves back to reposition- longer arm rests
• Maceration problems and skin breakdown because
of moisture; excess tissue creates shearing and
friction issues. Gap for posterior flow
Clinical Solutions
Issue?
Work around
The Issues Across the Span of Many
Settings
•
•
•
•
Ambulance- stretcher and transport capacity
ER gurney, transport w/c, scale
OR/Imagining operating table, CT, MRI
Room bed, lift system, slings, w/c, walkers, chair,
stretchers, commode, bed pan, shower chair, sit stand
device, mattress, gowns, BP cuffs, needles, socks, scale
• Home or facility transfer bed, w/c, shower chair, BSC,
lift, scale, entry access, door frame and footprint
• School desks, resource rooms, bathroom accessibility
“Equipment alone is not the answer for
improving quality of care unless
supported by sound clinical judgment,
robust policies and procedures which in
turn bring about systems of work that
is both safe for the patient and the
carers”
Cookson 2002
References
•
Watanabe, L; The Anatomy of Bariatric Mobility Understanding the Unique Clinical,
Accessibility & Funding Challenges; Mobility Management; 2010; electronically obtained
10/2015
•
Darrah, A. Campo, M, Frost, L. Safe-Patient Handling Equipment in Therapy Practice:
Implications for Rehabilitation. AJOT (2013) Vol 67 (1) Electronically obtained 9/2015
•
Faintuch, J. Souza, A. Rehabilitation Needs after bariatric surgery. European Journal of
Physical and rehabilitation Medicine (2013) Vol 49 (3) Electronically obtained 9/2015
•
Budd, G. Mariotti, M. Health care professionals attidudes about obesity: An integrative
Review. Applied Nursing Research 24 (2011) p. 127-137. Electronically obtained 8/2015
•
Bell, S. Current Issues and Challenges in the Management of Bariatric Patients. J WOCN
Vol 32 (6) . Electronically obtained 8/2015
•
Hammond, K. Practice Issues in the Surgical Care of the Obese Patient. The Oschner
Journal 13; 224-227, 2013, Electronically obtained 8/2015
•
Olowski, B. Stolfi, A, Safe Patient Handling Perceptions and Practice: A survey of Acute
Care Physical Therapists, PT 2014; 94: 682-695, electronical obtained 9/2015
References
•
Barr, J. Cunnenn, J. Understanding the Bariatric Client and Providing a Safe Hospital
Environment. Clinical Nurse Specialist, 2001. Vol 15 (5) 215-223; electronically obtained 8/2015
•
Saffari, M. Special Care for Special Needs. Journal of Rehabilitation, 2007, electronically obtained
8/2015
•
Muir, M. Archer-Hesse, G. Essentials of Bariatric Patient Handling Program. The online Journal
of Issues in Nursing. 2009. Electronic obtained 9/2015
•
Phelan, S.M. Burgess, D, J. The impact of weight bias and stigma on the quality of care and
outcomes for patients with obesity. Obesity Reviews, 2015; Vol 16; electronically obtained 9/2015
•
Porkorny, M. Scott, E. Challenges in Caring for Morbidly Obese Patients- Managing Activities for
Daily Living. Home Helath Care Nurse. Vol 27 (1) 2009. Electronically obtained 8/2015
•
Rush, A. Use of specialized equipment to mobilize bariatric equipment. International Journal of
Therapy and Rehabilitation, 2005. Vol 12 (6). Electronically obtained 8/2015
•
Liko (2004) Body Weight Distribution. Liko www.liko.com