Nursing and Interprofessional management: Obesity

Nursing and Interprofessional management: Obesity 150 150 Tony Guo

Nursing and Interprofessional management: Obesity

  • Nursing Assessment
    • Subjective Data
      • Important Health information
        • First rule out physical conditions that may be causing or contributing to obesity
          • Be sensitive and nonjudgmental
          • Clarify rationale for inquiries about weight, dietary habits, and exercise
          • Address patient concerns
      • Past health history
        • Time of obesity onset
        • Diseases related to metabolism and obesity
          • Hypertension
          • Cardiovascular problems
          • Stroke 
          • Cancer
          • Chronic joint pain
          • Respiratory problems
          • Diabetes mellitus
          • Cholelithiasis
          • Metabolic syndrome
      • Medications
        • Thyroid preparations
        • Diet pills
        • Herbal products
      • Surgery or other treatments
        • Prior weight-reduction procedures (bariatric surgery)
    • Functional Health patterns
      • Health perception–health management: Family history of obesity; perception of problem; methods of weight loss attempted
      • Nutritional-metabolic: Amount and frequency of eating; overeating in response to boredom, stress, specific times, or activities; history of weight gain and loss
      • Elimination: Constipation
      • Activity-exercise: Typical physical activity; drowsiness, somnolence; dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea
      • Sleep-rest: Sleep apnea, use of continuous positive airway pressure
      • (CPAP)
      • Cognitive-perceptual: Feelings of rejection, depression, isolation, guilt, or shame; meaning or value of food; adherence to prescribed reducing diets, degree of long-term commitment to a weight loss program
      • Role-relationship: Change in financial status or family relationships; personal, social, and financial resources to support a reducing diet
      • Sexuality-reproductive: Menstrual irregularity, heavy menstrual low in women, birth control practices, infertility; effect of obesity on sexual activity and attractiveness to significant other
    • Objective Data
      • General
        • Body mass index ≥30 kg/m2; waist circumference: woman >35 in (89 cm), man >40 in (102 cm)
      • Respiratory
        • Increased work of breathing; wheezing; rapid, shallow breathing
      • Cardiovascular
        • Hypertension, tachycardia, dysrhythmias
      • Musculoskeletal
        • Decreased joint mobility and flexibility; knee, hip, and low back pain
      • Reproductive
        • Gynecomastia and hypogonadism in men
      • Possible Diagnostic Findings
        • Elevated serum glucose, cholesterol, triglycerides; chest x-ray demonstrating enlarged heart; electrocardiogram showing dysrhythmia; abnormal liver function tests
  • Nursing planning
    • Overall Goals
      • Modify eating patterns
      • Participate in a regular physical activity program
      • Achieve and maintain weight loss to a specified level
      • Minimize or prevent health problems
  • Nursing implementation
    • Obesity is one of most challenging health problems
      • Successful weight management can be both difficult and lifelong
      • Treatment begins with patients understanding their weight history and deciding on a plan that is best for them
    • An “ideal” BMI is not necessary and may not be realistic
      • Modest weight loss of 3% to 5% can have clinical benefits
      • Greater weight loss produces greater benefits
      • Average weight loss programs result in a 10% reduction of body weight
    • Explore motivation – it is key
    • Supervised plan of care should be directed toward
      • Successful weight loss
        • Requires a short-term energy deficit
      • Successful weight control
        • Requires long-term behavior changes

 

Upper Gastrointestinal Bleeding

  • Each year, 300,000 hospital admissions for UGI bleeding
  • Approximately 60% of patients are older than 65 years
  • Mortality rate has been 6% to 13% for past 45 years

Etiology and Pathophysiology

  • Most serious loss of blood from UGI characterized by sudden onset
  • Insidious occult bleeding can be a major problem
  • Severity depends on bleeding origin
    • Venous
    • Capillary
    • Arterial
  • Types of UGI bleeding
    • Obvious bleeding
      • Hematemesis
        • Bloody vomitus 
        • Appears fresh, bright red blood or “coffee grounds”
      • Melena
        • Black, tarry stools
        • Caused by digestion of blood in GI tract
        • Black appearance—due to iron
    • Occult bleeding
      • Small amounts of blood in gastric secretions, vomitus, or stools
      • Undetectable by appearance
      • Detectable by guaiac test

 

Massive UGI Bleed

  • Massive upper GI hemorrhage is defined as 1500 mL of blood
    • Of patients who have massive hemorrhage, 80% to 85% spontaneously stop bleeding
    • Cause still must be identified and treatment started immediately

Common Causes of UGI Bleeding

  • Esophageal origin
    • Chronic esophagitis
      • GERD
      • Mucosa-irritating drugs
      • Smoking
      • Alcohol use
    • Mallory-Weiss tear
    • Esophageal varices
  • Stomach and duodenal origin
    • Peptic ulcer disease
      • Bleeding ulcers account for 40% of cases of UGI bleeding
    • Drugs 
      • Aspirin, NSAIDs, corticosteroids
    • Stress-related mucosal disease (SRMD)
      • Also called physiologic stress ulcers
      • Most common in critically ill patients
        • Severe burns, trauma, or major surgery
        • Patients with coagulopathy on mechanical ventilation
  • Drug-induced origin
    • Corticosteroids
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Salicylates
  • Systemic disease origin
    • Blood dyscrasias (e.g., leukemia, aplastic anemia)
    • Renal failure

 

Diagnostic Studies

  • Endoscopy
    • Primary tool for diagnosing source of upper GI bleeding
    • Before performing
      • Lavage may be needed for clearer view
        • NG or orogastric tube placed, and room-temperature water or saline used
        • Do not advance tube against resistance
    • Stomach contents aspirated through a large-bore (Ewald) tube to remove clots
  • Angiography
    • Used to diagnose only when endoscopy cannot be done
    • Invasive procedure
      • May not be appropriate for high-risk or unstable patient
    • Catheter placed into left gastric or superior mesenteric artery until site of bleeding is discovered
  • Laboratory studies
    • Complete blood cell count (CBC)
    • Blood urea nitrogen (BUN)
    • Serum electrolytes
    • Prothrombin time, partial thromboplastin time
    • Liver enzyme measurements
  • Laboratory tests
    • ABG measurements
    • Typing/cross matching for possible blood transfusions
    • Test vomitus/ stools for presence of gross and occult blood

 

Interprofessional Care

  • Endoscopic hemostasis therapy
    • First-line therapy of upper GI bleed
    • Goal: to coagulate or thrombose the bleeding vessel
    • Useful for gastritis, Mallory-Weiss tear, esophageal and gastric varices, bleeding peptic ulcers, and polyps
    • Several techniques are used including 
      • Thermal (heat) probe
      • Multipolar and bipolar electrocoagulation probe
      • Argon plasma coagulation (APC)
      • Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
      • Mechanical therapy with endoscopic clips or bands.
      • Multipolar electrocoagulation and thermal probe
  • Surgical Therapy
    • Indicated when bleeding continues 
      • Regardless of therapy provided
      • Site of bleeding identified
    • May be necessary when 
      • Patient continues to bleed after rapid transfusion of up to 2000 mL whole blood
      • Remains in shock after 24 hours
    • Site of hemorrhage determines choice of operation 
    • Surgeon must consider age of patient
      • Mortality rates increase considerably in older patients
  • Drug Therapy
    • During acute phase, used to 
      • Decreased Bleeding
      • Decreased HCl acid secretion
      • Neutralize HCl acid that is present
    • Empiric PPI therapy with high-dose IV bolus and subsequent infusion
    • Injection therapy with epinephrine during endoscopy for acute hemostasis
      • For bleeding due to ulceration
      • Produces tissue edema → pressure on bleeding source
    • Somatostatin or somatostatin analog octreotide 
    • Used for upper GI bleeding
      • Reduces blood flow to GI organs and acid secretion
      • Given in IV boluses for 3–7 days after onset of bleeding

 

Nursing Management

  • Nursing Assessment
    • Subjective Data
      • Important Health Information
        • Past health history: 
          • Precipitating events before bleeding episode
          • Previous bleeding episodes and treatment
          • Peptic ulcer disease
          • Esophageal varices
          • Esophagitis
          • Acute and chronic gastritis
          • Stress-related mucosal disease
        • Medications: 
          • Aspirin
          • Nonsteroidal anti-inflammatory drugs
          • Corticosteroids
          • Anticoagulants
      • Functional Health Patterns
        • Health perception–health management: 
          • Family history of bleeding
          • Smoking
          • Alcohol use
        • Nutritional-metabolic: 
          • Nausea
          • Vomiting
          • Weight loss
          • Thirst
        • Elimination: 
          • Diarrhea
          • Black, tarry stools
          • Decreased urine output.
          • Sweating
        • Activity-exercise: 
          • Weakness
          • Dizziness
          • Fainting
        • Cognitive-perceptual: 
          • Epigastric pain
          • Abdominal cramps
        • Coping–stress tolerance: 
          • Acute or chronic stress
    • Objective Data
      • General
        • Fever
      • Integumentary
        • Clammy, cool, pale skin. Pale mucous membranes, nail beds, and conjunctivae. Spider angiomas, jaundice, peripheral edema
      • Respiratory
        • Rapid, shallow respirations
      • Cardiovascular
        • Tachycardia, weak pulse, orthostatic hypotension, slow capillary refill
      • Gastrointestinal
        • Red or “coffee-ground” vomitus. 
        • Tense, rigid abdomen, ascites.
        • Hypoactive or hyperactive bowel sounds. 
        • Black, tarry stools
      • Urinary
        • Decreased urine output, concentrated urine
      • Neurologic
        • Agitation, restlessness. Decreasing level of consciousness
      • Possible Diagnostic Findings
        • Decreased hematocrit and hemoglobin, hematuria. Guaiac-positive stools, emesis, or gastric aspirate. Decreased levels of clotting factors, ↑ liver enzymes, abnormal endoscopy results
  • Nursing Diagnoses
  1. Risk for decreased cardiac output related to loss of blood
  2. Deficient fluid volume related to acute loss of blood and gastric secretions
  3. Ineffective peripheral tissue perfusion related to loss of circulatory volume
  4. Anxiety related to upper GI bleeding, hospitalization, uncertain outcome, source of bleeding
  • Nursing Planning
    • The overall goals are that the patient with upper GI bleeding will 
      • Have no further GI bleeding
      • Have the cause of the bleeding identified and treated
      • Experience a return to a normal hemodynamic state
      • Experience minimal or no symptoms of pain or anxiety
  • Nursing Implementation
    • Health Promotion 
      • Patient with a history of chronic gastritis, cirrhosis, or peptic ulcer disease is at high risk
      • Patient who has had previous upper GI bleeding episode is more likely to have another bleed
      • Patient on daily low-dose aspirin to reduce cardiovascular disease risk are at risk
      • Patient teaching
        • Avoidance of gastric irritants
          • Alcohol
          • Smoking
          • Stress-inducing situations
        • Take only prescribed medications
        • Methods of testing vomitus/stools for occult blood
        • Potential need for prophylactic PPI
        • Prompt treatment of upper respiratory infection in patient with esophageal varices
        • Take drugs that produce gastroduodenal toxicity with meals or snacks
    • Acute Care
      • Place IV lines
        • Preferably 2, with 16- or 18-guage needle for fluid and blood replacement
      • Administer fluid and blood replacement as ordered
      • Accurate I/O record
        • Record urine output hourly
        • At least 0.5 mL/kg/hr indicates adequate renal perfusion
        • Measure urine specific gravity
      • Maintain NG patency and position
      • CVP line or PAC readings every 1–2 hours
      • Observe older adults and patients with history of cardiovascular problems closely
        • ECG monitoring
        • Vital signs
      • Approach in calm, assured manner to decrease anxiety
      • Use caution when administering sedatives for restlessness
        • Warning sign of shock may be masked by drugs
      • Emergency management
Assessment Findings
Abdominal and GI Findings Hypovolemic Shock
  • Hematemesis
  • Melena
  • Nausea
  • Abdominal pain
  • Abdominal rigidity
  • Decreased BP
  • Decreased pulse pressure
  • Tachycardia
  • Cool, clammy skin
  • Decreased level of consciousness
  • Decreased Urine output (<0.5 mL/kg/hr)
  • Slow capillary refill
Interventions
Initial Ongoing Monitoring
  1. If unresponsive, assess circulation, airway, and breathing.
  2. If responsive, monitor airway, breathing, and circulation.
  3. Establish IV access with large-bore catheter and start fluid replacement therapy. Insert additional large-bore catheter if shock present.
  4. Give O2 via nasal cannula or non-rebreather mask.
  5. Initiate ECG monitoring.
  6. Obtain blood for CBC, clotting studies, and type and crossmatch as appropriate.
  7. Insert NG tube as needed.
  8. Insert indwelling urinary catheter.
  9. Give IV proton pump inhibitor (PPI) therapy to decrease acid secretion.
  1. Monitor vital signs, level of consciousness, O2 saturation, ECG, bowel sounds, and intake/output.
  2. Assess amount and character of emesis.
  3. Keep patient NPO.
  4. Provide reassurance and emotional support to patient and caregiver

 

  • Assess stools and NG output for blood
  • Rule out other sources of bleeding
  • When vomitus contains blood but stool does not, hemorrhage is considered to be of short duration
  • Nutrition
    • Observe for symptoms of nausea and vomiting
    • Recurrence of bleeding
    • Feedings: initially clear fluids given hourly
    • Gradually introduce of foods as tolerated
  • Hemorrhage that is result of chronic alcohol abuse
    • Closely observe for delirium tremens 
      • Agitation
      • Uncontrolled shaking
      • Sweating
      • Vivid hallucinations
  • Ambulatory Care
    • Patient teaching
      • Patient/family taught how to avoid future bleeding episodes
      • Made aware of consequences of not adhering to drug therapy
      • Emphasize that no drugs other than those prescribed should be taken
      • No smoking or alcohol
      • Need for long-term follow-up care
      • Instruction if an acute hemorrhage occurs in future
  • Nursing Evaluation
    • The expected outcomes are that the patient with upper GI
    • bleeding will
      • Have no upper GI bleeding
      • Maintain normal fluid volume
      • Experience a return to a normal hemodynamic state
      • Understand potential etiologic factors and make appropriate lifestyle modifications

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