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Care of the obese patient with pressure ulcers
OPTIONS IN PRACTICE FEATURE EDITOR: Maureen Hanlon, RN, MN, CWOCN
O
ptions in Practice presents different management approaches to the same clinical situation. You are invited to submit a brief case description, including the specialty nursing care provided, and several glossy color pho-
tographs of the clinical situation. The case material will then be sent to another wound, ostomy, or continence care nurse, who will also address management concerns. Alternative solutions to difficult wound, ostomy, or incontinence clinical situations will be published.
Care of the Obese Patient With Pressure Ulcers Anne Marie Knudsen, RN, MN, CNS, CETN, With Commentary by Susan Gallagher, RN, CWOCN, MSN, PhD
Case Situation A 29-year-old man was referred to the WOC nurse for management of extensive pressure-related skin breakdown. He weighed 284 kg and his body mass index was 89. His medical history was significant for sleep apnea, knee pain, and hypertension, but negative for diabetes and other conditions typically found among obese clients. The patient was single, had little immediate or extended family, and was unemployed. He had Roux-en-Y gastric bypass surgery (RYGB) 33 days previously. Throughout his life, the patient had made numerous attempts to lose weight. He tried multiple diet and activity strategies, but each weight loss success was followed by the disappointing experience of regaining weight. The consequences of his weight became increasingly evident as the patient had severe knee pain, was unable to bend over, and frequently became short of breath. As physical activity became increasingly more difficult, he considered alternatives for long-term or permanent weight loss. Ultimately he believed RYGB was his only option. For the first 7 days postoperatively he was cared for in the surgical intensive care unit (ICU). He required close observation because of respiratory problems and sleep apnea. While he was in the ICU, he was extremely reluctant to use bariatric equipment. The patient refused a wider bed, specialty mattress, or a lift system. He also declined to reposition himself or to be turned for pressure relief. The nurses documented that the patient refused cleaning when he was incontinent of stool. The clinical staff recognized that this patient was at risk for immobility-related complications. They were hopeful that once he was transferred out of the ICU environment, his reluctance to use bariatric equipment and be repositioned would resolve. Unfortunately, once the patient was transferred, he became increasingly unwilling to reposition himself. He also began to have multiple loose stools and refused to allow the staff to clean him or perform routine skin care. By postoperative day 33, the patient had
ulcers on the right and left buttock, lower back, and the buttock cleft. All 4 ulcers were covered with thick black eschar or slough tissue. The periwound skin was red and excoriated (Figure 1). The patient’s rejection of routine care may have been related to postoperative pain. Despite ongoing assessment of pain in the ICU and on the surgical unit, he denied pain as a factor. Eventually he verbalized that severe discomfort was the main reason for his refusal to be repositioned. The patient was using a patient-controlled analgesia pump in the ICU, and use of this pump was continued when he was transferred. Later his pain was managed with meperidine injections and hydrocodone and acetaminophen tablets. In view of his sleep apnea, oxygen saturation was maintained at 92% or higher. The head of the bed was elevated to facilitate deep breathing, and he was encouraged to use the incentive spirometer. The patient had been using a positive airway pressure device at home. Initially the pressure ulcers were managed by the surgical resident who performed mechanical debridement using a betadine scrub brush to loosen some of the necrotic tissue. The patient stood and leaned forward onto his hospital bed so that the involved area was exposed during the procedure. Sharp instrument debridement was also attempted at the bedside. Both treatments were exhausting and painful for the patient. He reported weakness and dizziness and soon refused these treatments. The patient’s emotional and physical well-being deteriorated. He expressed the desire to be left alone and attempted to isolate himself. His emotional state seemed to exacerbate his physical deterioration. When the wound team was consulted, the patient expressed frustration, humiliation, and anger. He used the WOC nurse for emotional support and clearly verbalized distress about his obesity, the surgery, the scrub brush treatment, and future plans. A positive patient/ nurse relationship developed and the patient started listening to suggestions given by the WOC nurse.
Anne Marie Knudsen, RN, MN, CNS, CETN, is a Board-certified Enterostomal Therapy Nurse, Harbor-UCLA Medical Center, Torrance, Calif, and Wound/Ostomy/Skin Consultant and Legal Nurse Consultant in the community. Susan Gallagher, RN, CWOCN, MSN, PhD, is Clincal Affairs Coordinator at SIZEWise Rentals, Ellis, KS. Reprint requests: Anne Marie Knudsen, RN, MN, CNS, CETN, 1000 W Carson St, HarborUCLA Medical Center, Nursing Department— Box 14, Torrance, CA 90509; e-mail: [email protected]. J WOCN 2003;30:111-8. Copyright © 2003 by the Wound, Ostomy and Continence Nurses Society. 1071-5754/2003/ $30.00 + 0 doi:10.1067/mjw.2003. 26
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When the wound team was consulted, the patient expressed frustration, humiliation, and anger.
J WOCN March 2003
Figure 1. Thick eschar and slough tissue covered the ulcers on the right and left buttock, lower back, and buttock cleft; periwound skin was excoriated.
The WOC nurse’s first intervention was to discontinue the bedside debridement procedures. Because the patient did not tolerate these treatments, he was taken to the operating room and the ulcers were surgically debrided. Once the necrotic tissue was completely removed, stage IV pressure ulcers were exposed on the right and left buttocks, measuring approximately 11.5 × 7 × 3.5 cm and 26 × 7 × 3.5 cm. The ulcers on the buttock cleft and the lower back were stage III and measured 3 × 2.5 × 0.5 cm and 4 × 3.5 × 1.2 cm. The WOC nurse coordinated the management of the wounds. The expected outcomes for this patient were healing of the pressure ulcers, reasonable weight loss of approximately 1.4 kg weekly, muscle strengthening, and discharge home. Once debridement was accomplished, the immediate goals of care were to control pain, reduce pressure, friction, and shear, increase mobility and activity, prevent caregiver injury, and manage wound bacterial load and odor. A specially designed oversized bed (BIG Turn, Continuous Full Body Lateral Rotation Therapy, Size-Wise Rentals, Prairie Village, Kan) was obtained, as well as an overhead trapeze, bariatric wheelchair, walker, and commode. The continuous full body lateral rotation support surface was set to turn 40 degrees every 20 minutes. The rotation was turned off at night per the patient’s request, because he believed it made him dizzy; however, the low air loss therapy continued. The specially designed oversized equipment helped relieve pressure and promote independence. Pain was controlled with meperidine injec-
tions and later hydrocodone and acetaminophen. Once the patient was placed on an oversized specialty bed and received appropriate local wound care, he seemed to be more relaxed and compliant. He started verbalizing when he was in pain. Local wound care was supervised by the WOC nurse. The ulcers were treated with 0.25% acetic acid moist gauze dressings to reduce the bacterial load and control odor. The dressings were changed 3 times daily from postoperative days 40 to 47. The treatment was then switched to daily cleansing with normal saline solution and application of IntraSite Gel (Smith & Nephew, Largo, Fla), a nonpreservative hydrogel. The ulcer cavities were loosely packed with gauze dampened with normal saline solution and covered with dry dressings. The gel was used for several reasons: (1) to provide moist wound healing; (2) to reduce the number of dressing changes; (3) to help numb the pain using the gels cooling effect; and (4) to encourage further tissue debridement by autolysis. Calmoseptine ointment (Huntington Beach, Calif) was used to coat the excoriated and macerated periwound skin and to provide a water-repellent protective barrier. The ointment was applied to the skin at the wound margins to act as a barrier and prevent further maceration from the damp dressings. The patient had extremely frail thin skin on the buttocks, so No-Sting Skin Prep (3M, St Paul, Minn) was applied wherever tape was placed because it contains no alcohol and did not further irritate the skin or burn upon application.
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Figure 2. Dressings over ulcers were secured with dressing straps; retention tape was applied around the strap borders.
Nu-Hope Dressing Straps (Pacoima, Calif) were used to hold the dressings in place because of the skin barrier to protect the skin and hooks that are used with elastic bands to secure the dressings. The straps were cut to accommodate the buttock area. Retention tape was applied at the outer edges of the straps to provide further support and better secure the dressings (Figure 2). This wound treatment and the specialty oversized bed were continued until the ulcers healed (Figures 3-6). Outcomes were accomplished 120 days after treatment was initiated by the WOC nurse. These included healing of the pressure ulcers, 58-kg weight loss, increasing independence in activities of daily living, and final preparation for discharge to his home. More subjective outcomes included increased patient comfort, dignity, and confidence. The patient received follow-up care in the surgical outpatient clinic and dietary counseling to ensure correct protein intake and electrolyte balance to avoid dehydration. Prevention is a cost-effective alternative to treatment. Although this particular patient was reluctant to accept prevention modalities, this probably would have prevented the adverse therapeutic, cost, and satisfaction outcomes associated with numerous pressure ulcers. The patient continues to lose weight and now weighs 104 kg. He has not had any recurrence of the pressure ulcers and is adapting to his new body. More importantly, this patient will now be able to take part in the ordinary activities that most of us take for granted.
Commentary: This patient had been morbidly obese most of his life, and with a body mass index of 89, activities of daily living would likely become more and more difficult for him. Bariatric weight loss surgery programs are becoming increasingly prevalent because of patients like the man in this case situation. Most communities and hospitals introduce such programs in response to the needs of the more than 60 million morbidly obese Americans1 who have decided to use this available tool to manage their lifelong struggle with weight issues. Obesity and other eating disorders claim monetary, physiologic, and psychologic tolls from the persons they affect. Obesity is thought to be a factor in 5 of the 10 leading causes of death in the United States, and some persons contend that it is the second leading cause of preventable death. As early as 1985, the National Institutes of Health Consensus Conference described obesity-related health risks, which include an increased risk for cardiovascular disease, hypertension, diabetes mellitus, gallbladder disease, and socioeconomic and psychosocial impairment.2 In the United States, more than 60% of adults and 25% of children are overweight. Researchers predict that 80% of obese children will become obese adults.1 Health professionals and the public in general are seeking ways in which to reduce the emotional and physical consequences of what is referred to as severe obesity. Part of the challenge in this is the complexity of weight gain and weight
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Figure 3. Postoperative day 66: ulcer bases were clean and healing following debridement, topical treatments, and pressure reduction.
Figure 4. Postoperative day 96: ulcers on buttocks continued to decrease in size; bases had pink granulation tissue and periwound skin was healed.
issues. The simplest explanation of weight gain is that it occurs when the caloric intake is more than the energy needed to maintain body functions and perform physical activities. These excess calories are stored as fat in the adipose tissue. The tradi-
tional view that obese people gain weight because they either eat more or exercise less than other people is only part of the explanation. In March 1991, the NIH Consensus Development Conference on Gastrointestinal Surgery for
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Figure 5. Postoperative day 96: ulcers on lower back and gluteal cleft also had pink granulation bases and continued to decrease in size.
Severe Obesity brought together surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals, as well as the public, to address treatment options for severe obesity. At that conference it was decided that in select cases, surgery was an appropriate treatment intervention. Since that time, bariatric surgery has become an increasingly important adjunct in caring for the larger patient. There is an increasing demand not only for surgeons who have skill in weight loss surgery, but for organizations that commit to managing the complex needs of this patient population postoperatively. A number of conditions influence the postoperative course of patients who undergo weight-loss surgery. The needs of the severely obese surgical patient are likely to be different than those of severely obese medical patients, who are often chronically ill. As in this case situation, patients who choose weight-loss surgery are often very independent at home, despite their weight. Weightloss surgery is an elective surgery. Other than morbid obesity, patients who undergo bariatric weight-
loss surgery are generally in good health, and their postoperative course is usually uneventful. Predictions can be made in length of stay, mobility, and progress along care pathways. However, unexpected complications can occur, and such was the case with this patient. Ms Knudsen addressed the local wound care needs during her first assessment. The patient’s full-thickness pressure ulcers were extensive, initially requiring debridement and then, later, protection from cytotoxic influences and bacterial invasion as healing began. Delays in wound healing often occur because of infection or the presence of necrotic material. Various modalities are available to help loosen and remove this necrotic tissue. Once the necrotic tissue is removed, the wound can begin the healing process. Traditional whirlpool therapy is sometimes effective, but many obese patients are not candidates for this type of therapy. Weight limits on equipment, caregiver and patient safety, and transportation challenges exist. The Pulsavac Wound Debridement System (Dover, Ohio) provides a method for pulsatile irrigation and debridement. Effective de-
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Outcomes were accomplished 120 days after treatment was initiated by the WOC nurse.
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Figure 6. Postoperative day 156: all ulcers were healed 120 days after initial treatment by the WOC nurse.
briding occurs by directing fluid right to the wound. The Pulsavac offers variable pressure settings and an assortment of irrigation tips to provide cleaning and debriding of all types of wounds. Bedside treatment can be done, preventing the potential for caregiver and patient injury because of frequent transfers and transportation issues. Determining a method to secure the dressing without causing further skin breakdown from tape and other adhesive products can be especially challenging in this patient population, where the body contours are very irregular. In my experience, patients report that the discomfort from superficial tape-related skin injury can be more intense than from the wound itself, especially in the presence of a large surface area. Knudsen’s strategy to adhere the dressing to the patient was creative and effective, and the photo documentation demonstrates the improvement of the periwound skin. Additionally, larger patients may not have adequate pressure relief, and that was also addressed as part of the comprehensive plan of care. Low air loss with the option of full-body lateral rotation was initiated. Low air loss was in place at all times, and rotation therapy was introduced during the times when the patient could not reposition himself or when there was insufficient staffing to safely turn him. Assessment for shearing injury is necessary at least daily. Settings on the support surface can be adjusted to balance the benefit of the product with the risks of shearing.3 If shearing injury begins to develop, the degree of rotation or the
firmness of the surface can be reduced to prevent further injury and ensure continued therapy. Rather than address other options in local wound care, I believe mobility was the greatest concern for this patient throughout the hospitalization. Early and continued mobilization is critical in the recovery period. However, I argue that mobilization and skin care are often complicated by the lack of appropriate equipment and an inadequate understanding of pain issues and obesity. Many larger patients are able to turn, ambulate, and transfer soon after surgery, whereas others might have difficulty because of pain or sedation. Many times the only special accommodation needed is a bed that is wide enough for the patient to turn independently, a walker to support his or her weight for the first few postoperative days, and an overhead trapeze to help the patient reposition himself. These 3 items are thought to help the patient maintain his or her strength and independence. Clinicians report that independent patients who have adequate supportive equipment are less likely to injure themselves or caregivers during that early postoperative period. Assessment for special equipment needs could use the patient’s actual weight, hip width, and degree of mobility as criteria. To ensure fairness in distribution of equipment, it is important for organizations to standardize access, based on established criteria. As this case situation demonstrates, in addition to specially designed postoperative equipment, pain can interfere with patient mobility for physio-
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logic and psychological reasons. Pain, in most cultures, serves as a warning that something is wrong. Patients experiencing pain often respond with reluctance to move or participate in rehabilitation. This patient was reluctant to turn or allow specially designed equipment because of discomfort. Often this reluctance is misinterpreted as noncompliance. One of the greatest challenges in health care is to ensure the physical, emotional, and spiritual comfort of our patients. Management of pain is an important factor in patient comfort, and all patients are entitled to the best pain relief that can safely be achieved. Yet the problem of pain is pervasive, and the myths and misconceptions surrounding the pain experience and the assessment of pain often preclude adequate comfort and quality care. This is especially true among bariatric patients, where little evidence-based practice is available to make decisions about patient care. Misconceptions not only affect clinical decisions, but patients also may hold these misunderstandings, further interfering with pain control. Pain must be managed adequately because research now shows that unrelieved pain can inhibit the immune system, increase oxygen demand, cause respiratory dysfunction, decrease gastrointestinal motility, and cause confusion. Severe acute pain is a major risk of chronic neuropathic pain.4 In addition to the challenges that all patients face, bariatric patients have additional concerns. More questions than answers arise when dealing with pain in patients whose bodies contain a greater percentage of adipose tissue. For example, is the medication of choice water or fat soluble, and what are the clinical consequences of either? Will a 11⁄2-inch needle deliver a medication into the muscle or into the fatty tissue, and should intramuscular injection even be attempted? What is the effect of opioids on sensorium or already compromised pulmonary function? What role does long-term chronic pain have on the surgical patient’s interpretation of acute pain, and how is this assessed preoperatively? Finally, is postoperative nausea among morbidly obese bariatric surgery patients related to surgery or an adverse effect of the medication? These largely unanswered questions further serve to complicate pain management for the obese patient. As in this case situation, this can lead to behaviors that appear to be health-defeating activities. Pain is a completely subjective experience. A widely used definition is that pain is whatever the experiencing person says it is and exists whenever he or she says it does.5 The self-report of pain by a patient should be considered sufficient evidence to establish pain as a nursing diagnosis. Overcoming the myths and misinformation that abound regarding pain assessment and treatment is a challenge.6 The acceptance of pain as a subjective experience is difficult for many health care professions. Often these old paradigms continue to
Knudsen, With Commentary by Gallagher 117
pose barriers to adequate pain control. Inadequate documentation tools fail to communicate pain and pain ratings. A pharmacist and pain specialist are essential in determining the most appropriate drug based on absorption mechanisms and rates, which can be complicated by the patient’s adiposity. The unique needs of the obese patient are especially important in making a drug selection. This clinical perspective also reinforces the need to clinically interpret the consequences of the chosen medication. In many settings, use of the intramuscular route is widespread, despite the fact that research suggests that the intravenous or intraspinal route for analgesics is usually safer and more effective.7 In the bariatric patient, it may be impossible to deliver an intramuscular injection because of the presence of a thick layer of fatty tissue. The intramuscular route may not provide predictable levels of drugs and therefore is not recommended.8 Respiratory depression is a potentially lifethreatening adverse effect among all patients but can be especially serious among morbidly obese patients. Respiratory depression is thought to be preventable by the clinician’s careful monitoring of sedation levels and easily treatable if it occurs. It is critical to assess for sedation levels and respiratory status when prescribing opioids for a patient who has moderate to severe pain and has not been receiving opioids regularly. When an opioid causes the patient to be so sedated that he or she has difficulty staying awake, the dose should be decreased to prevent respiratory depression. The likelihood of respiratory depression decreases the longer the patient has been taking opioids because tolerance to respiratory depression develops and information about the patient’s response to opioids is known. The antidote for respiratory depression is naloxone (Narcan) administered intravenously. Naloxone is a pure opioid antagonist that can reverse both analgesic effects and respiratory depression. Sufficient amounts of Naloxone should be given to decrease sedation and increase respirations to an acceptable level without completely reversing analgesia. Giving too much naloxone can also precipitate hypertension and ventricular dysrhythmias. Therefore, 0.4 mg of naloxone should be diluted in 9 to 10 mL of saline solution and 0.5 mL should be administered over 2 minutes.9 Each patient’s situation should be reviewed separately to determine the acceptable level of sedation and to assess the potential for harm from decreased sensorium. Some patients choose to endure more discomfort if it means less sedation. If the sedation level is still unacceptable after a few days of adaptation, another opioid can be substituted until a satisfactory one is found. Many patients who experience long-term chronic pain become depressed and anxious.10 Depression and anxiety can be exacerbated if it is difficult to
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establish a physical cause for the pain. These patients may begin to question their judgment, fear they will be perceived as troublesome, and worry that pain relief will be withheld because the pain is not real. These emotional responses may cause some health care providers to think that the pain is psychogenic and not physiologic.11 Physiologically, the body adapts to pain after a period of time, and vital signs normalize. This return to equilibrium is necessary to prevent physical harm and undue stress on the body. It does not necessarily mean pain has been controlled adequately. Additionally, patients might exhibit a behavioral adaptation to both acute and chronic pain. They may minimize their expressions of pain for a number of reasons. A patient may wish to be seen as a good patient or may place a personal or cultural value on a stoic response to pain. The patient may become too exhausted to respond vigorously to pain. Sometimes patients use distraction techniques to move the focus away from pain, especially when intense and unrelieved. One way of screening for pain among bariatric patients is to include questions on the clinical admission form, such as “Do you have pain now or have you experienced any pain recently?” If most patients are cognitively intact adults, the 0 to 10 (0 = no pain, 10 = worst pain) pain rating scale usually is used. If chronic pain is identified preoperatively, a more comprehensive pain assessment should include location, quality, onset, frequency, and intensity. These items are self-explanatory, and it is easy to ask the patient about them. Location can be assessed by asking the patient to point to the site of pain on his or her body or on a figure drawing. To assess quality, you may need to give the patient some examples, using terms such as burning, aching, dull knifelike, or shooting. With this assessment, a comfort/function goal is established by asking the patient what pain rating would make it easy for him or her to perform specific activities required for recovery or quality of life. For example, the patient in this case situation may need to ambulate 3 times daily to prevent skin and pulmonary complications. The patient would be asked, “What pain rating will make it easy for you to walk with the physical therapist 3 times daily?” He may respond that 3 on a scale of 0 to 10 would be sufficient. The comfort/function goal would be documented as “3/10 to ambulate with PT.” When establishing comfort/function goals, keep in mind that research has suggested that pain ratings above 4 significantly interfere with activities and mood.12 Nausea is not uncommon following bariatric weight loss surgery. However, opioids are often thought to be the source of the nausea. Other causes of nausea, such as nonopioid medications, hypercalcemia, uncontrolled pain, copious sputum, or coexisting medical conditions may be overlooked. Carefully review signs, symptoms,
and the patient’s case history before targeting opioids as the cause of nausea. In summary, the value of an interdisciplinary team should not be overlooked.13 Mobility can be affected by inadequate equipment and uncontrolled pain, which are 2 areas where the patient is best served when managed by a team who understands the special needs of larger patients. The pain specialist, pharmacist, physician, physical/ occupational therapist, WOC nurse, bariatric clinical nurse specialist, and other interested professionals are important members of the team. Research designed to investigate the meaning of pain, pain assessment, and management for obese patients provides opportunities for interested clinicians. Additionally, the processes related to developing, implementing, and measuring criteriabased protocols that provide bariatric resources in a timely and cost-effective manner present investigational opportunities. Together these research opportunities serve to begin building evidence so that responsible patient care choices can be made. Susan Gallagher, RN, CWOCN, MSN, PhD REFERENCES 1. American Obesity Association. AOA fact sheet. Available at: URL: http://www.obesity.org/subs/ fastfacts/obesity_US.shtml 2. NIDDK Weight-control Information Network. Statistics related to overweight and obesity.Available at: URL: http://www.niddk.nih.gov/health/nutri/pobs/ statobes.htm 3. Gallagher SM. Obesity and the skin in the critical care area. Critical Care Nursing Quarterly. 2002; 25(1):69-75. 4. Pasero C, Paice JA, McCafferty M. Basic mechanisms underlying the causes and effects of pain. In: McCafferty M, Pasero C. Pain: clinical manual. St. Louis: Mosby; 1999. 5. Gallagher SM. Ethical dilemmas in pain management. Ostomy Wound Manage 1998;44:16-21. 6. McCafferty M, Farrell B, Pasero C. Nurses’ personal opinions about patients’ pain and their effect on recorded assessments and titration of opioid doses. Pain Manage Nurs 2000;1:79-87. 7. Pasero C, Portenoy RK, McCafferty M. Opioid analgesics. In: McCafferty M, Pasero C. Pain: clinical manual. St Louis: Mosby; 1999. 8. Dominquez-Cherit G, et al. Anesthesia for morbidly obese patients. In: Dietel M, editor. Update: surgery for the morbidly obese patient. Toronto, Canada: FD-Communications; 2000. 9. Naloxone. Available at: URL: http://www.drugscope. org.uk/druginfo/drugsear 10. Pain and depression—The Mayday Project. Available at: URL: http://www.painandhealth.org/dep-links.html 11. Psychogenic pain. Available at: URL: http:// uihealthcare.com/topics/mentalemotionalhealth/ ment3164.html 12. Sirloin RC. When is cancer pain mild, moderate or severe? Grading pain by severity by its interference with function. Pain 1995;61:277-84. 13. Pasero C. Making your pain care committee effective. Am J Nurse 1997;97:17-9.
O
ptions in Practice presents different management approaches to the same clinical situation. You are invited to submit a brief case description, including the specialty nursing care provided, and several glossy color pho-
tographs of the clinical situation. The case material will then be sent to another wound, ostomy, or continence care nurse, who will also address management concerns. Alternative solutions to difficult wound, ostomy, or incontinence clinical situations will be published.
Care of the Obese Patient With Pressure Ulcers Anne Marie Knudsen, RN, MN, CNS, CETN, With Commentary by Susan Gallagher, RN, CWOCN, MSN, PhD
Case Situation A 29-year-old man was referred to the WOC nurse for management of extensive pressure-related skin breakdown. He weighed 284 kg and his body mass index was 89. His medical history was significant for sleep apnea, knee pain, and hypertension, but negative for diabetes and other conditions typically found among obese clients. The patient was single, had little immediate or extended family, and was unemployed. He had Roux-en-Y gastric bypass surgery (RYGB) 33 days previously. Throughout his life, the patient had made numerous attempts to lose weight. He tried multiple diet and activity strategies, but each weight loss success was followed by the disappointing experience of regaining weight. The consequences of his weight became increasingly evident as the patient had severe knee pain, was unable to bend over, and frequently became short of breath. As physical activity became increasingly more difficult, he considered alternatives for long-term or permanent weight loss. Ultimately he believed RYGB was his only option. For the first 7 days postoperatively he was cared for in the surgical intensive care unit (ICU). He required close observation because of respiratory problems and sleep apnea. While he was in the ICU, he was extremely reluctant to use bariatric equipment. The patient refused a wider bed, specialty mattress, or a lift system. He also declined to reposition himself or to be turned for pressure relief. The nurses documented that the patient refused cleaning when he was incontinent of stool. The clinical staff recognized that this patient was at risk for immobility-related complications. They were hopeful that once he was transferred out of the ICU environment, his reluctance to use bariatric equipment and be repositioned would resolve. Unfortunately, once the patient was transferred, he became increasingly unwilling to reposition himself. He also began to have multiple loose stools and refused to allow the staff to clean him or perform routine skin care. By postoperative day 33, the patient had
ulcers on the right and left buttock, lower back, and the buttock cleft. All 4 ulcers were covered with thick black eschar or slough tissue. The periwound skin was red and excoriated (Figure 1). The patient’s rejection of routine care may have been related to postoperative pain. Despite ongoing assessment of pain in the ICU and on the surgical unit, he denied pain as a factor. Eventually he verbalized that severe discomfort was the main reason for his refusal to be repositioned. The patient was using a patient-controlled analgesia pump in the ICU, and use of this pump was continued when he was transferred. Later his pain was managed with meperidine injections and hydrocodone and acetaminophen tablets. In view of his sleep apnea, oxygen saturation was maintained at 92% or higher. The head of the bed was elevated to facilitate deep breathing, and he was encouraged to use the incentive spirometer. The patient had been using a positive airway pressure device at home. Initially the pressure ulcers were managed by the surgical resident who performed mechanical debridement using a betadine scrub brush to loosen some of the necrotic tissue. The patient stood and leaned forward onto his hospital bed so that the involved area was exposed during the procedure. Sharp instrument debridement was also attempted at the bedside. Both treatments were exhausting and painful for the patient. He reported weakness and dizziness and soon refused these treatments. The patient’s emotional and physical well-being deteriorated. He expressed the desire to be left alone and attempted to isolate himself. His emotional state seemed to exacerbate his physical deterioration. When the wound team was consulted, the patient expressed frustration, humiliation, and anger. He used the WOC nurse for emotional support and clearly verbalized distress about his obesity, the surgery, the scrub brush treatment, and future plans. A positive patient/ nurse relationship developed and the patient started listening to suggestions given by the WOC nurse.
Anne Marie Knudsen, RN, MN, CNS, CETN, is a Board-certified Enterostomal Therapy Nurse, Harbor-UCLA Medical Center, Torrance, Calif, and Wound/Ostomy/Skin Consultant and Legal Nurse Consultant in the community. Susan Gallagher, RN, CWOCN, MSN, PhD, is Clincal Affairs Coordinator at SIZEWise Rentals, Ellis, KS. Reprint requests: Anne Marie Knudsen, RN, MN, CNS, CETN, 1000 W Carson St, HarborUCLA Medical Center, Nursing Department— Box 14, Torrance, CA 90509; e-mail: [email protected]. J WOCN 2003;30:111-8. Copyright © 2003 by the Wound, Ostomy and Continence Nurses Society. 1071-5754/2003/ $30.00 + 0 doi:10.1067/mjw.2003. 26
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When the wound team was consulted, the patient expressed frustration, humiliation, and anger.
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Figure 1. Thick eschar and slough tissue covered the ulcers on the right and left buttock, lower back, and buttock cleft; periwound skin was excoriated.
The WOC nurse’s first intervention was to discontinue the bedside debridement procedures. Because the patient did not tolerate these treatments, he was taken to the operating room and the ulcers were surgically debrided. Once the necrotic tissue was completely removed, stage IV pressure ulcers were exposed on the right and left buttocks, measuring approximately 11.5 × 7 × 3.5 cm and 26 × 7 × 3.5 cm. The ulcers on the buttock cleft and the lower back were stage III and measured 3 × 2.5 × 0.5 cm and 4 × 3.5 × 1.2 cm. The WOC nurse coordinated the management of the wounds. The expected outcomes for this patient were healing of the pressure ulcers, reasonable weight loss of approximately 1.4 kg weekly, muscle strengthening, and discharge home. Once debridement was accomplished, the immediate goals of care were to control pain, reduce pressure, friction, and shear, increase mobility and activity, prevent caregiver injury, and manage wound bacterial load and odor. A specially designed oversized bed (BIG Turn, Continuous Full Body Lateral Rotation Therapy, Size-Wise Rentals, Prairie Village, Kan) was obtained, as well as an overhead trapeze, bariatric wheelchair, walker, and commode. The continuous full body lateral rotation support surface was set to turn 40 degrees every 20 minutes. The rotation was turned off at night per the patient’s request, because he believed it made him dizzy; however, the low air loss therapy continued. The specially designed oversized equipment helped relieve pressure and promote independence. Pain was controlled with meperidine injec-
tions and later hydrocodone and acetaminophen. Once the patient was placed on an oversized specialty bed and received appropriate local wound care, he seemed to be more relaxed and compliant. He started verbalizing when he was in pain. Local wound care was supervised by the WOC nurse. The ulcers were treated with 0.25% acetic acid moist gauze dressings to reduce the bacterial load and control odor. The dressings were changed 3 times daily from postoperative days 40 to 47. The treatment was then switched to daily cleansing with normal saline solution and application of IntraSite Gel (Smith & Nephew, Largo, Fla), a nonpreservative hydrogel. The ulcer cavities were loosely packed with gauze dampened with normal saline solution and covered with dry dressings. The gel was used for several reasons: (1) to provide moist wound healing; (2) to reduce the number of dressing changes; (3) to help numb the pain using the gels cooling effect; and (4) to encourage further tissue debridement by autolysis. Calmoseptine ointment (Huntington Beach, Calif) was used to coat the excoriated and macerated periwound skin and to provide a water-repellent protective barrier. The ointment was applied to the skin at the wound margins to act as a barrier and prevent further maceration from the damp dressings. The patient had extremely frail thin skin on the buttocks, so No-Sting Skin Prep (3M, St Paul, Minn) was applied wherever tape was placed because it contains no alcohol and did not further irritate the skin or burn upon application.
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Figure 2. Dressings over ulcers were secured with dressing straps; retention tape was applied around the strap borders.
Nu-Hope Dressing Straps (Pacoima, Calif) were used to hold the dressings in place because of the skin barrier to protect the skin and hooks that are used with elastic bands to secure the dressings. The straps were cut to accommodate the buttock area. Retention tape was applied at the outer edges of the straps to provide further support and better secure the dressings (Figure 2). This wound treatment and the specialty oversized bed were continued until the ulcers healed (Figures 3-6). Outcomes were accomplished 120 days after treatment was initiated by the WOC nurse. These included healing of the pressure ulcers, 58-kg weight loss, increasing independence in activities of daily living, and final preparation for discharge to his home. More subjective outcomes included increased patient comfort, dignity, and confidence. The patient received follow-up care in the surgical outpatient clinic and dietary counseling to ensure correct protein intake and electrolyte balance to avoid dehydration. Prevention is a cost-effective alternative to treatment. Although this particular patient was reluctant to accept prevention modalities, this probably would have prevented the adverse therapeutic, cost, and satisfaction outcomes associated with numerous pressure ulcers. The patient continues to lose weight and now weighs 104 kg. He has not had any recurrence of the pressure ulcers and is adapting to his new body. More importantly, this patient will now be able to take part in the ordinary activities that most of us take for granted.
Commentary: This patient had been morbidly obese most of his life, and with a body mass index of 89, activities of daily living would likely become more and more difficult for him. Bariatric weight loss surgery programs are becoming increasingly prevalent because of patients like the man in this case situation. Most communities and hospitals introduce such programs in response to the needs of the more than 60 million morbidly obese Americans1 who have decided to use this available tool to manage their lifelong struggle with weight issues. Obesity and other eating disorders claim monetary, physiologic, and psychologic tolls from the persons they affect. Obesity is thought to be a factor in 5 of the 10 leading causes of death in the United States, and some persons contend that it is the second leading cause of preventable death. As early as 1985, the National Institutes of Health Consensus Conference described obesity-related health risks, which include an increased risk for cardiovascular disease, hypertension, diabetes mellitus, gallbladder disease, and socioeconomic and psychosocial impairment.2 In the United States, more than 60% of adults and 25% of children are overweight. Researchers predict that 80% of obese children will become obese adults.1 Health professionals and the public in general are seeking ways in which to reduce the emotional and physical consequences of what is referred to as severe obesity. Part of the challenge in this is the complexity of weight gain and weight
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Figure 3. Postoperative day 66: ulcer bases were clean and healing following debridement, topical treatments, and pressure reduction.
Figure 4. Postoperative day 96: ulcers on buttocks continued to decrease in size; bases had pink granulation tissue and periwound skin was healed.
issues. The simplest explanation of weight gain is that it occurs when the caloric intake is more than the energy needed to maintain body functions and perform physical activities. These excess calories are stored as fat in the adipose tissue. The tradi-
tional view that obese people gain weight because they either eat more or exercise less than other people is only part of the explanation. In March 1991, the NIH Consensus Development Conference on Gastrointestinal Surgery for
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Figure 5. Postoperative day 96: ulcers on lower back and gluteal cleft also had pink granulation bases and continued to decrease in size.
Severe Obesity brought together surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals, as well as the public, to address treatment options for severe obesity. At that conference it was decided that in select cases, surgery was an appropriate treatment intervention. Since that time, bariatric surgery has become an increasingly important adjunct in caring for the larger patient. There is an increasing demand not only for surgeons who have skill in weight loss surgery, but for organizations that commit to managing the complex needs of this patient population postoperatively. A number of conditions influence the postoperative course of patients who undergo weight-loss surgery. The needs of the severely obese surgical patient are likely to be different than those of severely obese medical patients, who are often chronically ill. As in this case situation, patients who choose weight-loss surgery are often very independent at home, despite their weight. Weightloss surgery is an elective surgery. Other than morbid obesity, patients who undergo bariatric weight-
loss surgery are generally in good health, and their postoperative course is usually uneventful. Predictions can be made in length of stay, mobility, and progress along care pathways. However, unexpected complications can occur, and such was the case with this patient. Ms Knudsen addressed the local wound care needs during her first assessment. The patient’s full-thickness pressure ulcers were extensive, initially requiring debridement and then, later, protection from cytotoxic influences and bacterial invasion as healing began. Delays in wound healing often occur because of infection or the presence of necrotic material. Various modalities are available to help loosen and remove this necrotic tissue. Once the necrotic tissue is removed, the wound can begin the healing process. Traditional whirlpool therapy is sometimes effective, but many obese patients are not candidates for this type of therapy. Weight limits on equipment, caregiver and patient safety, and transportation challenges exist. The Pulsavac Wound Debridement System (Dover, Ohio) provides a method for pulsatile irrigation and debridement. Effective de-
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Outcomes were accomplished 120 days after treatment was initiated by the WOC nurse.
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Figure 6. Postoperative day 156: all ulcers were healed 120 days after initial treatment by the WOC nurse.
briding occurs by directing fluid right to the wound. The Pulsavac offers variable pressure settings and an assortment of irrigation tips to provide cleaning and debriding of all types of wounds. Bedside treatment can be done, preventing the potential for caregiver and patient injury because of frequent transfers and transportation issues. Determining a method to secure the dressing without causing further skin breakdown from tape and other adhesive products can be especially challenging in this patient population, where the body contours are very irregular. In my experience, patients report that the discomfort from superficial tape-related skin injury can be more intense than from the wound itself, especially in the presence of a large surface area. Knudsen’s strategy to adhere the dressing to the patient was creative and effective, and the photo documentation demonstrates the improvement of the periwound skin. Additionally, larger patients may not have adequate pressure relief, and that was also addressed as part of the comprehensive plan of care. Low air loss with the option of full-body lateral rotation was initiated. Low air loss was in place at all times, and rotation therapy was introduced during the times when the patient could not reposition himself or when there was insufficient staffing to safely turn him. Assessment for shearing injury is necessary at least daily. Settings on the support surface can be adjusted to balance the benefit of the product with the risks of shearing.3 If shearing injury begins to develop, the degree of rotation or the
firmness of the surface can be reduced to prevent further injury and ensure continued therapy. Rather than address other options in local wound care, I believe mobility was the greatest concern for this patient throughout the hospitalization. Early and continued mobilization is critical in the recovery period. However, I argue that mobilization and skin care are often complicated by the lack of appropriate equipment and an inadequate understanding of pain issues and obesity. Many larger patients are able to turn, ambulate, and transfer soon after surgery, whereas others might have difficulty because of pain or sedation. Many times the only special accommodation needed is a bed that is wide enough for the patient to turn independently, a walker to support his or her weight for the first few postoperative days, and an overhead trapeze to help the patient reposition himself. These 3 items are thought to help the patient maintain his or her strength and independence. Clinicians report that independent patients who have adequate supportive equipment are less likely to injure themselves or caregivers during that early postoperative period. Assessment for special equipment needs could use the patient’s actual weight, hip width, and degree of mobility as criteria. To ensure fairness in distribution of equipment, it is important for organizations to standardize access, based on established criteria. As this case situation demonstrates, in addition to specially designed postoperative equipment, pain can interfere with patient mobility for physio-
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logic and psychological reasons. Pain, in most cultures, serves as a warning that something is wrong. Patients experiencing pain often respond with reluctance to move or participate in rehabilitation. This patient was reluctant to turn or allow specially designed equipment because of discomfort. Often this reluctance is misinterpreted as noncompliance. One of the greatest challenges in health care is to ensure the physical, emotional, and spiritual comfort of our patients. Management of pain is an important factor in patient comfort, and all patients are entitled to the best pain relief that can safely be achieved. Yet the problem of pain is pervasive, and the myths and misconceptions surrounding the pain experience and the assessment of pain often preclude adequate comfort and quality care. This is especially true among bariatric patients, where little evidence-based practice is available to make decisions about patient care. Misconceptions not only affect clinical decisions, but patients also may hold these misunderstandings, further interfering with pain control. Pain must be managed adequately because research now shows that unrelieved pain can inhibit the immune system, increase oxygen demand, cause respiratory dysfunction, decrease gastrointestinal motility, and cause confusion. Severe acute pain is a major risk of chronic neuropathic pain.4 In addition to the challenges that all patients face, bariatric patients have additional concerns. More questions than answers arise when dealing with pain in patients whose bodies contain a greater percentage of adipose tissue. For example, is the medication of choice water or fat soluble, and what are the clinical consequences of either? Will a 11⁄2-inch needle deliver a medication into the muscle or into the fatty tissue, and should intramuscular injection even be attempted? What is the effect of opioids on sensorium or already compromised pulmonary function? What role does long-term chronic pain have on the surgical patient’s interpretation of acute pain, and how is this assessed preoperatively? Finally, is postoperative nausea among morbidly obese bariatric surgery patients related to surgery or an adverse effect of the medication? These largely unanswered questions further serve to complicate pain management for the obese patient. As in this case situation, this can lead to behaviors that appear to be health-defeating activities. Pain is a completely subjective experience. A widely used definition is that pain is whatever the experiencing person says it is and exists whenever he or she says it does.5 The self-report of pain by a patient should be considered sufficient evidence to establish pain as a nursing diagnosis. Overcoming the myths and misinformation that abound regarding pain assessment and treatment is a challenge.6 The acceptance of pain as a subjective experience is difficult for many health care professions. Often these old paradigms continue to
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pose barriers to adequate pain control. Inadequate documentation tools fail to communicate pain and pain ratings. A pharmacist and pain specialist are essential in determining the most appropriate drug based on absorption mechanisms and rates, which can be complicated by the patient’s adiposity. The unique needs of the obese patient are especially important in making a drug selection. This clinical perspective also reinforces the need to clinically interpret the consequences of the chosen medication. In many settings, use of the intramuscular route is widespread, despite the fact that research suggests that the intravenous or intraspinal route for analgesics is usually safer and more effective.7 In the bariatric patient, it may be impossible to deliver an intramuscular injection because of the presence of a thick layer of fatty tissue. The intramuscular route may not provide predictable levels of drugs and therefore is not recommended.8 Respiratory depression is a potentially lifethreatening adverse effect among all patients but can be especially serious among morbidly obese patients. Respiratory depression is thought to be preventable by the clinician’s careful monitoring of sedation levels and easily treatable if it occurs. It is critical to assess for sedation levels and respiratory status when prescribing opioids for a patient who has moderate to severe pain and has not been receiving opioids regularly. When an opioid causes the patient to be so sedated that he or she has difficulty staying awake, the dose should be decreased to prevent respiratory depression. The likelihood of respiratory depression decreases the longer the patient has been taking opioids because tolerance to respiratory depression develops and information about the patient’s response to opioids is known. The antidote for respiratory depression is naloxone (Narcan) administered intravenously. Naloxone is a pure opioid antagonist that can reverse both analgesic effects and respiratory depression. Sufficient amounts of Naloxone should be given to decrease sedation and increase respirations to an acceptable level without completely reversing analgesia. Giving too much naloxone can also precipitate hypertension and ventricular dysrhythmias. Therefore, 0.4 mg of naloxone should be diluted in 9 to 10 mL of saline solution and 0.5 mL should be administered over 2 minutes.9 Each patient’s situation should be reviewed separately to determine the acceptable level of sedation and to assess the potential for harm from decreased sensorium. Some patients choose to endure more discomfort if it means less sedation. If the sedation level is still unacceptable after a few days of adaptation, another opioid can be substituted until a satisfactory one is found. Many patients who experience long-term chronic pain become depressed and anxious.10 Depression and anxiety can be exacerbated if it is difficult to
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establish a physical cause for the pain. These patients may begin to question their judgment, fear they will be perceived as troublesome, and worry that pain relief will be withheld because the pain is not real. These emotional responses may cause some health care providers to think that the pain is psychogenic and not physiologic.11 Physiologically, the body adapts to pain after a period of time, and vital signs normalize. This return to equilibrium is necessary to prevent physical harm and undue stress on the body. It does not necessarily mean pain has been controlled adequately. Additionally, patients might exhibit a behavioral adaptation to both acute and chronic pain. They may minimize their expressions of pain for a number of reasons. A patient may wish to be seen as a good patient or may place a personal or cultural value on a stoic response to pain. The patient may become too exhausted to respond vigorously to pain. Sometimes patients use distraction techniques to move the focus away from pain, especially when intense and unrelieved. One way of screening for pain among bariatric patients is to include questions on the clinical admission form, such as “Do you have pain now or have you experienced any pain recently?” If most patients are cognitively intact adults, the 0 to 10 (0 = no pain, 10 = worst pain) pain rating scale usually is used. If chronic pain is identified preoperatively, a more comprehensive pain assessment should include location, quality, onset, frequency, and intensity. These items are self-explanatory, and it is easy to ask the patient about them. Location can be assessed by asking the patient to point to the site of pain on his or her body or on a figure drawing. To assess quality, you may need to give the patient some examples, using terms such as burning, aching, dull knifelike, or shooting. With this assessment, a comfort/function goal is established by asking the patient what pain rating would make it easy for him or her to perform specific activities required for recovery or quality of life. For example, the patient in this case situation may need to ambulate 3 times daily to prevent skin and pulmonary complications. The patient would be asked, “What pain rating will make it easy for you to walk with the physical therapist 3 times daily?” He may respond that 3 on a scale of 0 to 10 would be sufficient. The comfort/function goal would be documented as “3/10 to ambulate with PT.” When establishing comfort/function goals, keep in mind that research has suggested that pain ratings above 4 significantly interfere with activities and mood.12 Nausea is not uncommon following bariatric weight loss surgery. However, opioids are often thought to be the source of the nausea. Other causes of nausea, such as nonopioid medications, hypercalcemia, uncontrolled pain, copious sputum, or coexisting medical conditions may be overlooked. Carefully review signs, symptoms,
and the patient’s case history before targeting opioids as the cause of nausea. In summary, the value of an interdisciplinary team should not be overlooked.13 Mobility can be affected by inadequate equipment and uncontrolled pain, which are 2 areas where the patient is best served when managed by a team who understands the special needs of larger patients. The pain specialist, pharmacist, physician, physical/ occupational therapist, WOC nurse, bariatric clinical nurse specialist, and other interested professionals are important members of the team. Research designed to investigate the meaning of pain, pain assessment, and management for obese patients provides opportunities for interested clinicians. Additionally, the processes related to developing, implementing, and measuring criteriabased protocols that provide bariatric resources in a timely and cost-effective manner present investigational opportunities. Together these research opportunities serve to begin building evidence so that responsible patient care choices can be made. Susan Gallagher, RN, CWOCN, MSN, PhD REFERENCES 1. American Obesity Association. AOA fact sheet. Available at: URL: http://www.obesity.org/subs/ fastfacts/obesity_US.shtml 2. NIDDK Weight-control Information Network. Statistics related to overweight and obesity.Available at: URL: http://www.niddk.nih.gov/health/nutri/pobs/ statobes.htm 3. Gallagher SM. Obesity and the skin in the critical care area. Critical Care Nursing Quarterly. 2002; 25(1):69-75. 4. Pasero C, Paice JA, McCafferty M. Basic mechanisms underlying the causes and effects of pain. In: McCafferty M, Pasero C. Pain: clinical manual. St. Louis: Mosby; 1999. 5. Gallagher SM. Ethical dilemmas in pain management. Ostomy Wound Manage 1998;44:16-21. 6. McCafferty M, Farrell B, Pasero C. Nurses’ personal opinions about patients’ pain and their effect on recorded assessments and titration of opioid doses. Pain Manage Nurs 2000;1:79-87. 7. Pasero C, Portenoy RK, McCafferty M. Opioid analgesics. In: McCafferty M, Pasero C. Pain: clinical manual. St Louis: Mosby; 1999. 8. Dominquez-Cherit G, et al. Anesthesia for morbidly obese patients. In: Dietel M, editor. Update: surgery for the morbidly obese patient. Toronto, Canada: FD-Communications; 2000. 9. Naloxone. Available at: URL: http://www.drugscope. org.uk/druginfo/drugsear 10. Pain and depression—The Mayday Project. Available at: URL: http://www.painandhealth.org/dep-links.html 11. Psychogenic pain. Available at: URL: http:// uihealthcare.com/topics/mentalemotionalhealth/ ment3164.html 12. Sirloin RC. When is cancer pain mild, moderate or severe? Grading pain by severity by its interference with function. Pain 1995;61:277-84. 13. Pasero C. Making your pain care committee effective. Am J Nurse 1997;97:17-9.