Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Obesity & Related Surgical Procedures RNSG 1247 Obesity and Overweight Obesity is an abnormal increase in the proportion of fat cells Primarily occurs in the visceral and subcutaneous tissues of the body Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 19712006 20 18 17 16 16 Prevalence (%) 15 12 11 11 10 10 7 5 7 5 6 5 4 5 0 2 to 5 years 6 to 11 years NHANES I (1971-74) NHANES II (1976-80) NHANES 1999-2002 NHANES 2003-2006 12 to 19 years NHANES III (1988-94) *Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sexspecific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category. Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05. Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, † 1960-2006 45 40 35 Prevalence (%) 34 33 35 34 35 36 32 31 28 30 26 23 25 21 20 15 13 16 17 15 15 11 17 12 13 10 5 0 Both sexes Men NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES 1999-2002 NHANES 2003-2004 NHANES 2005-2006 Women NHANES III (1988-94) *Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population. Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 20032004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007. Etiology and Pathophysiology Genetic/Biologic basis Environmental factors Psychological factors ** Most common form considered to be polygenic, arising from the interaction of multiple genetic and environmental factors Hormones & Peptides that Interact with Hypothalamus to Effect Obesity Fig. 41-3 Classification of Body Weight and Obesity Primary obesity (majority of obese) Excess caloric intake for the body’s metabolic demands Secondary obesity Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders Classification of Body Weight and Obesity Body mass index (BMI) Used to classify underweight, healthy (normal) weight, overweight, or obese Common clinical index of obesity or altered body fat distribution Uses weight-to-height ratios BMI chart Weight for height chart Classification of Body Weight and Obesity Waist-to-hip ratio (WHR) Preferred tool when predominantly muscular Waist measurement/hip measurement = ratio WHR <0.80 is optimal Visceral fat increases risk for cardiovascular disease and metabolic syndrome Visceral Fat Subcutaneous Fat Classification of Body Shapes Apple-shaped body Fat located primarily in the abdominal area At greater risk for obesity-related complications Android obesity Pear-shaped Fat body located primarily in upper legs Gynoid obesity Classification of Body Shapes . Fig. 41-5 Health Risks Associated with Obesity Problems occur at higher rates for obese patients Mortality rate rises as obesity increases Especially with increased visceral fat Obese patients have a decreased quality of life Most conditions improve with weight loss Health Risks Associated with Obesity Fig. 41-6 Nursing Problems Imbalanced nutrition Chronic low self-esteem Others related to complications Planning Modify eating patterns Participate in a regular physical activity program Achieve weight loss to a specified level Maintain weight loss at a specified level Minimize or prevent health problems related to obesity Management: Non-surgical Nutrition Exercise Behavior modification Support groups Drug therapy Nutrition Exercise Trends in Prevalence (%) of High School Students Attending PE Class Daily, by Grade, US, 1991-2007 70 60 Prevalence (%) 50 9th 40 10th 30 11th 20 12th 10 0 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year Source: Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008. Behavior modification Basic techniques include Self monitoring Stimulus control Rewards – short term vs long term, what’s acceptable vs unacceptable Support groups Drug Therapy Appetite-suppressing drugs or Sympathomimetic drugs for _____ term use Decrease food intake through nonadrenergic or serotonergic mechanisms in the CNS Phentermine – most commonly prescribed; causes appetite ___________ and _________ food intake Other exs: Diethylpropion, Phendimetrazine Drug Therapy Appetite-suppressing drugs or Sympathomimetic drugs for ______ term use Mixed Do nonadrenergic–serotonergic agents not stimulate release of serotonin Sibutramine (Meridia) – works by increasing _____________ Drug Therapy Nutrient absorption-blocking drugs (GI lipase inhibitors) Work by blocking fat breakdown and absorption in intestine Orlistat (Xenical) Drug Therapy Drugs that ↑ energy expenditure are not approved by the FDA. Ex: Ephedrine Appetite-suppressing drugs removed from market fenfluramine (Pondimin) dexfenfluramine (Redux) Bariatric Surgery Used to treat morbid obesity Currently the only treatment found to have a successful and lasting impact for sustained weight loss Bariatric Surgery Must meet all of the following criteria to be considered an ideal candidate BMI ≥40 kg/m2 with one or more obesity-related complication 18 years or older Understands the risks and benefits Has been obese for >5 years Has tried and failed to lose weight Bariatric Surgery Criteria to be considered an ideal candidate (cont’d) Has no serious endocrine problems Has psychiatric and social stability Availability of a team of health care providers Surgery would ↓ or eradicate high-risk conditions Bariatric Surgery Three broad categories Restrictive Malabsorptive Combination of restrictive and malabsorptive Restrictive Surgery Reduces the size of a stomach to 30 ml or less Causes patient to feel full quicker Normal stomach digestion and intestinal absorption of food ↓ Risk of anemia and cobalamin deficiency Restrictive Surgery Vertical banded gastroplasty Partitions stomach into a small pouch in upper portion Small pouch drastically limits capacity Stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch Restrictive Surgery Adjustable gastric banding (AGB) Also referred to as the LapBand Stomach size is limited by an inflatable band placed around fundus of stomach Band is connected to a subcutaneous port Can be inflated or deflated to change stoma size Restrictive Surgery AGB (cont’d) Can be done laparoscopically and can be modified or reversed Better choice for patients who are surgical risks Weight loss is slower than in other procedures Restrictive Surgeries Fig. 41-7A Malabsorptive Surgeries Biliopancreatic diversion (BPD) Removes ~3/4 of stomach to ↓ food intake and ↓ acid output Remaining 1/4 of stomach is connected to lower portion of small intestine Pancreatic enzymes and bile enter final segment of intestine Nutrients pass without being digested Malabsorptive Surgeries Biliopancreatic diversion with duodenal switch Variation of BPD By including duodenal switch, surgeons leave a larger portion of the stomach intact Helps prevent dumping syndrome BPD with or w/o doudenal switch Bariatric Surgeries How is weight loss accomplished? What are the specific nutritional risks or adverse effects? What should be monitored to avoid complications? What is/are the advantage/s over other procedures? Combination of Restrictive and Malabsorptive Surgery Roux-en-Y surgical procedure Has low complication rates Excellent patient tolerance Stomach size is ↓ with a gastric pouch anastomosis that empties directly into jejunum Combination of Restrictive and Malabsorptive Surgery Roux-en-Y surgery (cont’d) Variations Stapling stomach without transection to create a small 20- to 30-ml gastric pouch Creating an upper and lower gastric pouch and totally disconnecting the pouches Creating an upper gastric pouch and completely removing the lower pouch Restrictive Surgery Fig. 41-7D Cosmetic Surgeries Ideal candidates have Achieved weight reduction Excess skinfolds or fat Chooses surgery for cosmetic reasons Lipectomy Liposuction Preoperative Care Room and equipment should consider patient size prior to arrival Obtaining IV access maybe complicated Proper breathing techniques, positioning Hygiene and skin care prior to admission Prevention of wound infection and dehiscence Postoperative Care During transfer ensure that patient’s Airway is stabilized Pain is managed Early __________ is essential Patients undergoing bariatric surgery are often in considerable _________ ____ Patient is now _______ ______ due to anatomic changes Ambulatory and Home Care Diet prescribed is generally High protein Low in carbohydrates fats & roughage 6 small feedings Fluids not to be ingested with meals : < 1000 ml/day first 24 hrs post-op = water, sugar-free liquids Q 2hrs WA Day 1 to 2 wks = high protein liquids Q 2hrs WA 2-4 wks = pureed at frequent intervals 4-6 wks = transition diet w/solids & pureed Ambulatory and Home Care Possible complications from surgery Anemia Vitamin deficiencies Diarrhea Psychiatric problems Peptic ulcer formation Dumping syndrome Small bowel obstruction Evaluation Expected outcomes Long-term weight loss Improvement in obesity-related comorbidities Integration of healthy practices into lifestyle Monitoring possible adverse side effects Improved self-image Gerontologic Considerations Number of older obese persons has risen More common in women than men Decreased energy expenditure and loss of muscle mass are important contributors Exacerbates age-related problems Metabolic Syndrome A group of risk factors that increase an individual’s chance of developing cardiovascular disease and diabetes mellitus Metabolic Syndrome Risk factors: abdominal obesity, insulin resistance Diagnostic criteria: 1. 2. 3. 4. 5. Waist circumference Triglycerides HDL BP Fasting glucose