ADVERTISEMENT
Guest Editorial: The Intersection of Ostomy and Wound Management, Obesity, and Associated Science
In 1997, Ostomy Wound Management published one of the first articles addressing the common, predictable, and preventable skin and wound challenges associated with obesity.1 Since then, a number of important articles have emerged from the journal. As the science of ostomy and wound management intersects with other disciplines, opportunities to improve patient care, many detailed in this special issue of OWM, are rapidly forthcoming.
The word obesity originates from the Latin language and refers to the state of becoming fattened by eating.2Bariatrics is a term derived from the Greek word baros and refers to issues pertaining to weight.3 In some circles, the term bariatrics is associated with metabolic surgery. However, the word encompasses much broader meaning; currently, it refers to the practice of healthcare that relates to the treatment of weight and weight-related conditions. This includes bariatric surgery as well as bariatric gynecology, bariatric reconstruction after massive weight loss, bariatric pediatrics, bariatric wound care, and more. Care of larger, heavier patients has become important in the practice of ostomy and wound care.
Issues related to weight are of interest to the public for several reasons.4 Bariatrics as a specialty is becoming increasingly important in pace with the growing number of obese and overweight Americans. Recent estimates suggest that more than 67% of adults in the United States are overweight, 40% of adults and teens are obese, and 6.4% are morbidly obese. This increase has occurred regardless of age, gender, ethnicity, socioeconomic status, or race.5,6 The problem is pandemic — overweight and obesity are not limited to the US. Worldwide, nearly 2 billion individuals are overweight, exceeding the number of individuals suffering from starvation.7
Care challenges are substantial. Consider the effect of obesity-related consequences of care on patients and clinicians. Repositioning for pressure ulcer prevention, turning for examination or treatment of skin injury, or movement of the panniculus for ostomy care all may impact the outcome of patient care if the caregiver is physically unable to perform the task. Further, handling larger, heavier patients may put caregiver safety at risk8 if these tasks are performed manually.
Providing care for the larger, heavier individual who enters the healthcare facility for an unplanned event can be more complex and time-consuming than with normal-weight patients; seldom do staffing administrators or reimbursement plans accommodate this difference. Regardless of the practice setting, preplanning becomes an essential component of safe patient care.9 Therefore, hospitals across the country are creating bariatric teams in hopes of designing processes to control or prevent some of the untoward complications associated with caring for the obese patient.10 However, limited availability of resources with which to develop appropriate tools and plans presents numerous obstacles. Likewise, skin and wound considerations, adequate nutritional support, IV access, appropriately sized equipment, airway management, resuscitation, diagnostic testing, pain control, social and emotional concerns, and the prevention of complications all present special and unique concerns. Practical resources such as longer gloves, wider commodes, specialized tracheostomy tubes, bariatric furniture, and mobility devices are important to consider.
Articles in this issue of OWM address these care considerations. In her overview of common issues faced by people of size and their caregivers, Beitz11 describes types of skin injury, etiologies, and special needs of the obese patient with a wound or at risk for developing skin injury. She notes specialized equipment can be instrumental in preventing skin injury associated with obesity. Preplanning with manufacturers and vendors to provide equipment for the morbidly obese patient is essential. When selecting oversized equipment, the clinician needs to consider equipment weight and width limits. Institutional policies and procedures for obtaining oversized ambulation and transfer devices, bed frames and support surfaces, wheelchairs, walkers and commodes, or furniture need to be instituted.12 Beitz also emphasizes that education is a critical part of the care plan as a strategy to ensure basic skills or competencies are understood and met. Although this is important for all patients, the complexity of the obese patient makes knowledge exceedingly valuable to patient satisfaction and therapeutic outcomes.
Surgery for the obese patient, and especially surgery that results in an ostomy, offers particular challenges. Education is an essential component for good outcomes. When addressing ostomy care and the obese individual, consider conducting a survey to determine the actual learning needs of clinicians.13 Skin fold management around the ostomy, patient handling, stoma retraction, wound infection, visualizing the stoma, and other conditions are often different for the patient of size and pose patient care challenges for caregivers. Colwell14 provides an indepth description of the clinical issues associated with the patient who has an ostomy, providing practical care options.
Once rare obesity-related conditions are increasing along with the numbers of obese individuals. Fife15 presents a review and case study of one such condition — massive localized lymphedema.
Provider safety is crucial. Arnold16 presents a photo narrative in which she describes trends in the emerging science of safe patient handing and mobility. Specially designed slings, bands, and devices are available to mobilize heavier patients safely and with dignity, an especially important aspect of prevention and treatment of pressure ulcers or in strategies to examine the abdominal area, otherwise hidden by an abdominal panniculus.
With obesity on the rise, clinicians are increasingly responsible for managing the needs of this complex patient population. This is especially true in the case of the obese patient with a wound or ostomy. Caregivers provided the tools, resources, and knowledge to provide good patient care feel good about their efforts and their job satisfaction rises. Satisfaction scores reflect that the happier the caregiver, the happier the patient.17 Numerous resources are available to clinicians across practice settings, and use of resources in a timely and appropriate manner is thought to improve measurable therapeutic, satisfaction, and cost outcomes. Coordinating these resources in the form of a comprehensive bariatric care plan may ensure the most favorable outcome for the patient with a wound or ostomy. The obese patient presents numerous care challenges. It is in the interest of healthcare organizations to meet these care challenges in a dignified and sensitive manner.18
Dr. Gallagher is Founder and Senior Clinical Advisor, Celebration Institute, Inc; and a Certified Bariatric Nurse and Certified Safe Patient Handling professional.
References
1. Gallagher SM. Morbid obesity: a chronic disease with an impact on wounds and related problems. Ostomy Wound Manage. 1997;45(5):18–27.
2. The Online Etymology Dictionary. Available at: http://etymonline.com/index.php?term=obesity. Accessed December 19, 2013.
3. Deitel M, Melissas J. The origin of the word bari. Obes Surg. 2005;15(7):1005–1008.
4. Camden SG. Nursing care of the bariatric patient. Bariatr Nurs Surg Patient Care. 2006;1(1):21–30.
5. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults 1999-2008. JAMA. 2010;303(3):235–241.
6. Main ML, Rao SC, O’Keefe JH. Trends in obesity and extreme obesity among US adults. JAMA. 2010;303(17):1695.
7. The Global Burden of Disease 2010. Available at: www.thelancet.com/themed/global-burden-of-disease. Accessed December 2, 2013.
8. Gallagher SM. American Nurses Association Implementation Guide to Safe Patient Handling and Mobility Interprofessional National Standards: Implementation Guide. Silver Spring, MD: ANA Nursing World;2013.
9. Gallagher S. The meaning of safety in caring for the larger, heavier patient. In: Charney W. Handbook of Modern Hospital Safety. Boca Raton, FL: CRC Press;2011.
10. Camden SG. Shedding health risks with bariatric surgery. Nursing. 2009;39(1): 34–41.
11. Beitz J. Providing quality skin and wound care for the bariatric patient: an overview of clinical challenges. Ostomy Wound Manage. 2014;60(1):12–21.
12. Gallagher SM. Recognizing trends in preventing caregiver injury, promoting patient safety and caring for the larger heavier patient. Bariatric Times. 2009;6(2):20–25.
13. Gallagher SM. Special patient populations. In: Charney W. Epidemic of Medical Errors and Hospital-Acquired Infections. Boca Raton, FL: CRC Press;2012.
14. Colwell J. The role of obesity in the patient undergoing colorectal surgery and fecal diversion. Ostomy Wound Manage. 2014;60(1):24–28.
15. Fife C. Massive localized lymphedema a disease unique to the morbidly obese: a case study. Ostomy Wound Manage. 2014;60(1):30–35.
16. Arnold M. A pictorial overview of technology-assisted care options for bariatric patients: one hospital’s experience. Ostomy Wound Manage. 2014;60(1):36–42.
17. Edwards G. The experts speak. Bariatric Nurs Surg Patient Care. 2007;2(1):3–6.
18. Gallagher SM. Skin and wound care among obese patients. In: Bryant A, Nix D. Acute and Chronic Wounds. St. Louis, MO: Mosby;2012.
