Long-Term Care Survey Alert

Published on Mon Apr 20, 2009 PDF

Is your facility meeting obese residents' needs in these key areas?

For starters, make sure you have the right equipment to physically transfer or move the person, if needed. To care safely for a very obese patient, the facility needs a "bariatric triad" composed of a weight-graded bed and mechanical lift, and a "target surface," such as a wheelchair, advises bariatric care expert Michael Dionne, a physical therapist specializing in caring for people of size, in Gainesville, Ga.

Usually one bariatric lift that can handle someone up to 700 pounds will suffice, says Dionne. If the facility needs more lifts, it can rent them, he points out. "A ceiling lift is great, but you can't share it with other patients," he adds. Some manufacturers say the ceiling lifts are portable but by the time you move one, "you've lost half the day."

Another perk: Staff can also use the bedside lifts to move the resident from side to side to do peri-care, for example, and to help someone up if he falls on the facility grounds outside, says Dionne.

In addition to the bariatric triad, facilities have to provide other equipment and items to accommodate the larger resident, says Dionne. That includes everything from blood pressure cuffs to tracheostomy sets.

Perform this dignity litmus test: To provide safe care and avoid citations for dignity issues, take a look at how the very obese person fits into the facility and community. "Does the dining room provide appropriate seating or is the person" hanging off the sides of the chair? asks attorney and physical therapist Donna Senft with Ober/Kaler in Baltimore. "Is the person's room arranged so that staff doesn't constantly have to move things around when assisting the person to move around the room or to get in and out of bed from the wheelchair?"

Tip: If the person is both obese and short in stature, he may have trouble using a manual wheelchair, adds Senft. In such a case, he might need a power scooter to get around the facility, if it's feasible based on his cognitive status, etc., she says.

People of size have numerous other special care problems and needs to consider, including:

1. Individualized medication dosing based on weight. Give the pharmacist or pharmacy a heads up that the resident has special needs related to his weight, advises Lynda Mathis, RN, the lead clinical consultant for LTC Systems in Conway, Ark. "There's a whole range of medications that function based upon an estimated weight" to achieve the desired therapeutic goal;the list of medications includes antibiotics, anti-hypertensives and cardiac medications, she notes.

2. Pressure ulcer prevention and care. Overall, you have to be more meticulous in assessing the skin for people who carry more weight, Mathis notes. "Look in all the crevasses so you can make sure there aren't negative skin conditions developing," she advises.

Staff should also partner with the resident to ensure the person turns and repositions and gets up often enough to prevent or heal skin breakdown. For example, one 395-pound patient with pressure and stasis ulcers resisted being moved to one side, reports Debra Bakerjian, PhD, MSN, FNP, president of geriHEALTHsolutions Inc. in Novato, Calif. When staff asked him why, he said the TV was on his preferred side. And he liked to look out the doorway to see people coming by. So the staff moved the TV to the other side, and he agreed to reposition. (He eventually shed 175 pounds, which helped heal his pressure and stasis ulcers, but it took two years, says Bakerjian.)

Tip: Keep in mind that bariatric patients can actually be malnourished, which could affect pressure ulcer healing, advises Brenda Richardson, MA, RD, LD, CD, a nutrition expert in Pekin, Ind. For example, if someone is clinically obese, "make sure he's consuming enough protein to heal a pressure ulcer," she counsels.

3. Nutritional requirements. Long-term weight loss can reduce or eliminate many of the chronic health problems that plague a very obese person, including skin breakdown, shortness of breath, osteoarthritis, sleep apnea, diabetes and more.But when a person of size comes in with a disability, the goal is to get him walking -- not focus immediately on weight reduction, says Dionne.

Another problem: Putting someone on a rapid weight-loss diet will accelerate age-related muscle wasting, cautions nutritional expert Helen Battisti, MS, RD, who is doing a dissertation looking at the impact of obesity in nursing home residents on falls, pressure ulcers, and mobility. "And the less lean muscle we have, the more likely we are to fall."

Instead: If an overweight person wishes to go on a calorie-restricted diet, make it as painless as possible to ensure long-term success, advises Battisti. For example, cut out things that the person will miss the least, such as butter or an extra ounce of gravy, she adds. "Provide smaller portions or lower calorie versions. If the person drinks milk, switch from whole milk to 2 percent, which the person may tolerate."