EDITOR'S NOTE: Karen Schmidt, RN, if a freelance writer.
Weight is a big problem The CDC reports 1 in 3 adults in the U.S. is overweight — at least 36.5% have obesity. The CDC defines obesity as a body mass index of 30 or greater. The medical costs for people who have obesity were $1,429 higher in 2008 than those of normal weight, according to the CDC’s 2017 statistics. Among the needs for these patients in critical care units are mobility, airway management, skin care and medication adjustment. Mobilizing and transferring patients are of special concern, said Wanda Pritts, MSN, RN, CNS, citing a recent research article showing one-third of ICU patients are obese, and some are morbidly obese. Patients with obesity require more time, equipment and staff to move and transfer. “There are two things to consider — safety for the patient and for the staff member,” said Pritts, a clinical nurse specialist in bariatric care at Placentia (Calif.) Linda Hospital in. “It’s one of the primary concerns.” Pritts said the National Institutes of Health reports healthcare workers experience injuries five times more often than people working in similar capacities and lifting situations, even when using safety equipment. More and more healthcare facilities are becoming “no lift” or “minimal lift,” meaning staff do not use manual means to move patients. “If a facility labels itself “no lift,” no one is going to lift more than 35 pounds without adaptive technology and support,” Pritts said. Legislation in 11 states, often prompted by nursing and similar groups, has resulted in safe patient handling rules that require healthcare facilities to provide equipment to mobilize patients with obesity.
It’s no secret America’s obesity rate remains frighteningly high. For nurses, this creates a scenario in which not having the right equipment or the right processes in place can be dangerous. As Americans get heavier and obesity-related health conditions increase, nursing care practices and policies also must expand.
Make way for the airway
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Rachel Smigelski-Theiss, RN
Nurses need the right equipment Rachel Smigelski-Theiss, MSN, RN, ACCNS-AG, a clinical nurse specialist at The Queen’s Medical Center in Honolulu, co-authored a recent AACN Advanced Critical Care Journal article on acute care of patients with obesity, including mobility issues. She said Hospitals are realizing they need to adapt and procure equipment for lifting and moving patients, including different types of sit-to-stand slings to transfer patients from a bed to a gurney or chair and help the patient with obesity stand and begin to ambulate, she said.
Jill Kurasaki, RN-BC, MS, ACNS-BC, a nurse manager at The Queen’s, co-authored the article with Smigelski-Theiss. She said hospitals similar to The Queen’s often have a task force to address safe patient handling. “They look for ways to be sure we have the right tools and equipment to eliminate injury to staff. If there’s not the right equipment, they assess what’s needed,” she said. For example, The Queen’s recently bought a lateral transfer system with an air inflation mat that makes it possible for two staff to move a patient safely, Kurasaki said. Kurasaki said the facility’s lift team also has reduced injuries. “They’ve been instrumental to help with immobility,” she said. “When they come to the unit to help, they also train staff in what to use to safely move patients, such as transfer devices.”
Pritts said along with safe lifting, always remember the airway. “Obese patients can get into trouble very quickly,” she said. She explained critical care patients typically have underlying diseases, often including sleep apnea, which further compromises the airway. “The structure of the airway makes simple things like positioning important. Morbidly obese patients can become severely hypoxic in one to two minutes; then controlling the airway becomes more difficult,” Pritts said. She advocates for high vigilance in airway management and assessment.
Wanda Pritts, RN
If a facility labels itself 'no lift,' no one is going to lift more than 35 pounds without adaptive technology and support.”  
— Wanda Pritts, RN
Special medicine knowledge required
Pritts also said nurses must understand pharmacology may need to be adapted. “Often these patients can be both overdosed or under dosed,” she said. “Work carefully with pharmacy colleagues, understanding which medications are based on actual body weight versus ideal body weight,” she said, noting medications’ effect on patients with obesity can be altered because of metabolism, difference in blood volume and vasculature and volume shifts related to shock and resuscitation. From respiratory therapists to pharmacists to the lift team, caring for patients with obesity requires that nurses form a team approach. “Everyone will benefit from a multidisciplinary approach,” said Pritts.

Kurasaki agreed, recommending unit RNs also partner for skin care with wound care or ostomy specialists. “The high risk of pressure-related skin injuries is a constant concern for patients with obesity,” Kurasaki said. “Daily skin care including removal of moisture between folds of skin is essential to reduce maceration. Skin care is challenging and you have to pay close attention.”
Jill Kurasaki, RN
Laurie Duquette McGinley, RN
“Nurses need to move the patient to assess skin properly,” said Laurie Duquette McGinley, DNP, MSN, CNS-BC, APRN, CBN, RNFA, Bariatric Program Coordinator/Research Coordinator at Western Bariatric Institute. 
Avoiding pressure ulcers requires trying to keep skin dry, repositioning at least every two hours, and that’s difficult in a highly acute setting. Units are often supplied with mechanical, lateral transfer devices, air-assist devices and friction-reducing devices made of slippery-type material to reduce skin damage.

Nurses should be proactive to advance care for patients with obesity.

“The key it to plan ahead and have plans in place before problems happen,” Pritts said. “Simple procedures need to be adapted; for example, a patient doesn’t fit in the MRI, or if the cath lab table won’t hold them. There isn’t anything that won’t be affected [by a patient’s larger size].”

Tables can be adapted or have parts added, Pritts said. Everything from wheelchairs to commodes should be available in advance of patients needing them.

Both Pritts and Smigelski-Theiss said units need a champion or team leader to promote safe and appropriate care and ensure staff are following procedures.

“My personal opinion is that healthcare facilities aren’t making changes fast enough. It competes with other things that need resources,” Pritts said. “Technology is improving, but nurses have to make themselves use it and train on it. Often it takes time to change the habits on the floor. It takes more time and needs champions who keep cheering the process forward. You can’t just deploy a piece of equipment. There has to be a focus of keeping up the safety.”
Safety is big concern in treating patients who are overweight
Patients and nurses are both at risk
By Karen Schmidt, RN
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