Case Study 1: Bariatric Patient Janet Cuddigan, PhD, RN, CWCN, CCCN Assistant Professor University of Nebraska Medical Center Omaha, NE VA Post Doctoral Research Fellow Iowa City, IA and Omaha, NE

Scenerio l 47 year old female l Weight = 505 lbs l Height = 5’6” l BMI = 81.5 l Medical History: Asthma, sleep apnea, pulmonary hypertension, arterial hypertension, diabetes, DVT, osteoarthritis, non union of tib- fib fracture, bedrest for 1 year

Surgery & Initial Postop Course l Roux en Y gastric bypass on August 2, 2002 l Initial Postoperative Course Ventilator dependency Tracheostomy Atrial fibrillation Stroke Fluid and electrolyte imbalances Diarrhea from tube feeding Sepsis from TPN Acute renal failure Rashes from plastic allergy and Candida

Operating Room l Access to OR l Size of OR table l Size of instruments l Positioning l Visualizing the operative field l Anesthesia challenges & risks l Longer time

Post Operative Care l ABCs Airway Breathing Circulation Drugs

Post Operative Care l Vital signs Pulse Blood pressure Respirations Temperature Pain

Post Operative Care l Mobility & Early Ambulation Bariatric bed Supportive equipment Staff support Preventing Complications Thromboembolic Deconditioning Pressure ulcers

Post Operative Care l Wound Care Wound Assessment Dressings Binders Increased risk of infection

One Month Postoperatively l Height = 5’6” l Weight = 395 lbs l BMI = 63.7 l Albumin = 2.7 l Still on ventilator in AICU l Renal failure recovering– off dialysis l Multiple skin and wound problems

September 3, 2002

September 10, 2002

September 17, 2002

September 19, 2002

October 9, 2002

Treatment of Pressure Ulcers l Astute and thorough skin and wound assessment l Risk assessment l Adequate hygiene l Toileting assistance l Skin care l Encouraging mobility and independence l Appropriate equipment l Pressure reduction l Nutrition for healing l Local wound care l Oxygenation and perfusion