1. 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

2. 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

3. 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

4. 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

5. Post Operative Care l ABCs Airway Breathing Circulation Drugs

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

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

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

9. 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

10. September 3, 2002

12. September 10, 2002

13. September 17, 2002

15. September 19, 2002

18. October 9, 2002

19. 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