Nursing case study on obesity

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PMC What Do I Do with My Morbidly Obese Patient? A Detailed Case Study of Bariatric Surgery in Kaiser Permanente Southern California Pouya ShafipourArticle source, MD, Jack K Der-SarkissianMD, Fadi N HendeeMD, and Karen J ColemanMS, PhD Pouya Shafipour MS, MD, is a Family Physician at obesiry Motion Picture and Television Fund Medical Group in Los Angeles, CA.

Jack K Der-Sarkissian, MD, is the Assistant Obesuty of Service in the Department of Family Medicine at the Los Angeles Medical Center in Los Angeles, CA. Fadi N Hendee, MD, is an Endocrinologist at the South Bay Medical Center in Harbor City, CA. Karen J Coleman, MS, PhD, is a Research Scientist in the Continue reading of Research and Evaluation at the Kaiser Permanente Regional Offices in Pasadena, CA.

This has led to the development of surgical approaches to weight loss, generally referred to as bariatric read more. There is sttudy some evidence that most patients maintain some level of weight loss for up to ten years after surgery. The purpose of this article is to provide primary care physicians and syudy clinicians with some background regarding kn surgical procedures and their risks and benefits.

We also summarize the bariatric surgery process at Kaiser Permanente Southern California KPSCand then provide a detailed case study as an example of how KPSC screens patients referred for surgery, prepares them for the nursing case study on obesity, and cares for them once they have undergone surgery. Introduction Stdy many of the traditional methods for weight loss, such as dietary restriction, exercise, meal replacement, psychosocial and behavioral interventions, and continue reading, have limited effectiveness in long-term weight maintenance ogesity regulation of chronic diseases such as type 2 diabetes.

The purpose of this article is to provide primary care physicians PCPs and other clinicians with some background regarding bariatric surgical procedures and their risks and benefits. Other possible surgery obesiity for patients with a BMI of 35 to Shinogle et stuey 18 provide an excellent overview of bariatric surgery and its complications, and the most recent ASMBS guidelines for perioperative care of obese patients nurssing provide an extensive review of procedures as well as published cade outcomes from these procedures.

Currently there are two surgical options available for KPSC patients: Some older procedures require careful monitoring of after-surgery weight loss and nutritional status 11 and sttudy are not commonly used.

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Surgical Procedures Ibesity Gastric Bypass Because it produces superior long-term weight loss compared with other procedures that only restrict food intake, RYGBP nursijg the most prevalent procedure in the US. The boesity of mortality due to suicide in US patients who have just click for source RYGBP is higher than the national rates of suicide for men essay 3582 does application have essay women of similar age who have not casee the procedure.

Given that food cannot be fully absorbed in obesitu patients, it would stand to reason that medications such as psychotropics may not be absorbed adequately and thus dosage would have to be adjusted and carefully monitored after surgery. Laparoscopic Band Laparoscopic banding surgery 18 has recently received nursimg media and commercial www.

Nursing case study on obesity

Consequently, obese patients are asking their PCPs about the procedure and for referral to a link surgery center. Although the procedure does not result in the same weight loss outcomes as RYGBP surgery, 5 it is far superior to results produced by meal replacement, 9 and recent evidence supports its use as a treatment for type 2 diabetes in the severely obese.

Sleeve Gastrectomy Sleeve gastrectomy, or gastric sleeve, is a procedure that results in weight loss by restricting food intake. Gastric sleeve is meant to serve as a bridge to a bypass procedure at a njrsing date, once the patient has achieved sufficient weight loss. Bariatric Surgery at Kaiser Permanente Southern California Approximately surgeries, primarily RYGBP, are performed per year on Kaiser Permanente Stufy patients nationwide.

Half of these surgeries are done for patients in the KPSC Region. Currently, KPSC has two internal bariatric surgery centers. The Csse Los Angeles Medical Center recently began in Most KPSC patients are still referred to outside bariatric surgery centers in Los Angeles, Riverside, and San Diego counties with whom KPSC has contracted. Although there is a brief period after surgery up to six months when patients are monitored by the surgery centers, all patients return to KPSC for treatment by their PCPs.


Nursing case study on obesity

KPSC also provides care for patients who have had bariatric surgery in other health care systems before joining KPSC including those who have cade surgeries in other countries. These data are similar obesitj that reported for other insured populations. Criteria for referral to a bariatric surgeon in Kaiser Permanente Southern Californiaa Once the patient has finished the Options program, the bariatric care manager arranges a surgery consultation nureing the PCP takes over the cas care in collaboration with the bariatric care manager after surgery, although the patient may also nurxing seen at the surgery center for up to one year after surgery.

The bariatric care manager works closely onn the critical essay response centers and will continue to send periodic reports to the Read more about any surgery complications, revision procedures, and any other post-surgery issues. As with any program or procedure for rapid weight loss, the PCP must monitor the patient's medications, blood pressure, comorbid conditions, and psychologic state.

Referral Process Table 1 summarizes the criteria for referral of a KPSC patient for bariatric surgery. Disease burden and cawe for surgical complications stuvy just a few of see more issues a surgeon must consider in proceeding with bariatric surgery.

Other issues include severe mental illness, poor social support for behavioral changes required after surgery, and failure to lose some weight typically 2. These factors are not necessarily contraindications to surgery. Some patients who have not lost weight or have gained weight before surgery may be good candidates for surgery. Surgeons, the regional bariatric surgery steering committee, the regional bariatric medical director, and the local champion for adult weight management oversee decisions regarding patient referral and eligibility. Surgery Preparation In an effort to provide responsible medical treatment and the best possible outcomes from surgery, KPSC has institutionalized a program called Options, administered either through the Department of Health Education or through Preventive Medicine at most medical centers, which prepares all patients for surgery.

The Options curriculum is designed to help patients lose weight; master behavior-change techniques; educate them about surgery and post-surgery care, including nutrition and vitamin supplementation; inform them of possible complications of the surgery; and help them set realistic goals for both their weight loss and their behavior change after surgery.

Each patient has a personalized exercise program to use outside of the classes. The Options program is provided to each patient free of charge, however, patients can enroll concurrently in a meal-replacement program offered at their KPSC medical center low-calorie and very low-calorie diet programs to help them lose weight before surgery. There is an additional cost associated with all meal-replacement programs. Surgery Eligibility In addition to meeting the criteria necessary for referral to Options Table 1patients must attend all Options classes, with makeup sessions provided for those who miss classes.

Patients have a clinical and psychologic assessment during Options before meeting with the bariatric surgeon. A set of laboratory tests must be done before week ten of the Options program Table 2. These are usually ordered by the bariatric care manager.

Study obesity who were taking medications for nursing case health conditions before surgery should be monitored carefully because dosages will likely have to be adjusted. At the time of this writing, Tommy was bicycling his way to better health. Cosmetic Surgery Depending on link amount of weight lost and the patient's level of exercise after surgery, there is often some amount of excess skin that does not retain its elasticity after bariatric surgery. Rush A, Muir M. Even pharmacological care is difficult, because drug pharmacokinetics are altered by excess adiposity. If insulin doses are not lowered in conjunction with caloric restriction, a cycle begins of hypoglycemia, overeating, further hyperglycernia, increasing insulin requirements, and subsequent weight gain. KP will cover a panniculectomy if the PCP or plastic surgeon details the skin conditions that result from this excess skin and if the pannus extends below the pubis.

Tests are also done within 30 days of the surgery consultation. These tests differ somewhat by surgery center and thus will vary depending on where the patient will undergo surgery. Patients with serious psychiatric or physical illness are referred for treatment before they can advance to surgery, regardless of their performance in the Options program. Laboratory tests to be done before week ten of the Options program Postoperative Follow-Up Care For those KPSC patients who have surgery at one of the contract surgery centers, their follow-up care is often handled by surgeons at these centers.

However, the PCP should also see the patient during this time to monitor medications, comorbid conditions, and psychological state. The laboratory part of this care is handled at KPSC facilities. Suggested post-surgical laboratory tests are shown in Table 3. Surgery centers monitor complications and weight loss and provide this information to bariatric care managers for review. The timing of follow-up visits varies, but patients generally are scheduled for multiple laboratory tests and examinations in the first weeks after surgery, and then for laboratory tests and examinations at three- to six-month intervals thereafter.

Laboratory tests recommended for post-bariatric nutrition assessment for Kaiser Permanente Southern California bariatric surgery patients Malnutrition The recommended tests for nutrition monitoring are shown in Table 3 and are available as Smart Sets through KP's HealthConnect system.


Nursing and Obesity

These recommendations are based upon those of the ASMBS 111617 as well as the experiences of KPSC nutritionists in caring for bariatric patients. For the first two years after the surgery, the PCP should work closely with a staff nutritionist and refer patients who are having persistent dietary problems. In general we recommend that all bariatric patients take a daily serving of a balanced multivitamin that has minerals including zinc, folic acid, selenium, and copper.

Patients should also take a calcium citrate supplement for mg Laparoscopic Band or mg per day Gastric Sleeve and RYGBP in divided doses not to exceed mg. For the first six months after surgery, all bariatric patients should take 50 mg of thiamine Vitamin B1 daily. Only RYGBP patients need to continue thereafter.

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Mental Health In addition to nutritional monitoring after bariatric surgery, these patients also need close monitoring for depression, suicide, and substance abuse. Although not extensively studied, preliminary research has shown that these patients are at increased risk for suicide and drug overdose, 25 especially one year or more after surgery. If a change in mental health status is suspected, the PCP is encouraged to follow the KPSC clinical practice guidelines for major depressive disorder.

Patients who were taking medications for mental health conditions before surgery should be monitored carefully because dosages will likely have to be adjusted. In the case of type 2 diabetes, bariatric surgery may lead to full remission. Patients will likely need lower doses of medication as they continue to lose weight and may even be able to discontinue medications.

Table 2 contains recommended postsurgery laboratory tests; however, the PCP should order any additional tests relevant to the patient's comorbid conditions throughout this period. Pregnancy and Reproductive Health A new review of recommendations regarding bariatric surgery and pregnancy was published in General practice at KPSC is to advise women to wait 18 months after having surgery to become pregnant to insure that they are not losing weight during pregnancy. Even for women of reproductive age who do not plan to be pregnant, bariatric surgery shows promise for resolving polycystic ovary syndrome.

Cosmetic Surgery Depending on the amount of weight lost and the patient's level of exercise after surgery, there is often some amount of excess skin that does not retain its elasticity after bariatric surgery. KP will cover a panniculectomy if the PCP or plastic surgeon details the skin conditions that result from this excess skin and if the pannus extends below the pubis. However, no other skin removal is covered, so patients should be made aware of this possible outcome of bariatric surgery. JR had tried multiple commercial weight-loss programs but could not achieve and maintain a healthy body weight.

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He had never had a bariatric surgical procedure. He had numerous comorbidities related to his weight, including type 2 diabetes for more than 13 years, with diabetic nephropathy and polyneuropathy, hyperlipidemia, hypertension, erectile dysfunction, gastroesophageal reflux disease, gout, and depression. His diabetes had been steadily worsening despite his taking multiple oral hypoglycemic agents as well as insulin. His medications included pioglitazone HCl Actosmetformin, glyburide, insulin, ezetimibe—simvastatin Vytorinfelodipine Plendillisinopril, atenolol, tadalafil Cialisfamotidine, naproxen, and paroxetine Paxil.

At his referral to the Options program in Junehe weighed lb He started the Options program in August and finished in May He was then evaluated by the bariatric care management nurse practitioner under the supervision of the program's medical director. Although he had lost the recommended amount of weight, his diabetes was still uncontrolled, with worsening fasting blood glucose levels and hemoglobin A1c HbA1c of 8.

JR was able to change his diet and improve his use of insulin, so that six months later—in August —his HbA1c was improved to 6. He was then reevaluated and referred for surgery, which was scheduled for November At surgery, JR weighed lb Despite the weight gain, he underwent a laparoscopic RYGBP and had no complications. By his five-month postoperative appointment, JR had lost lb In addition to having achieved excellent weight loss, he no longer needed any medications, including those he was taking for depression, diabetes, hypertension, and hyperlipidemia. His HbA1c was 5. He has been monitored by the bariatric care management team and has been following the recommended diet and exercise regimen.

The only complication that he has experienced has been occasional nausea and vomiting after eating large meals. As of OctoberJR had lost lb Conclusions and Recommendations A PCP who decides to refer a patient for bariatric surgery must be aware of the proper criteria for surgical referral, preparation, and follow-up care.

The Options bariatric surgery preparation program at KPSC was developed to provide patients with comprehensive information about the surgery so that they could make an informed choice about treatment options. The case study presented here illustrates the process of preparing for, undergoing, and recovering from regional bariatric surgery within KPSC. The KPSC Department of Research and Evaluation has formed a partnership with the regional bariatric surgery program to develop an interactive patient registry to track patients from their referral to the Options program, through their surgery, and throughout the years after surgery.

This registry will be used to assist care managers and clinicians in treating these patients as well as providing KPSC leadership with information to make decisions regarding the expansion of the bariatric surgery program. Disclosure Statement The author s have no conflicts of interest to disclose.

Acknowledgment Katharine O'Moore-Klopf, ELS, of KOK Edit provided editorial assistance. The Body Too Thick This is a very great deformity, especially in young women. There are different ways of curing it, the most certain is: These ashes are very effective to hinder the body from growing fat. Dr Brody is a retired physician from the Northwest Permanente Department of Pediatrics. Photography has been his passion for over 40 years. Management of obesity as a chronic disease: Hainer V, Toplak H, Mitrakou A. Treatment modalities of obesity: Karmali S, Shaffer E. The battle against the obesity epidemic: Shah M, Simha V, Garg A.

J Clin Endocrinol Metab. Buchwald H, Avidor Y, Braunwald E, et al. JAMA Apr 13; Christou NV, Look D, Maclean LD. Weight gain after short-and long-limb gastric bypass in patients followed for longerthan 10 years. Swedish Obese Subjects Study Scientific Group.

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  • She responded immediately to its anti-inflammatory effects on the heart14 and improved markedly.
  • On laboratory testing, chemistries, BUN, creatinine, and liver function tests are normal.

Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. Differentiated long-term effects of intentional weight loss on diabetes and hypertension. O'Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: Schernthaner G, Morton JM. Bariatric surgery in patients with morbid obesity and type 2 diabetes. Mechanick JI, Kushner RF, Sugerman HJ, et al.

Dixon JB, O'Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: Vetter ML, Cardillo S, Rickels MR, Iqbal N. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. National Institutes of Health.

Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement Online. NIH Consensus Development Program 9[1], Consensus conference statement bariatric surgery for morbid obesity: Surg Obes Relat Dis. American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic and Bariatric Surgery.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Shinogle JA, Owings MF, Kozak LJ. Gastric bypass as treatment for obesity: Maggard MA, Shugarman LR, Suttorp M, et al.

Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Persistent anemia after Roux-en-Y gastric bypass. Bypassing medicine to treat diabetes. Omalu BI, Ives DG, Buhari AM, et al.

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Death rates and causes of death after bariatric surgery for Pennsylvania residents, to Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. Band and port-related morbidity after bariatric surgery: Cottam D, Qureshi FG, Mattar SG, et al.

  • For the first six months after surgery, all bariatric patients should take 50 mg of thiamine Vitamin B1 daily.
  • General practice at KPSC is to advise women to wait 18 months after having surgery to become pregnant to insure that they are not losing weight during pregnancy.
  • Specialized equipment is a basic requisite for organizations caring for morbidly obese patients.

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Beard JH, Bell RL, Duffy AJ. Reproductive considerations and pregnancy after bariatric surgery:

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3 Comments
  1. Nursing case study on obesity
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