Providing Care for Patients of Size

A few years ago, Nancy Kaser, MSN, APRN, ACNS-BC, NEA-BC viewed a webinar on the increasing number of patients between 450 and 750 pounds. The webinar addressed a host of considerations for caring for patients with obesity, from availability of adequate equipment and safe mobilization to emergency preparedness.

The presentation inspired a closer look at nursing care for patients of size at Cleveland Clinic, says Kaser, a clinical nurse specialist at Lutheran Hospital.

“When we look at providing care for patients who have the disease of extreme obesity, it’s far more encompassing than one might realize at first glance,” she says. And care needs for this patient population are only likely to escalate. The prevalence of adult obesity in the U.S. increased from 30.5% in 1999-2000 to 42.4% in 2017-2018, according to the Centers for Disease Control and Prevention.

A focus on facilities and equipment

Cleveland Clinic has implemented several strategies to help ensure quality care for patients of size. The healthcare system has a Mobility with Safe Patient Handling Committee, which includes a bariatric subcommittee. In September 2021, Kim Kalo, MSN, APRN, AGCNS-BC, OCN, was named Cleveland Clinic’s first Program Manager of Mobility with Safe Patient Handling. Her role is to ensure that early progressive mobility of patients and safe patient handling is part of the culture and that caregivers have the necessary equipment and training to move patients safely and prevent injuries to themselves.

The following questions must be addressed regarding care for patients of size:

• Do we have the proper equipment and supplies, such as bariatric beds that extend to 50 inches, handrails that accommodate larger weight capacities, bedside commodes, wheelchairs, walkers, patient lifts and patient gowns?
• Can patient care areas accommodate the equipment and supplies necessary?
• Can elevators support the transport of equipment and patients?
• Do the pathways from the hospital entrance to nursing units, medical offices and testing areas allow for easy entrance and accommodate bariatric size wheelchairs or stretchers?

Caregiving guidelines for nurses

Caring for patients of size goes beyond equipment and infrastructure needs. Cleveland Clinic also has patient care guidelines for this population. “The guidelines highlight the more salient points that caregivers may not be familiar with based on the disease of obesity,” says Kaser.

Topics that pertain to nurses include the following:

• Baseline Assessments – A thorough assessment is key to detect subtle changes in patient condition.
• Respiratory Function – The cardio-respiratory status of patients of size may decompensate more quickly than that of a non-obese person.
• Mobility – Repositioning, lifting and transferring patients of size may require special equipment and extra caregiver support.
• Patient Care – Tasks such as bathing and toileting may require extra assistance, tools and supplies.
• Skin Care – Patients of size face challenges in maintaining skin integrity and may need care for atypical pressure injuries, skin folds, pannuses and lymphedema.
• Medication Management – Excess body fat may alter transdermal drug absorption, and standard needles may not be able to penetrate past adipose tissue in intramuscular injections.
• IV Access – It may be difficult to start a peripheral IV or obtain vascular access.

Advice for improving care of patients of size

Kalo and Kaser offer several suggestions to nurses who want to improve care of patients of size. First, they recommend reviewing the American Nurses Association’s Safe Patient Handling and Mobility programs and resources offered by the Association of Safe Patient Handling Professionals. In addition, they encourage nurses to reach out to other healthcare institutions and ask about their protocols and best practices for caring for patients of size.

Internally, caregivers should review equipment, tools and supplies for patients of size to identify any gaps. Kalo also recommends working across disciplines to ensure you’re providing quality care. Partners should include bariatric professionals, patient transport and physical therapy.

Finally, it’s important to be sensitive to patients of size. Cleveland Clinic includes sensitivity training on unconscious bias related to weight in its annual competency training for caregivers.

“As we look at patient-centric care, we don’t have an obese patient. We have a patient who has the disease of obesity, much like a patient who has diabetes or arthritis,” says Kaser.

Ultimately, it’s about providing quality care to all patients. “The same principles apply, regardless of the size of the patients,” says Kaser. “They all deserve world class care.”