Obesity: A Nursing Challenge

Obesity is becoming an epidemic in the United States and is changing and challenging health care. Obesity is a problem not only because it can cause other medical conditions in patients, but also because it presents challenges to the nurse caring for a larger client.

The nurse plays a critical role in preventing, treating and reversing obesity and its effects. Clients should be educated by nurses about diet and exercise to prevent and reverse the progression of obesity. Nurses should be knowledgeable about the safe use of equipment made for the larger client and adjustments necessary during assessments to receive accurate results. Nurses are also responsible for preventing and recognizing common problems that coexist with obesity.
Obesity is defined as a body mass index of 30% or greater (Arzouman, Lacovara, Blackett, McDonald, Traver & Fran, 2006, ¶3). According to the Surgeon General, in 1999, 61% of Americans were overweight or obese; the percentage having increased since then (“Overweight and Obesity,” 2007, ¶1). Obesity puts individuals at greater risk for other health problems like hypertension, cardiac and vascular disease, respiratory dysfunction, cancer, Diabetes Mellitus, and depression (“Overweight and Obesity,” 2007, ¶1). Because the incidence of obesity is increasing and the implications on health are so great, nurses must take action to educate and efficiently care for the obese, and those at risk for obesity.
A major aspect of preventing or reversing obesity is maintaining or losing body weight. The nurse should educate clients on how to lose weight during health history intake, while the client is being treated in the facility, and during discharge. The U.S. Surgeon General’s website stresses the importance of balancing calorie intake with calorie expenditure to maintain weight, and using more energy than is taken in to lose weight (“Overweight and Obesity,” 2007, ¶4). The client should also select an enjoyable activity and commit to the exercise regimen; making it more likely for the patient to continue with the regimen (“Overweight and Obesity,” 2007, ¶4). When considering the patient’s diet, Cleator (2004) recommends the “staged approach” (¶36). In step one, Frost (2003) recommends discussing a client’s normal diet in order to evaluate lifestyle, food intake, and food triggers (as cited in Cleator, 2004, ¶38). In step two, it is important to “stabilize eating behavior” by discouraging erratic binging and making meals a routine (Cleator, 2004, ¶39). Step three requires implementing healthier eating and healthier notions about food (Cleator, 2004, ¶42). The last step incorporates decreasing intake by 500 kilocalories which Melanson and Dwyer (2002) attribute to a 1-2 pound weight loss per week (as cited in Cleator, 2004, ¶35 & 43). Along with promoting a healthy diet and adequate exercise, the nurse should seek additional information from the client during health history intake. According to Goldstein (1992), the nurse should identify the patient’s motivation for weight loss because it is an indicator of the likelihood of success depending on how committed the client will be in managing his or her weight (as cited in Cleator, 2004, ¶24). A weight history should also be reviewed in order to identify any setbacks and to allow for realistic goal setting (Cleator, 2004, ¶28 & 31).
Because of the size of the client, the nurse must use equipment tailored for the obese to ensure safety and comfort while providing care. Equipment that should be considered when treating an obese client include specialty beds, wide front-wheeled walkers, wide room chairs, wide beds that lower close to the floor, lifts, transport stretchers, scales, and bed trapeze (Arzouman et al., 2006, ¶10). All of these are necessary for the safety and competent care of the obese client, but also for the safety of staff, as Spratley, Johnson, Sochalski, Fritz, & Spencer (2000) attribute “older nurses moving heavier patients [as a contributor] to workplace injuries (as cited in Arzouman et al., 2006, ¶4). Along with using special equipment, the nurse should use special techniques during head-to-toe assessment to ensure accurate data is collected. Hahler (2002) recommends using an appropriate size blood pressure cuff of obtain accurate readings that are not falsely high and to prevent tissue injury (¶5). Skin folds should be displaced when auscultating breath sounds and the diaphragm of the stethoscope placed in areas where the lung is closest to the chest (Hahler, 2002, ¶6). Hahler (2002) also recommends “nurses should listen for heart sounds either over the left lateral chest wall while the patient is turned toward the left side, or over the aortic or pulmonic areas to the left or right of the sternal border at the second intercostals space” (¶7). Bowel sounds will take longer to distinguish because of the thicker layer of adipose tissue. Marking where the sounds are most easily heard can make assessments from other care team members easier and their findings more consistent with those made previous (Hahler, 2002, ¶7).
In addition to accurately assessing system functions, the nurse should also perform an aggressive skin assessment on the obese client because of his or her high risk for developing skin breakdown and pressure ulcers (Hahler, 2002, ¶8). The nurse should perform a baseline skin assessment as part of the initial head-to-toe assessment, and do regular skin assessments thereafter, in order to identify skin breakdown. All areas of the skin should be assessed especially under folds of the breasts, abdomen, back, and perineal areas because of the presence of moisture, pressure, and friction (Hahler, 2002, ¶8; Arzouman et al., 2006, ¶10). Dermatitis can be prevented by placing gauze or washcloths in folds to help keep the area dry, applying antifungal agents to decrease rashes, and applying lubricants and ointments to treat superficial skin irritations (Hahler, 2002, ¶20). “Often, [patients] are protein deficient, and lack essential nutrients necessary for healing,” so a nutritional assessment is also vital to promote epithelialization. It is the nurse’s duty to obtain this information along with laboratory values in order to track and treat the common problem of skin breakdown found in obese clients (Hahler, 2002, ¶8).
The nurse is an important member of the healthcare team who can do much to aid the fight against obesity. In all clinical settings, the nurse can teach clients about ways to prevent obesity and reverse the process if it has manifested. He or she can effectively treat the obese using bariatric tools and adjusted assessment. The nurse can also identify and care for common problems of those already afflicted with obesity. In all of these actions, the nurse is an integral educator and caregiver who can change the life of obese clients and change the status of the obesity epidemic for the better.

Intervention 1: Clients should be educated by nurses about diet and exercise to prevent and reverse the progression of obesity.
Disadvantage1: Although education is a good way to encourage power and change through knowledge, education alone cannot promote the obese or those at risk for obesity to prevent or reverse the disease. Obesity is a multifactorial disease that includes many predisposing factors such as socioeconomic status. In a study surveying the relationship between socioeconomic status and weight in US women, it was shown that women of lower socioeconomic status reported a greater intake of calories (including a higher percentage from fat), and utilized fewer behaviors to promote a low-fat diet (Jeffery & French, 1996, ¶21).
Although obesity and socioeconomic status were shown to be inversely related, the same could not be said about exercise (Jeffery & French, 1996). Jeffrey and French state, “physical activity did not vary significantly by income group […] higher income women were slightly more likely to engage in recreational physical activity, whereas lower income women reported more work-related and home maintenance-related physical activity” (1996, ¶21).
Because studies about the relation between socioeconomic status and obesity are varied due the many factors contributing to obesity, it is important to further evaluate client motives and other aspects of client life that lead to weight gain or weight loss. Further research is necessary to develop a thorough plan of care for obesity especially since general theories point to a correlation between obesity and culture, restricted environmental opportunities and discrimination (Jeffery & French, 1996, ¶2).
• Disadvantage 2: Feelings of discrimination can deter obese clients from making behavioral changes to aid in a healthier living by lowering self esteem. In an interview process conducted by Rogge and Greenwald, subjects reported feelings of stigmatization and oppression due to their obesity (2004). When exploring Western culture and beliefs, feelings of condemnation can be attributed to gluttony and sloth (two of seven deadly sins); unattractiveness, undesirability, and self-indulgence portrayed by media; and lack of personal/social power related to low socioeconomic status (Rogge & Greenwald, 2004). Subjects felt that these and other stereotypes placed on the obese allowed others to feel more superior and cause intentional and unintentional hurt (Rogge & Greenwald, 2004). Rogge and Greenwald found that many obese subjects felt shame and humiliation especially when testifying to experiences during childhood, shopping, eating out, and dating; these situations leading to self-alienation in many subjects, as a coping mechanism (2004).
Rogge and Greenwald state that the stigma transcends into healthcare also – that “the lack of sensitivity to their weight problem was often cited among our research subjects” and as stated in research by Petrich, “healthcare providers, like others in society, describe overweight individuals as repulsive, disgusting, weak, and lacking self-discipline” (as cited in Rogge & Greenwald, 2004, ¶85 & 87). So, not only does the medical aspect of care for the obese need to be addressed, but so also does the psychological and social aspect of care. It is the nurses obligation to be aware and sensitive to the client’s experiences and beliefs.
Intervention 2: Nurses should be knowledgeable about the safe use of equipment made for the larger client and adjustments necessary during assessments to receive accurate results.
Disadvantage 1: Financial issues can contribute to client dilemmas, but the same goes for the hospital. In an article evaluating healthcare challenges regarding obesity, Butch de Castro stated, “Most hospitals are ill-equipped to meet the needs of obese patients, such as having adequate or any lifting devices” (as cited in Trossman, 2005, ¶10). Lack of specialized equipment can disrupt the continuity of care and cause inaccurate assessment. In practice, small room sizes, narrow beds and chairs, inadequate sized blood pressure cuffs, speculums, and many other aspects of care are insufficient for the larger patient (Trossman, 2005). More funds need to be put toward diagnostic equipment, assistive tools, and much more in order to provide quality care to all clients.
Disadvantage 2: Knowledge, assessment, and innovation are key to the nurse’s competent care of his or her clients because with those, appropriate accommodations can be made to increase positive outcomes in obese clients. Barbara Hahler does much to identify ways to improve nursing knowledge where there are deficits in order to improve client outcomes (2002). Hahler suggests many care accommodations such as using a larger blood pressure cuffs, auscultating over areas where there is the least amount of tissue, inspecting the skin thoroughly, and assessing nutrition and related laboratory values carefully (2002). Also, knowledge of common comorbities is essential so that anything from rash treatment to acute respiratory distress or sleep apnea can be addressed or resolved (Hahler, 2002). The nurse is obligated to cultivate a wealth of knowledge regarding proper assessment, treatment, and related factors of the obese client because a knowledge deficit and insufficient assessment could compromise patient care.

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