Introduction
Obesity is a chronic, progressive, relapsing metabolic disease that arises from the interaction of genetic predispositions with external environmental factors. Biological, demographic, social, and economic factors are involved in its development, as well as the environment, while their proportional contribution differs for each person. High energy intake and, conversely, low energy expenditure, along with genetic factors, are considered the main factors leading to overweight and obesity (Trnková, 2019). The disease is characterized by increased accumulation of body fat and its insufficient mobilization from tissues where it is stored under physiological conditions, as well as a concurrent increase in body weight due to energy imbalance. It often leads to structural and functional changes that culminate in the emergence of multiple organ-specific pathological complications (metabolic, structural, inflammatory, neoplastic, degenerative). Obesity therefore needs to be understood both as a chronic disease and as a risk factor for the development of further serious complications. It significantly affects morbidity and mortality from metabolic and cardiovascular diseases, as well as the quality and length of life of the obese individual. Globally, it is considered a global epidemic with extensive health and socioeconomic consequences. Its “globality” therefore requires a comprehensive preventive, diagnostic, therapeutic, and long-term controlled approach focused on the individual, while simultaneously requiring a society-wide approach (Obezita a jej manažment, 2018). Society has certain biases toward obese people, which often also influences healthcare professionals’ approach to them. According to Brown (2011), when interacting with obese patients, nurses are aware of the associated problems in providing nursing care. Morbid obesity (BMI > 40 kg/m²) affects body physiology, requiring a multidisciplinary medical and nursing management approach. In essence, almost every intervention and procedure in the diagnostic, therapeutic, and nursing process can become problematic, which increases risk for both the patient and the healthcare team (Trnková, 2017).
Among the most commonly occurring diseases associated with overweight and obesity we can include: Diabetes mellitus, whose onset is associated with insulin resistance. In obese patients, type II diabetes mellitus is often present, and among the most common factors influencing its development are positive family predisposition, low physical activity, excessive body weight, hypertension, and other components of the metabolic syndrome. For the patient, stable blood glucose values are safer than fluctuations, so regular glucose monitoring is an important part of patient care.
Metabolic syndrome is a cluster of typical risk factors that frequently occur together and whose development is conditioned by insulin resistance, which brings a higher risk of developing diabetes mellitus and cardiovascular diseases.
Tumour diseases are also often related to obesity. Kunešová et al. (2016) state that people with excess body weight are at greater risk of colorectal cancer, kidney cancer, bowel cancer, breast cancer, and uterine cancer.
Diseases of the respiratory system are also a common complication in morbidly obese patients. Sleep apnea syndrome often occurs, in which breathing is intermittently interrupted during sleep due to the relaxation of the upper airways. A very serious complication is the occurrence of Pickwick syndrome. Insufficient gas exchange in the lungs causes hypercapnia, which is caused by excessive fat deposition in the abdominal area that compresses the lungs, resulting in under-ventilation.
Cardiovascular diseases: obesity greatly influences increased cardiac output and subsequent left ventricular hypertrophy. This leads to increased resistance in the pulmonary circulation and the development of pulmonary hypoventilation. The higher the BMI, the greater the risk of cardiac failure. Fat accumulated around cardiac tissue causes myocardial disease with impaired cardiac function. Obesity very frequently causes atherosclerosis. Pericardially stored fat represents a risk for atrial fibrillation. Obese patients also have increased risk of ischemic heart disease.
Digestive tract diseases: it has been proven that obese patients more often present with adenocarcinoma, gallbladder disease, nonalcoholic steatosis, and gastroesophageal reflux.
Other complications, also called mechanical and related for example to overload of muscles and joints, development of osteoarthritis, and more frequent injuries, are also common. Other complications include stress incontinence, edema, poorer wound healing, dyspnea, and varices (Kunešová and colleagues, 2016; Hainer and colleagues, 2022).
Challenges in Nursing Care for the Morbidly Obese Patient
Nursing care is care whose aim is to maintain, support, restore health, and satisfy needs; to develop, preserve, or restore self-sufficiency. Nursing care includes assessment, evaluation, planning, and satisfying biopsychosocial and spiritual needs of healthy and ill persons through the nursing process. The goal of nursing care is to help the patient adapt as soon and as well as possible to the changed environment and to regain independence in meeting needs, with a holistic approach (Kilíková, 2019).
Nursing care for a patient with morbid obesity (BMI > 40 kg/m²) is specific and very demanding not only for the patient but also for the care staff during all nursing interventions, which often require non-standard approaches, improvisation, and considerable effort on the part of nurses, while effective team engagement is crucial (Vévoda et al., 2013). It is appropriate to prepare precise protocols and procedures in advance, so all team members know them and act accordingly in care delivery.
The stay of a morbidly obese patient in hospital is accompanied from the very beginning by complications due to high body weight, from ambulance transport by emergency medical services through diagnostic tests, therapeutic interventions, surgery, invasive procedures, positioning, to rehabilitation.
Very often, during the diagnostic process, imaging methods such as ultrasound, radiography, or fluoroscopy, as well as computed tomography and magnetic resonance imaging, fail because they are limited by ring diameter constraints of the equipment. ECG interpretation can also be problematic: because signal transmission through subcutaneous fat is hindered, readings may be distorted and show low voltage. During physical examination by auscultation, the stethoscope must be pressed more firmly against the auscultation site. If the site lies in a skin fold or crease, assistance from another person is needed. Assessing intestinal peristalsis by auscultation is also quite difficult because of excessive abdominal fat. In patients with heart failure, it is often difficult to assess edema and jugular vein distension. Discrepancies may also occur during pulse oximetry monitoring; values may be distorted. However, at every examination, a correct history is the basis (Phillips, 2013; Brabcová, 2013).
When meeting biopsychosocial and spiritual needs in care for a morbidly obese patient, the nurse always approaches with awareness of the patient’s specific features, assesses, and identifies individual needs.
The need for breathing is a basic biological need. When this need is unmet, dramatic situations can occur, often even death. In obese patients, breathing is influenced by several factors. Assessment of breathing need by the nurse includes anamnesis data, physical examination, with evaluation of chest shape and movements, respiratory rate per minute, breathing mechanics, skin and mucosal color, and appearance.
Chronic hypoventilation and hypercapnia, obstructive sleep apnea syndrome, and increased risk of aspiration are the most common causes of increased risk of respiratory failure in morbidly obese patients, in whom desaturation occurs very quickly and adequate ventilation becomes a challenge for the entire healthcare team. Metabolically active fat tissue also increases oxygen demand. It is necessary to choose an appropriate airway management method, determine AHI score (index of apnea/hypopnea events per minute), eliminate obstructive sleep apnea, and also comorbid conditions affecting breathing (Kapounová, 2020; Trnková, 2017). If ventilation parameters are not improved by placing the patient in an elevated Fowler or semi-Fowler position, and even by noninvasive supportive ventilation, rapid airway securing and connection to mechanical ventilation are important. The nurse prepares the patient, the environment, necessary equipment, and collaborates with the physician. Tracheal intubation is often difficult because patients often have limited neck mobility, and their neck is short and broad with restricted movement. Securing the airway is frequently a complex, multifactorial problem, and its management involves a comprehensive interaction among patient factors, clinical situation, and the skills of the anesthesiology team. Simple head extension does not always achieve airway release because of excessive fat tissue in the upper airway region. To open the airway, a nasopharyngeal or oropharyngeal airway may sometimes be needed. Swollen, enlarged tongue, soft tissues of the oral cavity and neck, and higher Mallampati score can also be obstacles. If endotracheal intubation is unsuccessful, the method of choice may be cricothyrotomy or tracheostomy, while even these airway securing methods are less feasible due to anatomical changes. Standard lengths of endotracheal cannulas are insufficient for morbidly obese patients, so several elongated cannulas should be available on the ward. In ventilated patients, setting an adequate ventilatory mode can be problematic because standard ventilation modes calculated from patient weight may be too aggressive for lung tissue. Better lung inflation is also supported by proper patient positioning. Elevated positioning allows larger tidal volumes and lowers respiratory rate, which reduces atelectasis formation. Most patients are better compensated in a seated position; problems arise when changing to supine. Elevated positioning also has preventive effect against aspiration of gastric contents, thereby reducing development of aspiration pneumonia (Lewandowski, K., Lewandowski, M., 2011; Jamadarkhana et al., 2014; Krbila, Soboňa, 2015). Complications may also occur during ventilator weaning, with a high risk of post-extubation respiratory failure. In nursing interventions related to breathing needs it is important to ensure adequate patient movement, as movement eliminates secretion stasis in the airways, minimizing bacterial colonization. If the patient’s condition allows, breathing exercises play a major role, including support for expectoration through percussion and vibration. In patients with reduced ability or complete inability to expectorate secretions, suctioning of airway secretions should be performed as needed. During this procedure, an aseptic approach is followed and a closed suction system is used.
Obesity and sleep have a bidirectional relationship, where obesity may contribute to sleep disturbances and, conversely, poor sleep quality can influence body weight. Sleep is one of the basic biological needs, and its disturbances cause negative consequences in everyday life. During hospitalization, the need for sleep is particularly important because it contributes to an effective treatment process. Patient sleep during hospitalization is influenced by biological, social, and diagnostic-therapeutic factors. Ondrejka (2013) specifies and characterizes factors that significantly influence sleep. These are physical (age, circadian rhythm, diseases), psychological (emotions, stress, mental disorders), environmental (noise, humidity, lighting level, uncomfortable bed), lifestyle (insufficient movement, passive approach to life, smoking, alcohol, drugs), social (shift work, parenthood, social isolation, severely ill relative, unfavorable economic situation), and spiritual (value system, meaning of life, hope, life goals). Mucska (2016) states that obesity is a causal factor in development of obstructive sleep apnea syndrome due to adipose tissue deposition in the upper airway and disruption of neuromuscular balance through adipokine effects in central obesity, and it may indirectly worsen other breathing-related sleep disorders. Planning, selecting, and implementing nursing interventions related to sleep-satisfaction needs depend on patient individuality, abilities, and possibilities. Sleep hygiene principles and pre-sleep habits should be respected, and suitable conditions for sleep and rest should be created even if the patient is sedated in intensive care. A measure promoting comfort is also placing the patient in a suitable position.
Each person has individual demands for meeting mobility needs. Physical inactivity contributes to various problems and is also linked with psychological and social risk. Among the physiological factors influencing mobility are age, body constitution and body weight, functional capacity of sensory and motor organs, and presence of disease. Psychological factors include self-concept, where a patient dependent on another person or using compensatory devices may feel helplessness, being a burden, or hopelessness. The nurse continuously assesses the need for mobility and then plans and implements appropriate nursing interventions and collaborates with the physiotherapist. It is important to equip the patient’s bed with assistive devices and provide suitable compensatory and positioning aids to prevent immobilization syndrome. In prevention of muscle atrophy in hospitalized morbidly obese patients, timely mobilization is very important. The nurse, together with the physiotherapist, gradually mobilizes the patient with attention to current condition. They assist with active or passive exercises. Rehabilitation is staff- and physically demanding. Possibilities of using aids are severely limited and limited by load capacity; hospital wards usually do not have aids specifically designed for morbidly obese rehabilitation. The range of compensatory devices for obese patients is not broad (for example, most walkers have a load capacity up to 130 kg). Finding a proper prosthesis after limb amputation is also very difficult for obese patients. Patients often prefer to sit, for which a repositioning bed or chair with sufficient width and load capacity is needed. Timely verticalization and rehabilitation reduce the risk of lung atelectasis and pneumonia (Syslová, Novotná, 2012; Jamadarkhana et al., 2014). Intellectual activity and maintenance of a sense of autonomy and independence are supported by social interaction and sensory stimulation using basal stimulation. DVT prevention must not be forgotten, because in patients with metabolic syndrome, substances released from viscerally stored fat tissue cause chronic inflammation, increasing thrombosis risk. Preventing thromboembolic complications is equally important, with the goal of increasing blood flow in the lower extremities and pelvis. Lower limbs are raised by 20 degrees, and calf massage is performed. Suitable interventions include bandaging the lower limbs with intermittent pneumatic compression or elastic stockings and administering low-molecular-weight heparin according to medical order. If the patient’s condition allows, timely mobilization is required (Trnková, 2017).
Regular repositioning of the patient does not replace an anti-decubitus mattress or a bed with lateral tilt. During repositioning, accidental extubation, dislocation, or accidental removal of peripheral or central venous lines must be prevented. Supine position is dangerous for morbidly obese patients because of the risk of sudden death syndrome and respiratory insufficiency, so patients should never be placed in this position. Multiple studies also indicate that in Trendelenburg position blood oxygen partial pressure decreases markedly, not only in morbidly obese patients but also in overweight patients. Therefore this position is not suitable for the morbidly obese patient. If circumstances require placing the patient in this position, airway management and resuscitation equipment must always be available. Cardiac arrest can occur in an obese patient even in horizontal supine position. Proper positioning helps preserve joint mobility, prevents pressure injury, reduces risk of muscle and tendon shortening, prevents blood stasis especially in lower limbs, improves circulatory function, and helps prevent pneumonia. For safety reasons, placing a patient on a side-tilt bed is not suitable because of fall risk. Positioning a morbidly obese patient is, however, demanding for staff; it is physically strenuous and requires many aids. Manual lifting should be minimized, and hospitals should include overhead lifting systems or mobile lift devices in their equipment. This reduces staff injury risk (Drábková, 2013). As the most suitable positions we may consider the anti-Trendelenburg and Fowler positions, in which intra-abdominal pressure is relieved, facilitating spontaneous breathing and breathing on mechanical ventilation (Kapounová, 2020). Obese patients have limited movement ability and reduced lung capacity, which often negatively affects their participation in movement activities. Safety is essential, and determinants affecting it must always be assessed. According to Thomas and Lee-Fong (2011), these are mainly patient cooperation level, reduced muscle strength, presence of comorbidities, changes in respiratory function, and availability of suitable aids. Obese patients are at increased risk of falls. Rose et al. (2010) report that nurses consider transferring a morbidly obese patient from bed to chair or transport bed as the riskiest task. Risk also comes from beds themselves, as they are not adapted to patient proportions. When lifting and turning an obese patient, safety principles must be followed. An inappropriate type of bed or chair can cause fall and injury. Their load capacity should be clearly marked. Sometimes this can also cause feelings of shame for the patient.
The need to be pain-free is one of the most common patient needs and affects all physical and psychosocial needs (Kilíková, 2019). Nursing care also includes pain monitoring and treatment. A patient with pain minimizes movement and respiratory activity, which can reduce tidal volume and very quickly lead to respiratory failure. In assessing this need, an accurately taken history is important. We determine pain location, radiation, character, intensity, quality, triggers, and relieving factors. For determining pain intensity, pain assessment scales are used. During physical assessment, the nurse observes pain reactions, both physiological and behavioral. Subsequently, both pharmacological and non-pharmacological pain management are important. Within the nurse’s scope is, for example, applying heat or cold, distraction techniques, and relaxation methods. Physical touch is important for the patient, as it gives a sense of closeness.
Enteral, intramuscular, and subcutaneous drugs prescribed by a physician may have different absorption times or effects compared with individuals with normal body weight. Obese people have a higher proportion of fat tissue and less muscle and water, so different pharmacokinetics may occur especially with lipophilic drugs. Drugs may be deposited in fat and have longer effects. Altered pharmacokinetics also affects opioids and analgesics, so precise dose titration is necessary. Insulin absorption is also poorer, as are all drugs given subcutaneously. In intramuscular administration, a longer needle is appropriate because a standard-length needle does not reach the muscle in such obese patients and the drug remains in adipose tissue, which is poorly vascularized. Therefore it is advisable to reconsider some routes of drug administration and monitor drug effects. Altered pharmacokinetics may also affect transdermal patch administration; the effect is calculated for a person with normal body weight and correct skin perfusion is required for proper action (Hahler, 2002; Charlebois, Wilmoth, 2004). An essential part of nursing care is meeting nutrition and hydration needs. Nutrition is an essential condition for human existence. It is a complex set of biochemical and physiological processes of nutrient intake, processing, and use in support of proper body functioning. The human body requires significant energy for many metabolic chemical reactions necessary for life. In critically ill patients, vital functions are unstable, requiring intensive care and organ support. Nutritional therapy is considered a treatment with all attributes of pharmacotherapy and an integral component of comprehensive therapeutic, preventive, and nursing care. Failure to provide or incorrectly providing it is non lege artis care. The aim of nutrition therapy is to provide substrates for the patient’s bioenergetic needs, protect muscle mass, support the function of individual organs and immunity. Nutritional status must be assessed and monitored regularly. Correct assessment starts with history-taking, which on intensive care units is to some extent limited by consciousness and patient cooperation. During physical assessment from head to toe, it is appropriate to evaluate muscle strength using dynamometry or a relaxometer. The nurse collects biological samples to determine specified substances or metabolites according to physician order. For nutritional status assessment, these substances are examined in blood and urine. Laboratory parameters must be interpreted in relation to the overall health status because they reflect not only nutrition status but also function of individual organs. An essential part of assessment is determining the patient’s energy expenditure, which can be distorted by current physiological and pathophysiological changes, therapeutic interventions, possible starvation, or presence of pressure injury. The most accessible method to estimate energy requirement is calculating 25–30 kcal/kg/day. We calculate energy expenditure using Harris-Benedict equation or indirect calorimetry. A nurse can also assess nutritional status with available assessment tools and scoring systems, which help objectify findings. Among anthropometric data, BMI is most frequently evaluated, and arm circumference, triceps skinfold thickness, and arm muscle circumference are measured (Trnková, 2024). The energy reserves of obese individuals cannot be adequately used during stress, as catabolism occurs. The critically ill patient is more prone to malnutrition even when excess body weight is present. In metabolic stress, proteins are consumed, which can lead to faster loss of muscle mass. Several studies show that low-calorie, high-protein nutrition shortens ICU stay and the duration of connection to mechanical ventilation (Jamadarkhana et al., 2014). Meeting nutritional needs is among basic human biological needs. The nurse assesses patient self-sufficiency in food intake and factors affecting nutrition. If the patient cannot, does not want to, or must not be fed orally, a supplemental form of nutrition must be applied enterally or parenterally (Trnková, 2024).
Enteral nutrition is optimally started via oral route within 24 hours of admission to the hospital or from worsening of condition. If the patient’s status requires insertion of a nasogastric tube, confirming its position is not simple and often requires radiographic examination with contrast medium. With enteral feeding and fluid administration, aspiration risk must be eliminated. The stomach volume of obese patients is much greater, and excessive fat generates greater pressure on the stomach. Food should be administered in Fowler or semi-Fowler position.
When meeting needs for urinary and bowel elimination, the risk of infection must also be considered, as well as technical difficulties in inserting an indwelling urinary catheter or a catheter for managing frequent stools. A permanent urinary catheter causes the bladder not to fill or stretch, the external sphincter does not close, and tone of bladder muscles decreases, which causes problems even after removal of a long-term catheter. Frequent incontinence is influenced by reduced mobility, pressure on the bladder and bowel, and requires appropriate-size absorbent products (Phillips, 2013). Nursing interventions should focus on maintaining or restoring normal elimination patterns, preventing infection, and protecting skin and mucous membranes. Improving reduced self-esteem, providing sufficient privacy, and psychological support to reduce negative emotions are very important and help relieve muscular tension. Depending on condition and level of self-sufficiency, it is necessary to ensure a position that best replicates the elimination posture and suitable devices to ease elimination. Sensory stimulation may also be used.
Activities of daily living include basic activities such as hygiene and dressing. If patient abilities are limited, a partial or total deficit in self-care arises. In intensive care units, patients are usually completely dependent on healthcare workers. If the patient’s condition allows, nursing care focuses on encouraging self-care and self-help activities. Otherwise, comprehensive substitute interventions are implemented. In assessing self-care needs, objective assessment instruments are used. The goal of nursing interventions is to improve the current self-care state according to the patient’s condition and gradually achieve the highest possible level of independence. If help is needed, the nurse assists only to the extent required for adaptation. It is necessary to ensure a suitable, safe environment, provide compensatory aids, and remove barriers. Hygiene need is a basic biological need, distinctly individual, and is expressed in three dimensions: biological—supporting cleanliness, infection prevention, and maintaining healthy skin; psychological—creating pleasant sensations, satisfaction, and relaxation; and social—creating a comfortable environment and fostering positive interpersonal relationships (Kilíková, 2019). Initial nursing examination should also include assessment of patient self-sufficiency. Morbidly obese patients can be considered a risk population. Assessment of hygiene needs is based on anamnesis, physical examination, and use of objective measurement tools (Norton scale, Knoll scale, Waterlow scale, Braden scale, and others). In overall assessment of body habitus and skin condition, tactful conduct and respect for patient privacy are essential. Hygiene care for a morbidly obese patient usually occurs with assistance from a multidisciplinary team. Obese people frequently have skin problems, approximately 1.5–3 times higher risk of pressure injuries, chafing, perianal dermatitis, pretibial ulcers, and diabetic angiopathies and neuropathies. Increased subcutaneous fat impairs wound healing, with frequent complications including infections and wound dehiscence (Phillips, 2013; Jamadarkhana et al., 2014). The nurse should regularly inspect and monitor the patient’s skin carefully, including high-risk areas and skin folds especially under the breasts, in the perianal region, and folds of the abdomen. Skin folds pose risk of chafing, fungal infections. Excess pressure on redundant skin can close capillaries and cause tissue necrosis. To prevent skin chafing, it must be cleaned thoroughly, folds separated with gauze or nonwoven inserts, and the patient repositioned. Powders and creams should not be used in fold areas, as they create lumps that irritate skin. Creams and protective ointments are suitable only for superficial skin care. Increased attention should be paid to perineal and genital skin care. Skin erosion in obese patients may also be caused by improperly placed catheters, hoses, or cables in skin folds or under the body. Obese patients have an increased risk of pressure injuries. The nurse regularly monitors and evaluates risk-prone areas using the Braden, Norton, or Waterlow scales. In the event of a pressure injury, the nurse determines its stage and thoroughly examines skin condition. Photograph documentation is recommended to better assess effectiveness of prescribed treatment and nursing interventions. At the same time, external (moisture, pressure, friction) and internal factors (mobility, hydration, breathing, consciousness disturbances) that led to pressure injury should be identified. For cyclical assessment, nurses use measurement tools, scales, and classifications (NPUAP pressure injury classification).
Tissue integrity can also be disrupted by incorrect manipulation of the patient with shear force, so aids that facilitate handling and adequate staffing should be used. Limiting factors also include changing bed linen and caring for skin on the back and sacral area. Skin condition and wound healing are often also affected by tissue hypoxia, hypotension, consciousness disorders, fluid overload, and fever (Jamadarkhana et al., 2014; Krbila, Soboňa, 2015).
During illness, not only the hierarchy but also the way psychosocial needs are met changes. A higher degree of obesity correlates with more comorbidities, physical and psychological limitations, fatigue, and changes in perception of one’s own body, shaped through individual relationships to one’s body. Disturbed body perception particularly occurs when a person’s body shape does not match the body ideal preferred by society (Málková, I., Málková, H., 2014). Obese patients commonly face contempt, misunderstanding, and even pity. They evaluate their bodies negatively and are often dissatisfied with themselves, which significantly affects behavior. Stigmatization linked to excess body weight is a lifelong issue for them.
The need for safety and security is also a basic human need. Each person copes differently with a demanding life situation. One option is aggression or avoidance, including negativism, isolation, or resignation. Most common manifestations of unmet safety needs are fear, anxiety, anger, and sadness. Morbidly obese patients have the right to be treated with the same respect, comfort, and dignity as other patients. They often feel ashamed of their obesity, which requires a more sensitive approach. During examination and care, they do not want many people around them and prefer the presence of only one nurse and one physician, favoring privacy. They feel discriminated against. In communication with obese patients, a more personal and empathetic approach is appropriate. At no time should healthcare staff judge them; instead, they should offer support, because this patient is also a sick person who needs compassionate care and kind interaction. Appropriate communication is an important component of nursing care and reduces the risk of adverse events. Effective communication with the patient, family members, and within the multidisciplinary team expresses respect, helps build a relationship based on trust, supports patient autonomy, and reduces uncertainty, fear, anxiety, and shame. It is also important to praise patient achievements.
In care of morbidly obese patients, psychological intervention as part of a multidisciplinary team is appropriate. A psychologist helps address the patient’s current problems and primarily supports the patient in gradually gaining a new self-view and starting the path toward lifestyle change. The patient’s mental state is often affected by current dependence in meeting needs.
Another demanding nursing intervention in care of the morbidly obese patient is blood sampling or placement of intravenous cannula, because in these patients orientation points used in peripheral or central venous cannulation are often altered or absent (Krbila, Soboňa, 2015). Selecting an appropriate insertion site is difficult because veins are often hidden under a fat layer and repeated punctures are unpleasant for both nurse and patient (Pokorná et al., 2019). To improve venous visibility, it is possible to massage the patient’s arm, apply local warm compresses, or run the patient’s hand off the edge of the bed. For higher success, better orientation, and minimizing complications during venipuncture, ultrasound guidance should be used, or central venous cannulation performed. In morbidly obese patients, due to insertion site conditions and increased infection risk, cannulation of the femoral vein is not suitable. The safest option is cannulation of the internal jugular vein. The nurse’s task is to prepare the patient, environment, equipment, and cooperate with the physician in securing central venous access. After the procedure, the nurse monitors the intravenous catheter site, eliminating risk of dislocation and occlusion. For regular assessment of phlebitis risk, the insertion site should be monitored using the Madlon scale. In difficult blood sampling using a vacuum system, blood may be collected with a single-use needle and syringe, while careful manipulation of the syringe plunger is required due to risk of hemolysis and vessel wall trauma. A fairly serious procedural complication is insufficient length of intravenous cannulas, which does not allow insertion into the vessel because the venous system in obese patients lies deeper beneath fat. Therefore insertion angle and depth should be adjusted. For continuous blood pressure monitoring and obtaining relevant values, placement of an intra-arterial catheter is suitable.
Obesity is very often associated with hypertension. Workplaces frequently lack blood-pressure cuffs of varied sizes, creating another nursing problem. For correct blood-pressure measurement, the applied cuff should cover two-thirds of the patient’s arm. If it is too narrow or too wide, false blood-pressure values are obtained. Obese patients require a cuff 14–15 cm wide and 30.5–33 cm long (Vytejčková et al., 2011). For extremely obese patients, blood pressure can be measured using a thigh cuff. If such a cuff is unavailable, blood pressure may be measured on the forearm provided the forearm can be positioned at heart level.
Transport of a morbidly obese patient requires participation of multiple healthcare staff. Another limitation is the load capacity and dimensions of chairs and transport beds. Stability and material strength are also very important (for example, a stretcher may weigh up to 25 kg but can carry a person weighing 300 kg). Handling the body of a deceased morbidly obese patient is also complicated. Transporting and positioning the body are very difficult due to weight and size.
Nursing care for morbidly obese patients in intensive care is clearly associated with increased physical burden for staff. Nurses often exceed the threshold for long-term sustainable physical load for women. A solution to prevent these complications is to ensure sufficient nursing staff (including male staff), and use suitable mechanical aids for handling immobile patients. Among the simplest and most cost-effective are positioning sheets to facilitate transfer to bed, rollboards to facilitate movement between two beds, or electromechanical lifting devices, which are not available in every unit (Vytejčková, 2011).
Conclusion
Morbid obesity is a complex problem affecting all areas of a patient’s life. It impacts health, well-being, and relationships. In nursing care, it is essential to have knowledge of the specific characteristics of care for morbidly obese patients and to respect them, so as to avoid possible harm to the patient. Care requires a multidisciplinary approach. Thoughtless care without knowledge of these specifics can endanger the patient’s life and simultaneously causes a major burden for staff, who are also exposed to risk of harming their own health. It is necessary to know weight limits of all tools used in care and to consider the weight of auxiliary equipment (infusion pumps, monitors, or ventilators). Material and staffing resources on ward units are often insufficient; healthcare institutions are not fully prepared in their equipment for caring for such patients, which can negatively affect the quality of nursing care provided, lead to adverse events, and thus prolong patient hospitalization. An important component of care is an empathetic and tactful approach. Patients frequently encounter bias and judgment from healthcare workers, which makes relationship-building and effective collaboration difficult. Given the increasing number of hospitalized obese patients, there is a need to educate professionals with focus on atypical procedures and use of equipment suitable for care of morbidly obese patients.
Autorky: PhDr. Mgr. Ing. Trnková Ľubica, PhD. MPH PhDr. Rybárová Daniela, PhD., MPH Vysoká škola zdravotníctva a sociálnej práce sv. Alžbety, detašované pracovisko Rožňava
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