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Complex Care Issues Resulting from Social Change: Bariatric Care

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1 Complex Care Issues Resulting from Social Change: Bariatric Care
Cindy Fehr Malaspina University-College Nursing 335 Spring 2006

2 FACTS Weight issues a serious problem with complex issues and consequences At epidemic levels worldwide Estimated 60% American adults overweight, 30% obese & 6 million morbidly obese More prevalent amongst certain ethnic & racial groups, plus age & sex play a role Considered a chronic disease like any other (diabetes, AIDS, hypertension) Wide-ranging medical, physical, social, psychological effects Estimated 300,000 premature deaths in USA each year from obesity-related complications Over $60 billion direct health care and $56 billion indirect economic costs annually Source: Statistics Canada - The Daily (July 6, 2005) available from While 23% of Canadian adults were obese in 2004, the rate was nearly 30% south of the border. the proportion of children aged two to five who were either overweight or obese remained virtually unchanged from 1978 to 2004. overweight/obesity rate of adolescents aged 12 to 17 more than doubled from 14% to 29%, while their obesity rate alone tripled from 3% to 9%. This upturn among adolescents is of particular concern because overweight or obese conditions in adolescence often persist into adulthood. Rates of overweight and obesity among youth varied across the country, with the highest rates being in the Atlantic provinces. More prevalent amongst certain ethnic & racial groups, plus age & sex play a role  likelihood of having BMI >25 rises around age 35 and declines around 75 Women more likely than men to be overweight (across all age groups)

3 % of population overweight
Obesity statistics Overweight Canadians, provincial comparison, 1998 Province % of population overweight Overall Rural Urban P.E.I. 59.0% 62.0% 56.7% Newfoundland 58.9% New Brunswick 58.3% 61.2% 56.0% Saskatchewan 57.9% 66.9% 54.4% Manitoba 54.3% 56.1% 53.8% Nova Scotia 52.5% 56.9% 49.1% Ontario 49.6% 55.3% 48.7% Alberta 48.5% 47.6% 53.3% B.C. 43.3% 41.4% Quebec 42.7% 44.8% 42.2% Canada 47.9% 46.6% Source: National Population Health Survey 1998, Statistics Canada

4 Source: Statistics Canada – The Daily (Oct. 18, 2005) available from
                                                         Source: Statistics Canada – The Daily (Oct. 18, 2005) available from

5 Measuring Weight & Fat #1 BMI examples
an adult male  1.8 metres tall (five feet, 10 inches) and weighs 95 kg (210 pounds) BMI of 30 and considered obese adult female 1.6 metres tall (five feet, 4 inches) and weighs 80 kg (175 pounds) BMI of 30 and also be considered obese same formula for children and adolescents however, the cut-off points for being overweight and obese vary by the age and sex of the child. #1 BMI BMI = weight (kg) / height (m2) Source: AJN January 2006

6 Measuring Weight & Fat cont.
#2 Waist-to-hips Ratio Recent research suggests that this is a better predictor of acute MI than BMI  likelihood of MI rises as the waist-to-hip ratio s Different types of weight gain Source: AllRefer Health.com (http://health.allrefer.com) Source: US Food & Drug Administration

7 Healthy Weight Chart for Adults – Source: BCHealth Guide www
Healthy Weight Chart for Adults – Source: BCHealth Guide

8 ADIPOGENESIS/LIPOGENESIS
Mesenchymal cells give rise to preadipocytes which proliferate locally Preadipocytes  unlimited supply t/o life so can be produced as needed Lipocytes – Fat Cells Source: AllRefer Health.com (http://health.allrefer.com) Adipocyte  from cell differentiation; fills with lipids Adipocyte hypertrophy ( size) and hyperplasia (#) leads to obesity – continue to acculumate lipid & enlarge up to 1000 times original size  once reaches a certain size, tiggers other preadipocytes to differentiate

9 Why a Rise in Obesity? (continued)
Weight gain & loss is complex interaction of psychological, environmental, evolutionary, biologic, genetic causes Genetics Account for 70% variability in people’s weight Estimated 300 genes involved in body weight Metabolic challenges Environment High fat calorie dense diet & overeating (portion size) Sedentary lifestyle (behavioral) Sociocultural norms Evolution Store fat for famines & hunt for food Estimated 85% dieters regain weight within 5 yrs – WHY??? Estimated that $30 billion spent each year in USA on dieting Genetics Affect variations in metabolism (dysfunctional BMR), body fat distribution, appetite regulation (impaired satiety mechanism) Abnormal conversion of ingested calories to fat Not the sole factor in any case – if parents obese, more likely to be obese May make certain individuals more vulnerable to negative effects of poor diets & limited exercise Metabolic challenges – insulin resistance or hypothyroid/Cushing’s Environment DIET - High fat and sugar content diets wreaks havoc on homeostatic appetite control  shift from neuroendocrine mediators to limbic system (pleasure & reward) Eating governed by sensory pleasure & often exceeds energy requirements EXERCISE – resting metabolic rate will rise as level of daily activity increases; factors hindering ability or willingness for regular exercise  modernization of households, sedentary occupations, lower socioeconomic status, communities not designed for outdoor activities, education level; activity not encouraged or modeled by family or leaders SOCIOCULTURAL NORMS – advertisements for supersizes  lose sense of fullness; buffets (more for your $), cost of simple carbs & fats is cheaper than more complex carbs & proteins (socioeconomic status is major factor then)  determinants of health; eating habits & exercise patterns are established during childhood Evolution Store fat for famines  developing countries still but not North America where access to high energy food abundant & activity level low Don’t need to hunt for food – less energy to drive to fast food shop and buy in drive through Neuroendocrine regulation See next slide Psychological  wgt often associated with  self-esteem & (morbidly obese) fewer relationships & higher risk of depression Younger develop obesity  less happy with body appearance & lower self-esteem than if develops in adulthood Discrimination & lack of respect & stigmatization by society and health care providers (blame health challenges on weight) Emotional trauma or emotional challenges following trauma – use food as comfort (link between early emotional trauma and morbid obesity)

10 Why a Rise in Obesity? Neuroendocrine
Hormones involved in appetite regulation Psychological Self-esteem, # of relationships, depression Discrimination, lack of respect, stigmatization Emotional trauma, ETOH or drug addiction Medications Prednisone (corticosteroids) antidepressants Estimated 85% dieters regain weight within 5 yrs – WHY??? Estimated that $30 billion spent each year in USA on dieting Genetics Affect variations in metabolism (dysfunctional BMR), body fat distribution, appetite regulation (impaired satiety mechanism) Abnormal conversion of ingested calories to fat Not the sole factor in any case – if parents obese, more likely to be obese May make certain individuals more vulnerable to negative effects of poor diets & limited exercise Metabolic challenges – insulin resistance or hypothyroid/Cushing’s Environment DIET - High fat and sugar content diets wreaks havoc on homeostatic appetite control  shift from neuroendocrine mediators to limbic system (pleasure & reward) Eating governed by sensory pleasure & often exceeds energy requirements EXERCISE – resting metabolic rate will rise as level of daily activity increases; factors hindering ability or willingness for regular exercise  modernization of households, sedentary occupations, lower socioeconomic status, communities not designed for outdoor activities, education level; activity not encouraged or modeled by family or leaders SOCIOCULTURAL NORMS – advertisements for supersizes  lose sense of fullness; buffets (more for your $), cost of simple carbs & fats is cheaper than more complex carbs & proteins (socioeconomic status is major factor then)  determinants of health; eating habits & exercise patterns are established during childhood Evolution Store fat for famines  developing countries still but not North America where access to high energy food abundant & activity level low Don’t need to hunt for food – less energy to drive to fast food shop and buy in drive through Neuroendocrine regulation See next slide Psychological  wgt often associated with  self-esteem & (morbidly obese) fewer relationships & higher risk of depression Younger develop obesity  less happy with body appearance & lower self-esteem than if develops in adulthood Discrimination & lack of respect & stigmatization by society and health care providers (blame health challenges on weight) Emotional trauma or emotional challenges following trauma – use food as comfort (link between early emotional trauma and morbid obesity)

11 Neuroendocrine Regulation
CNS – appetite regulated by hypothalamus CNS control feedback loop from stomach to brainstem Leptin –Don’t affect satiety but play a part in energy expenditure and appetite regulation Obesity associated with high leptin levels but may also be related to leptin resistance Ghrelin – stimulates appetite- Increase shortly before eating & decrease rapidly afterward  in obese the decline does not occur or less quickly   appetite & overeating Thyroid Hormones – involved in setting resting metabolic rate & thermogenesis Cholecystokinin – Inhibits gastric emptying & signals hypothalamus Peptide YY – Inhibits appetite by slowing gut motility & gastric emptying & suppressing NPY Diminished in obese patients Cortisol – Facilitates gluconeogenesis Insulin – Genetically prone to obesity have altered responses to insulin & glucose CNS – appetite regulated by hypothalamus through appetite inhibiting Poropiomelanocortin (POMC) & appetite stimulating neuropeptide Y (NPY) CNS control feedback loop from stomach (mechanical & chemical receptors) to brainstem to stop eating regardless of nutritional content of food eaten Leptin – directly inhibits NPY receptors & stimulates POMC receptors; secreted by white adipose tissue in direct proportion to total amount of body fat Don’t affect satiety but play a part in energy expenditure and appetite regulation Obesity associated with high leptin levels but may also be related to leptin resistance Ghrelin – produced primarily by stomach, stimulates appetite & promotes food intake through stimulation of NPY receptors & ing release of adrenocorticotropic hormone Increase shortly before eating & decrease rapidly afterward  in obese the decline does not occur or less quickly   appetite & overeating Thyroid Hormones – involved in setting resting metabolic rate (accounts for 2/3 total energy expenditure & varies depending on % muscle mass, fat mass, age, sex, genetics Have a reciprocal relationship in regulation of leptin & part control of adaptive thermogenesis (important in burning body fat) Cholecystokinin – peptide secreted in duodenum & jejunum; rapidly released into circulation in presence of digestive products Inhibits gastric emptying & signals hypothalamus via vagal nerve Peptide YY – rapidly released from descending colon & rectum in proportion to calories consumed at meal Inhibits appetite by slowing gut motility & gastric emptying & suppressing NPY Diminished in obese patients Cortisol – glucocorticoid, released from adrenal glands in response to corticotropin releasing hormone – part of the hypothalamin-pituitary-adrenal system Facilitates gluconeogenesis   blood glucose levels, stimulation NPY, lipolysis (triglycerides released from adipose tissue for energy) Stimulates adipogenesis & tendency for fat storage in central & visceral organs Obesity thought to be associated with hyperactive hypothalamus-pituitary-addrenal axis Insulin – produced by pancreas; basal circulating levels directly proportional to adipose level & rise rapidly after eating Suppresses NPY and stimulates POMC Genetically prone to obesity have altered responses to insulin & glucose Source: AJN Jan 2006

12 Feedback model for body-weight regulation
Source: ACP Medicine on Medscape

13 Costs to Society Costs of illness Absence from work
Reduced productivity Disability

14 Costs to Person Physical Costs Psychological Costs
Social Isolation, stigmatization, bias, discrimination $ for healthcare related costs – adaptive devices and support services Prejudices – study of children’s beliefs about normoweight and overweight Overweight – lazy, less intelligent, lack of willpower

15 Obesity-Related Consequences
Hypertension Heart disease Type 2 Diabetes Stroke Hyperlipidemia/dyslipidemia Arthritis Sleep apnea Gallstone formation Certain cancers (breast, colon, uterus, pancreas, kidney, prostate, gallbladder) Pickwickian Syndrome Modest weight gain (11-15 lbs) s risk of diabetes by 50% & losing this much weight s risk by same amount Health Risks of Obesity  with weight loss Excess weight burdens various organs & joints impairs immune system Release of excess endogenous hormones & proinflammatory cytokines Obesity usually accompanied by comorbidities Combo of obesity, HTN & dyslipidemia (all interrelated) called Metabolic Syndrome Pickwickian Syndrome Group of symptoms primarily affecting patients with extreme obesity Major health problem is sleep apnea – excessive fatty tissue surrounding chest muscles  strains heart, lungs, diaphragm and contributes to breathing difficulties Chest wall muscles difficulty expanding enough to exchange air effectively   ability to oxygenate blood  retain CO2  respiratory acidosis; chronic fatigue d/t sleep loss, poor quality sleep, chronic hypoxia Other symptoms Excessive daytime sleepiness SOB Disturbed nighttime sleep Flushed face or bluish tint to face HTN Enlarged liver Elevated RBC count Treatment is non-invasive mechanical ventilation (BiPAP, CPAP, wgt loss) Source: AllRefer Health.com (http://health.allrefer.com)

16 The Ultimate Risk = Death
Source: University of Queensland, Australia The Ultimate Risk = Death Medications – absorption, metabolism, distribution Fat soluble medication (anesthetics) lead to prolonged sedation Medication information & standard prescriptions researched for normoweight patients therefore need to adjust for those overweight Obesity  lower gastrib pH  affects absorption if medication needs normal or high gastric pH for absorption Co-morbidities (kidney function, fatty liver etc.)  alter medications and doses Morbid Obesity results in increased morbidity & mortality & shorter life span Source: Source: missbellorinna.tripod.com/ weightloss.htm

17 Cardiac weight strains heart function HTN  cor pulmonae (® heart failure) Atherosclerosis  CAD Vascular disease – venous insufficiency venous stasis Thrombotic Stroke Pulmonary  fat around tongue, neck (short neck) intermittent obstruction, obstructive sleep apnea, obesity hypoventillation syndrome (Pickwickian’s) Shallower, less VC proportional to weight which pressures diaphragm (especially when lying down) Asthma, reactive airway  r/t chronic aspiration of stomach juices with GERD (d/t pressure on abdomen from excess weight) Gatrointestinal/Genitourinary Cycles of extreme wt loss/gain  cholelithiasis (presence/formation stones) & cholecystitis (inflammation) Hyperlipidemia (high cholesterol)  fatty liver (steatosis) and cirrhosis  abd pressure  GERD, ventral hernias, urinary/fecal incontinence,  risk dehisence Hyperuricemia  gout & kidney stones Endocrine Type II Diabetes Insulin resistance  disruptions in menstrual cycle, abnormal menstrual flow,  dysmenorrhea, infertility Polycystic ovarian disease  infertility & early miscarriage/delivery Musculoskeletal Osteoarthritis & longer healing time for soft tissue damage of joints  due to weight on joints  ability to exercise due to pain and damage of joints from weight Integumentary Pressure, moisture (perspiration d/t lower skin ratio to body mass), difficulty controlling body temperature  excoriation, fungus, odor, irritation, rashes, ulceration at folds and pressure areas same even though have more weight Difficult to cleanse perineal area   risk of skin breakdown, UTI

18

19 Metabolic Syndrome Also known as insulin resistance syndrome & dysmetabolic syndrome & syndrome X Incidence up to 1 in 3 within general North American population Syndrome characterized by: HTN, central obesity, insulin resistance, high LDL/low HDL cholesterol & high triglycerides Now looking at this syndrome as one entity instead of separate disease states Leads to diabetes & heart disease & stroke Treatment involves coordinated care, appropriate goals for each disease & patients as partners in care insulin resistance key factor in metabolic syndrome What happens:  Insulin receptors on cells stop recognizing insulin so when CHO intake levels increase so does insulin levels  but the insulin levels overwhelm insulin receptors which won’t let glucose enter the cells  Over time, insulin receptors develop resistance to higher amounts of circulating insulin this results in high blood glucose levels and hyperinsulinemia yet the cells are starving for energy source  body needs even more insulin to control blood sugar levels (pancreas) Higher levels of glucose in blood although usually still within normal range Can lead to type II diabetes from abnormally high blood glucose levels over sustained periods of time

20 Source: Nursing made Incredibly Easy! Sept/Oct 2003 p. 22
Consequences of Insulin Resistance: Remember insulin powerful growth factor  too much = muscle hypertrophy & vascular remodeling Triggers  triglyceride levels s LDL cholesterol levels s serum uric acid level (gout) s platelet adhesion s response to angiotensin II s amounts of nitric oxide (vasodilator) produced by endothelium All these can alter lining of vascular endothelium & put at further risk Renin-Angiotension system When blood pressure decreases in the kidneys, they produce an enzyme called renin. Renin cleaves the peptide bond between the leucine (Leu) and the valine (Val) residues creating the ten amino acid peptide angiotensin I. Angiotensin I has little biological effect. Its main role is to become angiotensin II The main enzyme that cleaves Angiotensin I to Angiotensin II is called Angiotensin-converting enzyme (ACE, also known as kininase) and is found predominantly in the lungs. This enzyme is a target for drugs (ACE inhibitors) that inactivate it, decreasing the rate of angiotensin II production. Effects of Angiotensin II Vascular It is a potent direct vasoconstrictor, causing arteries and veins to constrict and so leading to an increase in blood pressure. It also potentiates the release of norepinephrine by a direct action on postganglionic sympathetic fibres. Brain Angiotensin II acts on the brain to increase the sense of thirst via the subfornical organ (SFO), decrease the response of the baroreceptor reflex and increase the desire for salt. It also increases the secretion of vasopressin and ACTH. Adrenals It acts on the adrenal cortex, causing it to release aldosterone, a hormone that causes the kidneys to retain sodium and lose potassium. Renal It has a direct effect on the proximal tubules to increase Na+ resorption, and although it contracts mesangial cells due to increased sympathetic effects, its overall effect is to increase the glomerular filtration rate by increasing the renal perfusion pressure. Other It has been thought that angiotensin II could be a cause of cardiac muscle hypertrophy (when the heart wall grows bigger). Angiotensin II has prothrombothic potential through adhesion and aggregation of platelets Source: Nursing made Incredibly Easy! Sept/Oct 2003 p. 22

21 Key Clinical Indicators of Metabolic Syndrome
Waist/hip ratio (umbilicus/hip) Abd waist circumferance ♀ > 35” & ♂ > 40” BMI > 30 Abnormal lipid levels HDL LDL & VLDL Triglycerides BP > 130/85 Two elevated fasting blood glucose levels Nicotine dependence also common  potent vasoconstrictor & primary cause of heart disease Risk Factors HDL - high density lipoprotein LDL – low density lipoprotein VLDL – very low density lipoprotein RISK FACTORS Age As age s, risk s (~ 20% in 20’s & 40% in 60’s have some form of this) 1/8 school children have 3 or more components of metabolic syndrome Race Those of hispanic and black race at highest risk Obesity  risk with BMI > 25 Family history type II diabetes or gestational diabetes Other diseases HTN, heart and BV diseases, polycystic ovarian syndrome in which excess of male hormones are produced, lack of ovulation (insulin helps regulate ovarian function)

22 Nursing Considerations
Unconditional acceptance Empathy not sympathy Sensitivity to needs Understanding Open communication Adaptive devices – mechanical lifts, special beds, bed trapezes, wheelchairs, bedside chairs, walkers, bed lifters, bedpans, commodes, etc… Avoid personal injury & patient injury Nursing assessments & interventions altered to obtain accurate information, decision-making, effective treatment

23 Weight Loss Diets - many choices Dietary supplements Exercise Regimens
Psychotherapy Motivation Exploration of why want to lose weight Success related to… Diets – reducing calorie intake, limiting fats & carbohydrates, eating well balanced diet Dietary supplements to boost metabolism (phentermine) (ephedrine) – change brain chemicals that affect mood & appetite curb appetite (sibutramine) – makes you feel full sooner lipase inhibitor (orlistat) – inhibits intestine from absorbing fat from food  more fat excreted in stools Potential to interfere/interact with other medications on Psychotherapy Triggers for eating Motivation – exploration of lifestyle choices & changes (diet, exercise) Exploration of why want to lose weight Enhance appearance, wear fashionable clothes Avoid embarrassment of buying larger sizes Improve self-confidence Improve health Specific trigger – seeing picture of self, comments from others, death of relative, life transition, realization of impact on health

24 Bariatric Surgery Definition – surgery done with the goal of weight reduction Candidates BMI > 40 or >35 with co-morbidity (apnea, diabetes, degenerative joint disease, HTN, ischemic heart disease, asthma, history of CVA) 18 years or older Obese for at lease 5 years Documented lack of success to lose weight with other methods Demonstrated ability to comply with post-op long term dietary & behavioral changes Detailed health & weight histories Can literally be life-saving procedure for morbidly obese but only one part of the treatment plan Bariatric  derived from two Greek words Baros  weight Iatrike  treatment Discovered after patients who’d undergone gastric resection for gastric cancer or peptic ulcers lost weight. Many different procedures refined over the years due to metabolic complications 1991 National Institutes for Health in USA experts concluded that surgical intervention “is the only method proven to have a significant long-term impact on the disease of morbid obesity”

25 Gastric Surgery types Restrictive Procedures
Create a gastric pouch with narrow outlet Gastroplasty or gastric banding Feel full sooner (1 oz initially  4 oz capacity max) Small outlet delays gastric emptying  feel full longer Potential complications = severe GERD & stomal obstruction Vertical banded gastroplasty Circumgastric or adjustable banding Source: Nursing Made Incredibly Easy Jan/Feb 2006

26 Gastric Surgery types cont.
Malabsorptive Procedures Bypass a significant length of small intestine, reducing absorption of calories & nutrients Associated with long-term metabolic complications & nutritional deficiencies (liver disease, osteoporosis, diarrhea, dehydration, electrolyte imbalances, malnutrition)

27 Gastric Surgery types cont.
Combination Restrictive & Malabsorptive Techniques Gold standard in North America is Roux-en-Y gastric bypass procedure Small pouch created in upper part of stomach by separating it from remaining portion of stomach using staples; portion of jejunum separated and anastomosed to new pouch  bypass occurs at stomach Laparoscopic or open technique Gastric Restriction & Malabsoprtion surgery or Roux en Y technique Source: Nursing Made Incredibly Easy Jan/Feb 2006

28 Post-op Considerations
Virtually every aspect of treatment is impacted by size AIRWAY -  respiratory compliance d/t more tissue pressure on chest wall, diaphragm (from large abdomen), intercostals, upper airway HEMODYNAMIC STABILITY – large BP cuff; fluid shifts could make vascular dehydration; in/out monitoring; blood chemistries PAIN MANAGEMENT – promotes DB&C; post-lap shoulder pain; antiemetics; doses may need to be different HOB  30-45° - decreases abdominal pressure on diaphragm & maximizes tidal volume (obesity hypoventilation syndrome)- in morbidly obese – hypercapnic respiratory failure as a result of decreased response to CO2 and hypoxia Medication administration – obesity can alter pharmacokinetic properties of medications Changes in drug distribution may require dose alteration depending on how drug absorbed in fatty tissue (subtherapeutic to toxic)

29 Post-op Considerations cont.
ACTIVITY/AMBULATION – high risk DVT/PE, SKIN/WOUND/DRAIN SITE CARE – risk for pressure ulcers, prone to yeast infections in skin folds; urinary incontinence common; challenges with personal hygiene; delayed wound healing/dehisence DIET & NUTRITIONAL SUPPLEMENTS – NPO following bariatric sx to r/o anastamotic leaks  water  clear fluids  DAT (no sugar, caffeine, carbonation) high protein supplements/shakes good PSYCHOLOGICAL ADJUSTMENTS – anorexia nervosa, changes in body image with excess skin, depression r/t many life changes ACTIVITY/AMBULATION – high risk DVT/PE (immobility, stasis, polycythemia r/t chronic respiratory insufficiency Low molecular weight heparin (not standard dose) Sequential compression devices at rest Early ambulation – more staff to support this, bariatric equipment (chairs, commodes, walkers, w/c, bed) SKIN/WOUND/DRAIN SITE CARE – risk for pressure ulcers, prone to yeast infections in skin folds; urinary incontinence common ( abd pressure, difficulty mobilizing); challenges with personal hygiene antifungal cream Daily inspection & assistance with cleaning/drying Delayed wound healing – adipose tissue poorly vascularized & may cause delayed healing of open wounds – abdominal binder for abd incisions DIET & NUTRITIONAL SUPPLEMENTS – NPO following bariatric sx to r/o anastamotic leaks  water  clear fluids  DAT (no sugar, caffeine, carbonation) high protein supplements/shakes good 30 ml medicine cups to learn volumes Usually on liquid diet for several weeks then soft Permanent to high protein, low fat, low carbohydrate & dietary consult prior to d/c PSYCHOLOGICAL SUPPORT – Years of discrimination (family, social, professional settings); often suffered psychological or physical abuse (shame, hope, fear, embarrassment with surgery); impossible to fully understand their life, some compensate with strong personality, others don’t want attention – MUST BE PROFESSIONAL (Our duty)

30 Following Weight Loss Health promotion initiatives
Long-term diet goals Emotional Support – many changes Plastic Surgery & liposuction Sources for photos – Google Images

31 Body Contouring Following Weight Loss
Overall changes in body shape Should be referred to a plastic surgeon purpose of body contouring is to reduce excess skin and tissue lengthy recovery period Areas for challenge Lower trunk produces lots of complaints Abdominal wall weakness or hernia Upper trunk & breasts Upper arms Thighs Many people are not sufficiently prepared for how they look after massive weight loss and are unpleasantly surprised that they are dissatisfied with their appearance. Depending upon the pattern of weight loss, they present with complaints that include some or all of the following: * excess rolls of skin and tissue on the back, flanks, and hips; * sagging abdomen with a possible “hanging apron”; * abdominal wall laxity; * folds along the lateral chest; * drooping breasts; * poorly defined waist or no waist; * drooping buttocks; * mons pubis ptosis; * “batwing” skin and tissue along upper arms; and overly large thighs. Candidates for body contouring must be carefully selected. Patients must have realistic expectations and understand that perfection is not a realistic goal. produces scars that will always be present following surgery Patients need to be motivated to cope with an extended recovery following surgery. Significant complications can result after body contouring, and the patient must be stable enough (both mentally and physically) to cope with problems that arise. Body contouring, especially belt lipectomy, is possibly the most extensive surgery a patient will ever experience. A psychiatric clearance should be obtained from a health professional who can provide counseling if needed during the recovery period Weight should be stable for 6 to 12 months Patient after weight loss of 170 lb; legs still have good appearance Source: Plastic Surgical Nursing (2004) 24(3)

32 Marking for upper body lift and brachialplasty.
Benefits to Body Contouring clothing size down by one or two sizes clothes easier to find more vigorous activity is possible body image improves Panniculus (fatty apron) Panniculectomy – exaggerated tummy tuck Marking for upper body lift and brachialplasty. Source: Plastic Surgical Nursing (2004) 24(3)

33 Marking for belt lipectomy
Source: Plastic Surgical Nursing (2004) 24(3)

34 Preoperative (top row) and postoperative (bottom row) belt lipectomy
Source: Plastic Surgical Nursing (2004) 24(3)

35 Preoperative (top row) and postoperative (bottom row) brachialplasty
Source: Plastic Surgical Nursing (2004) 24(3)

36 Preoperative (top row) and postoperative (bottom row) medial thigh resection
Source: Plastic Surgical Nursing (2004) 24(3)

37 Potential Complications
Infection Seroma formation Hematoma formation Wound dehiscence Scars Decreased sensation Major complications – DVT & PE Large flaps of skin are raised to provide tight closure of the areas excised, and fluid accumulates in the areas that are raised. While drains are used to remove fluid and keep the flaps closed, fluid may accumulate after drains are removed. Treatment of seroma consists of aspiration that can be done in the clinic. Persistent or large amounts of seroma may require insertion of a new drain Hematoma may result after surgery because of inadequate hemostasis during surgery, coughing or emesis following surgery, or coagulation deficiencies - tx is aspiration Wound dehiscence is always possible following body contouring because the suture lines are purposefully tight. - can possibly occur as late as 3 to 4 weeks postoperatively if sudden extreme movements are made. Scars are inevitable with surgical procedures; however, scars associated with body contouring are usually extensive and may be in areas that are not always concealed with clothing - will gradually fade from a red and raised scar present immediately after surgery to one that is flat and white - requires time Decreased sensation along the incision lines and over any areas of liposuction is to be expected

38 Prevention What it Takes Basic Principles of Activ8Kids!
Up to 1/3 children eat fast food everyday (Boston Children’s Hospital Study) What it Takes Culture shift, changes in behaviour & lifestyle Influences – family, friends, colleagues, media, food & leisure industries, immediate environments Improving diet – fats & simple and added sugars Increasing physical activity Even modest weight loss improves health Low income one factor in childhood obesity – addressing Determinants of Health Source: California State University Library Source: New York State Department of Health Basic Principles of Activ8Kids! 5 fruits and vegetables each day 1 hour of physical activity each day 2 hours OR LESS of TV or screen time daily Not the toddlers or young children who Buy nutrient poor calorie high foods Drive the children to fast food restaurants Control how much activity/lack of activity Role model for themselves Tell each other they are fat or skinny – they see it on TV, magazines, hear their parents talk about weight issues, failed diets - this is negative reinforcement Children need role models and society that encourages activity, balanced nutrition, self-esteem not linked to social norms (abnormals) PREVENTION Home – less sedentary activities, less processed foods, balanced diet School – PE, active recess & after school activities Work – less sedentary nature of jobs; work out areas provided Community & Society – less reliance on motor vehicles (carpooling, bike paths); less fast food restaurants, buffets, processed foods (France slow food revolution) Health Care Focus – focus on prevention initiatives, education Government - $$$ for prevention & education & activities to support healthy lifestyle for all generations

39 Resources Appel, S.J., Giger, J.N., & Floyd, N.A. (2004). Dysmetabolic syndrome: reducing cardiovascular risk. The Nurse Practitioner, 29(10), Blackwood, H.S. (2005). Help you patient downsize with bariatric surgery. Nursing, 35(9), supplement: Med/Surg Insider, 4-9. Blackwood, H.S. (2004). Obesity: a rapidly expanding challenge. Nursing Management, May, Daniels, J. (2006). Obesity: America’s epidemic. American Journal of Nursing, 106(1), Edelman, R. (2005). Obesity, type 2 diabetes, and cardiovascular disease. Nutrition Today, 40(3), Forman, A. (2004). The second national conference on diabesity® in America. Nutrition Today, 39(6), Gabriel, S., & Garguilo, H. (2006). Bariatric surgery basics: getting to the heart of a weight subject. Nursing made Incredibly Easy!, 4(1), Heddens, C.L. (2004). Body contouring after massive weight loss. Plastic Surgical Nursing, 24(3), Hoolihan, L. (2005). The role of education and tailored intervention in preventing and treating overweight. Nutrition Today, 40(5), Walker-Sterling, A. (2005). African Americans and obesity. Clinical Nurse Specialist, 19(4), Woods, A. (2003). X marks the spot: Understanding metabolic syndrome. Nursing made Incredibly Easy!, 1(1),


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