Perioperative care of the patient with morbid obesity - Home Study Program

AORN Journal,  April, 2003  by Paula Graling,  Hazem Elariny

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The article "Perioperative care of the patient with morbid obesity" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

A minimum score of 70% on the multiple-choice examination is necessary to earn 4.6 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is April 30, 2006.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

AORN Customer Service
c/o Home Study Program
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711
or fax the information with a credit card number to (303) 750-3212.

BEHAVIORAL OBJECTIVES

After reading and studying the article on perioperative care of the patient with morbid obesity, the nurse will be able to

(1) describe overnutrition,

(2) compare medical and surgical treatment options for patients with morbid obesity,

(3) define nursing considerations of caring for a patient undergoing surgery for morbid obesity,

(4) differentiate between the types of surgical procedures available to treat morbid obesity, and

(5) describe the postoperative course of a patient after having undergone surgical treatment for morbid obesity.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

Obesity is the underlying pathogenesis of a number of disease processes that are among the top causes of mortality in industrialized societies. Recently, it has been called an epidemic. (1) In the United States, more than 60% of adults are overweight. (2) Obesity differs greatly from morbid obesity. Although obesity and morbid obesity share numerous etiological factors (eg, genetic, environmental, psychosocial, economic), accepted treatment, options differ. Obesity deserves attention and treatment to prevent potential complications. Morbid obesity, however, requires urgent and definitive correction to treat both current and possible future complications and to help prevent a probable shortened lifespan. Currently, therapy for obesity and obesity-related medical conditions costs nearly $1 trillion dollars per decade in the United States alone. (3)

CLASSIFICATIONS OF OVERNUTRITION

States of overnutrition are classified based on body mass index (BMI). This is calculated by dividing a person's weight in kilograms by his or her height in meters squared. Table 1 provides a simplified version of the categories of overnutrition as described by the American Society of Bariatric Surgery (ASBS) and the National Institutes of Health (NIH). (4)

Using BMI as a measure of obesity can be misleading for very muscular people or people with little to no central or abdominal fat. This problem, however, is limited to people with BMIs less than 35. When a person reaches a BMI greater than 35, measurements such as waist to hip ratio and sagittal abdominal diameter become less important. (5) Patients are considered candidates for surgical treatment if they previously failed at medical weight loss attempts and are currently severely obese (ie, BMI > 35) with one or more associated comorbidities or morbidly obese (ie, BMI > 40) with or without comorbidities.

Effects of obesity on body systems. Obesity adversely affects almost all body systems and has been associated with increased risk for a number of malignancies. Table 2 lists those conditions and comorbidities that occur more frequently in people who are obese. This clearly supports the justification that care providers should aggressively treat morbid obesity.

COMPARISON OF MEDICAL VERSUS SURGICAL TREATMENT

Few people who are obese have benefited from medical attempts at excess body weight loss. Medical weight loss for people who are morbidly obese has a 95% failure rate and is extremely unlikely to provide sustained results, reduction of morbidity, or improved survival. Generally, it is accepted that nonsurgical approaches to weight loss for a person who is morbidly obese consistently are unsuccessful. No intervention, other than surgery, has provided any meaningful long-term success. This includes dieting, exercise regimens, psychotherapy, or prescription medications. The consensus, therefore, is that for a person who is morbidly obese, surgery is the only known effective treatment. (6)

Success rate. Almost all available surgical interventions result in an approximately 70% excess body weight loss during the first year. (7) Rather than facing a 95% failure rate for nonsurgical excess body weight loss interventions, the patient can be offered a range of surgical interventions that offer greater than 90% long-term success when using 35% excess body weight loss as the cutoff for success. When using 50% excess body weight loss as the cutoff, the success rate still is better than 70%, even for purely restrictive procedures. With bypass procedures and biliopancreatic diversion, success is even greater.