Tag Archives: bariatric patients

Providing skin care for bariatric patients

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By Gail R. Hebert, MS, RN CWCN, DWC, WCC, OMS

How would you react if you heard a 600-lb patient was being admitted to your unit? Some healthcare professionals would feel anxious—perhaps because they’ve heard bariatric patients are challenging to care for, or they feel unprepared to provide their care.

With the obesity epidemic showing no signs of abating, you’re likely to encounter bariatric patients at some point. How can you care for them with the dignity and respect they deserve? If we expect to conduct “business as usual” on our units, we’ll be caught off guard without the tools and knowledge we need to make the experience a positive one for the patient, family, and staff. This article reviews how to prepare for and manage one of the most challenging aspects of caring for bariatric patients—providing skin care.

Skinfolds: A special focus of care

Bariatrics is the branch of health care that specializes in treating people with obesity and associated conditions. Defined as a body mass index (BMI) over 30, obesity reflects how a person’s weight relates to height. Bariatric patients have an excessively large size, with excess adipose tissue under the skin and throughout the body.

Skinfolds may develop in various locations—including behind the neck; under the arms, breasts, and abdomen; between the inner thighs; and under the pannus (an overlapping tissue flap formed from the abdomen that extends downward like an apron). Complications commonly arise in skinfolds and include intertriginous dermatitis, candidiasis, and pressure ulcers. (See Understanding skinfold complications in bariatric patients.)

Understanding skinfold

OBESE: An apt mnemonic

Use the word OBESE as a mnemonic tool to help you remember key clinical issues in bariatric skin management.

O: Observe for atypical pressure ulcer development.

B: Be knowledgeable about common skin conditions.

E: Eliminate moisture on skin and in skinfolds.

S: Be sensitive to the patient’s emotional distress.

E: Use equipment to protect the skin and for safe patient handling.

Observe for atypical pressure ulcer development.

Bariatric patients are at higher risk for pressure ulcers, as their extra padding doesn’t necessarily protect them from the forces of pressure and shear. Although the data supporting higher risk for this population aren’t cut and dried, most expert clinicians believe the risk is higher, so be sure everyone knows that fat pads don’t provide protection.

Also, bariatric patients commonly are malnourished and less mobile than others, making it hard for them to avoid excess pressure on the skin. Many have multiple comorbidities, such as diabetes, that further increase their pressure ulcer risk. We lack a risk assessment instrument specifically designed for this population, so we must use our clinical skills and experience to anticipate risk.

In this population, pressure ulcers can develop in atypical and unique locations—hips, lower back, buttocks, in skinfolds, and in areas with medical devices, such as tubes. Also, foreign objects, such as medicine cups and TV remote controls, can get lost in the bed and lead to pressure areas. Bariatric patients require frequent turning and repositioning to help prevent breakdown from pressure and shear forces.

Be knowledgeable about common skin conditions.

Intertriginous dermatitis is an inflammatory skin condition commonly seen in the skinfolds of bariatric patients. It results from the weight of skin, which creates skin-on-skin contact coupled with friction forces and trapped moisture from perspiration. Dermatitis most often occurs in skinfolds behind the neck, under the arms and breasts, under the abdomen or pannus, on the side, and on the inner thigh.

Intertriginous dermatitis is partial thickness and typically presents in a mirror-image pattern on each side of the skinfold. Initially, the involved area of the skin shows mild redness, which may progress to more intense inflammation with erosion, oozing, drainage, maceration, and crusting. Associated findings include pain, itching, burning, and odor. As clinicians, we should anticipate this problem and not wait for intertriginous dermatitis to develop. To help prevent and intervene for intertriginous dermatitis, read “Eliminate moisture on skin and in skinfolds” below. (For information on other common skin conditions in bariatric patients, see Candidiasis, acanthosis nigricans, and chafing.)

Candidiasis, acanthosis nigricans, and chafing

Eliminate moisture on skin and in skinfolds.

Many barriers to healthy skin in bariatric patients can be eliminated by reducing moisture on the skin, avoiding skin-to-

skin contact, minimizing heat build-up on these tissues, and keeping the skin clean. Using absorbent materials can accomplish these goals. For instance, Interdry AG® Textile (from Coloplast, Inc.) is impregnated with ionic silver, which provides broad-spectrum antibacterial and antifungal action for up to 5 days. It’s designed to wick away moisture and reduce skin-to-skin friction.

Clean the patient’s skin frequently with a pH-balanced cleanser, using gentle strokes to avoiding harming fragile tissues. Avoid scrubbing. Handheld showers and no-rinse cleansers can simplify this pro­cess. Advise patients to wear loose-fitting clothing made of absorbent fibers.

Be sensitive to the patient’s emotional distress.

Everyone involved in caring for bariatric patients should receive sensitivity training to increase their awareness and compassion. Many of us hold an unconscious negative view of these patients, which can manifest in our interactions with them. Bariatric patients have reported many incidents of unprofessional treatment by staff who are otherwise excellent caregivers but lack empathy and understanding.

To make matters worse, bariatric patients frequently suffer from depression, altered self-esteem, and social isolation. Take care not to demonstrate prejudice through your actions and words, or to show reluctance to render care due to fear of injury, inadequate equipment, inadequate staffing, or a misunderstanding of obesity.

Be aware of possible obesity bias. View: “Weight bias in healthcare,” from Yale Rudd Center.

Use equipment to protect the skin and for safe patient handling.

Equipment must be the proper size and construction to prevent rubbing and creating pressure points against the skin (for example, from the side panels of a too-small wheelchair). Reposition patients frequently to prevent skin breakdown; also, reposition any tubes and tube fixation devices. Use support surfaces of the appropriate weight limit to prevent bottoming out. With skin moisture a common concern, most bariatric patients should use a low-air-loss mattress.

Transferring and moving patients presents a hazard to both staff and patients. Ideally, healthcare facilities should have the proper equipment on hand and ready for use when the patient reaches the unit. The best way to ensure the right type and amount of equipment is to work with companies that specialize in safe patient-handling programs. They can conduct a needs analysis and provide evidence-based recommendations that can be reviewed before equipment purchase or rental. Although facility administrators may believe they lack the budget for equipment purchase, I would advise them they don’t have the budget not to purchase it. A single lawsuit or injury claim by a patient or a workers compensation claim by staff can cost considerably more than the investment in proper patient-handling equipment.

Meeting the challenge

Specialized knowledge of common conditions and appropriate treatments can help us meet the challenge of caring for ba­ri­atric patients’ skin. That knowledge must be coupled with planning activities to address such issues as required staff, devices, and lifting and repositioning equipment. Accomplishing these goals long before you hear of a 600-lb patient on the way to your floor will greatly enhance the chance of a successful outcome.

Selected references

Beitz JM. Providing quality skin and wound care for the bariatric patient: an overview of clinical challenges. Ostomy Wound Manage. 2014;60(1):12-21.

Black JM, Gray M, Bliss DZ, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2011;38(4):359-70.

Blackett A, Gallagher S, Dugan S, et al. Caring for persons with bariatric health care issues: a primer for the WOC nurse. J Wound Ostomy Continence Nurs. 2011;38(2):133-8.

Bryant RA. Types of skin damage and differential diagnosis. In: Bryant RA, Nix DP. Acute & Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Mosby; 2012;83-105.

Corbyn C, Rush A. Challenges of wound management in bariatric patients. Wounds UK. 2010;6(4):62-71.

Cuddigan JE, Baranoski S. Wounds in special populations: bariatrics. In: Baranoski S, Ayella EA, eds. Wound Care Essentials: Practice Principles. 3rd ed. Ambler, PA: Lippincott, Williams & Wilkins; 2012;542-51.

Doughty D. Differential assessment of trunk wounds: pressure ulceration versus incontinence associated dermatitis versus intertriginous dermatitis. Ostomy Wound Manage. 2012;58(4):20-2.

Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39(3):303-15.

Clark L, Black JM. Keeping the bariatric patient’s skin intact. Bariatric Times. May 17, 2011. bariatrictimes.com/keeping-the-bariatric-patient%E2%80%99s-skin-intact/

Miller JH. Acanthosis nigricans. Medscape. July 15, 2010; updated September 26, 2014. emedicine.medscape.com/article/1102488-overview

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Haesler E, ed. Osborne Park, Western Australia: Cambridge Media; 2014.

Sardina D. Skin and Wound Management Course Workbook. Lake Geneva, WI: Wound Care Education Institute; April 2011.

Swezey L. Top 5 ways to prevent skin breakdown in bariatric patients. April 2, 2014. woundsource.com/blog/top-5-ways-prevent-skin-breakdown-bariatric-patients.

Zulkowski K. Diagnosing and treating moisture-associated skin damage. Adv Skin Wound Care. 2012; 25(5):231-6.

Gail R. Hebert is a clinical instructor with the Wound Care Education Institute in Plainfield, Illinois.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Case study: Bariatric patient with serious wounds and multiple complications

By Hedy Badolato, RD, CSR, CNSC; Denise Dacey, RD, CDE; Kim Stevens, BSN, RN, CCRN; Jen Fox, BSN, RN, CCRN; Connie Johnson, MSN, RN, WCC, LLE, OMS, DAPWCA; Hatim Youssef, DO, FCCP; and Scott Sinner, MD, FACP

Despite the healthcare team’s best efforts, not all hospitalizations go smoothly. This article describes the case of an obese patient who underwent bariatric surgery. After a 62-day hospital stay, during which a multidisciplinary team collaborated to deliver the best care possible, he died. Although the outcome certainly wasn’t what we wanted, we’d like to share his story to raise awareness of the challenges of caring for bariatric patients.

Health hazards of obesity

Obesity isn’t just a cosmetic problem; it’s a health hazard. Someone who’s 40% overweight is twice as likely to die prematurely as someone of normal weight. Obesity has been linked to many serious medical conditions, including cardiovascular disease and stroke, high blood pressure, diabetes, cancer, gallbladder disease and gallstones, osteoarthritis, gout, respiratory problems (such as sleep apnea), depression, gynecologic disorders, erectile dysfunction and other sexual health issues, nonalcoholic fatty liver disease, and metabolic syndrome (a combination of high blood glucose, high blood pressure, and high triglyceride and cholesterol levels). Obesity also causes skin problems, such as poor wound healing. In obese persons, most wounds arise secondary to poor hygiene related to obesity.

Obesity in adults is determined from body mass index (BMI). (See Defining obesity in adults.)

Understanding bariatric procedures

Bariatric procedures fall into two main categories—restrictive and malabsorptive. Restrictive procedures limit the amount of food the stomach can hold, with the goal of reducing caloric intake. Malabsorptive procedures bypass part of the small intestine, decreasing the amount of calories and nutrients the body absorbs. Some procedures are both restrictive and malabsorptive.

Restrictive bariatric procedures include laparoscopic adjustable gastric band and laparoscopic sleeve gastrectomy. Bariatric procedures that are both restrictive and malabsorptive include biliopancreatic diversion with duodenal switch (BPD-DS) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgical complications associated with LRYGB and BPD-DS include anastomotic leaks, anastomotic strictures, and intestinal obstructions (See Visualizing the Roux-en-Y procedure.)

Importance of nutrition in bariatric patients

Various GI complications may arise after bariatric surgery, including abdominal pain, nausea, vomiting, diarrhea, hernias, and ulcers. Common nutrient deficiencies associated with such surgery involve protein, calories, calcium, iron, copper, thiamine, vitamins A, B1, B6, B12, C, D, E, and K, and folic acid.

Nutrient deficiencies depend on the length of the absorptive area and percentage of weight loss. These deficiencies progress over time. However, they can be prevented with the help of a multidisciplinary team. Unless nutrition is addressed, patients with surgical complications may experience impaired wound healing, wound dehiscence, pressure ulcers, chronic wound infections, necrotizing fasciitis, decreased cardiac and respiratory functions, increased morbidity, and even death.

Nutrition before and after surgery

Nutrition plays a critical role in skin integrity, and lack of proper nutrition can lead to pressure ulcers, necrotizing fasciitis, venous stasis ulcers, wound dehiscence, and chronic wound infections.

Preoperative diet

Adhering to a strict preoperative diet helps reduce the risk of complications. For 2 weeks before bariatric surgery, patients should consume a liquid diet, which provides several benefits:

  • promotes weight loss
  • helps train the brain to eat less
  • helps shrink the liver, which commonly is enlarged in morbidly obese persons due to excessive intake of complex carbohydrates
  • promotes postoperative healing, which helps avoid complications.

Postoperative nutrition support

After bariatric surgery, barriers to adequate nutrition include lack of physician and nutritionist collaboration, poor I.V. access, hemodynamic instability, hyperglycemia, and fluid volume imbalances. Removing these barriers requires a nutritional plan that begins before surgery.

For 24 to 48 hours after surgery, the patient should receive nutritional support (preferably enteral feedings). Such support is based on factors that contribute to physiologic stress, such as mechanical ventilation, fever, and extent of surgical wounds. Patients should receive a high-protein diet: 2 to 2.5 g/kg of ideal body weight (IBW), with 11 to 14 kcals/kg actual dry weight, or 22 to 25 kcals/kg IBW. Clinicians should stay alert for common nutrient deficiencies.

Enteral nutrition support commonly is the first choice for patients with a functional gut. Parenteral nutrition support is considered in patients with severe nausea or vomiting and gastric leaks. Ongoing monitoring of response to nutrition therapy with timely adjustment of the nutrition care plan is an important part of patient management.

The case of Gary T.

Gary T. (not his real name), a 42-year-old male, weighed 671 lb (304 kg) before LRYGB surgery; his BMI was 86.1. (Sixty days after surgery, his BMI had dropped to 66.1.) His comorbidities included diabetes, hypertension, and peripheral vascular disease.

Before and after surgery, the dietitian worked with Gary to address his nutritional needs. However, within 24 hours after surgery, his vital signs became unstable and he developed rhabdomyolysis (probably from his morbid obesity in conjunction with prolonged surgery). The nurse noted a deep-tissue injury (DTI) to the sacrum, possibly from the prolonged (7-hour) surgery and inadequate padding of the operating-room (OR) table. Eschar was firm, and the nurse applied an intact foam dressing to prevent further tissue injury.

Gary subsequently suffered multiple complications, many resulting at least partly from his poor nutritional status secondary to obesity. Below, members of the care team present their perspectives.

Intensivist Youssef

One day after surgery, Gary developed rhabdomyolysis, a syndrome of muscle necrosis with release of muscle enzymes into the circulation, leading to electrolyte imbalances and acute kidney injury. His creatine phosphokinase (CPK) level rose to 50,380 mcg/L; normal range is 0 to 235 mcg/L.

At the time, we thought his extremely high CPK level resulted from the sacral DTI secondary to prolonged surgery with the patient in one position and an inadequately padded OR table, in the setting of morbid obesity. CPK rises within 2 to 12 hours after onset of muscle injury and peaks in 24 to 72 hours; half-life is 1.5 days. CPK decreases by 40% to 50% daily unless continuous muscle injury occurs. Gary’s CPK level stayed above 1,000 mcg/L for 2 weeks and didn’t normalize until 6 weeks later. This contributed to prolonged renal failure, which persisted throughout his 2-month hospital stay.

Infectious disease specialist Sinner

Gary received prophylactic cefazolin during and immediately after surgery. We expected him to have early postoperative fevers. His initial urine, blood, and respiratory cultures were negative, as was a methicillin-resistant Staphylococcus aureus nasal swab. He also received 1 to 2 days of piperacillin-tazobactam as empiric therapy due to the fevers.

One week after surgery, Gary’s white blood cell (WBC) count rose and purulent drainage appeared in his Jackson-Pratt drain. Drainage cultures showed two modestly resistant Escherichia coli strains, a few streptococcal species, an anaerobe, and one yeast strain. GI flora were presumed to be present due to an anastomotic leak.

Four weeks after surgery, Gary’s blood cultures showed carbapenem-resistant Enterobacter, limiting his treatment options. At 5 weeks postoperatively, his necrotic decubitus ulcer was debrided; cultures were mixed but included the highly resistant Enterobacter.

At 7 weeks, Pseudomonas was isolated from another decubitus debridement; this probably resulted from his previous tigecycline therapy, to which Pseudomonas is inherently resistant (given during postop week 3). Stenotrophomonas, which is inherently resistant to carbapenems, was isolated from his sputum following carbapenem treatment. In addition, non-albicans Candida was isolated in the urine, and stemmed from his previous fluconazole therapy. Vancomycin-resistant enterococci were isolated in his blood because of his previous broad-spectrum antibiotic therapy.

Gary’s case underscores two important concepts:

  • Duration and breadth of antibiotic therapy predicts which resistant organisms will be found later.
  • Antibiotics can’t fix surgical problems—in this case, anastomotic leaks and necrotic ulcer tissue. Extended and broad antibiotic therapy can lead to additional complications, including excess drug toxicity, multidrug resistant infections and Clostridium difficile colitis.

Nurses Stevens and Fox

On the first postop day, Gary required bilevel positive-airway pressure treatment because he developed atelectasis from complications of prolonged surgery and inability to move due to acute postoperative pain. This condition eventually progressed to acute respiratory failure, necessitating ventilation.

Mechanical ventilation continued for 2 weeks, with multiple failed weaning attempts related to new emergence of various infections, in turn leading to a cycle of systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and multi-organ dysfunction syndrome (MODS). As a result, Gary required multiple vasopressors and continuous venovenous hemofiltration to manage hemodynamic MODS complications. After one infection was treated, another one emerged, and the cycle began again.

Two weeks after surgery, a tracheostomy was done because of Gary’s inability to wean; the goal was to reduce the risk of ventilator-associated pneumonia linked to longer intubation. Maximum duration for an internal jugular dialysis catheter is 3 weeks, due to the infection risk. Gary’s catheter had to be replaced three times during his hospital stay. He also had a left subclavian central line for central venous pressure (CVP) monitoring and vasopressor therapies. Keeping a CVP line in place too long can lead to infection, so a peripherally inserted central line was placed.

Throughout his entire stay, Gary was compromised and had abnormal laboratory values. His albumin level ranged from 1.9 to 2.2 g/dL (normal range, 3.5 to 5.2 g/dL); blood glucose ranged from 79 to 424 mg/dL (normal range, 80 to 120 mg/dL); prealbumin measured 9 mg/dL (normal range, 18 to 45 mg/dL); and WBC count ranged from 15,100 to 39,400 cells/mm3 (normal range, 4,000 to 11,000 cells/mm3). Gary’s weight ranged from 671 lb (304 kg) to 514 lb (233 kg).

Although the dietitians and physicians collaborated to develop a plan for nutritional support, Gary’s obesity and comorbidities made it difficult to gain traction in healing his wounds.

Wound care

Wound care was a particular challenge. It took more than 1 hour daily to reposition Gary and clean and dress his wound with intact eschar, and nearly 2 hours for open wounds. Transporters (usually three or four at a time) aided in turning and repositioning him. A self-turning bed that assists with right and left turns was used. The wound care nurse, physicians, and a dietitian were present for daily wound care. Gary’s wife was at the bedside to provide comfort.

For patients in optimal health, debridement, pressure relief, and moisture-retentive dressings can aid wound healing. But Gary wasn’t in optimal health. When his hospital stay exceeded 30 days, he had to be transferred to another facility. The extra-special handling required for the move included an additional air mattress and additional foam protection. His situation became even more complicated and he required additional care and handling.

In the new location, Gary’s sacral wound suddenly became malodorous. The eschar was boggy but remained intact with no drainage. A partial CT scan (Gary couldn’t fit into the scanner entirely) revealed gas gangrene. Bedside sharp debridement was performed immediately. The pathology report showed Gram-positive cocci and rods—morphologies of common anaerobic organisms that can cause gangrene.

Sad outcome

Over the next several weeks, Gary’s wounds worsened. Large amounts of purulent matter continued to drain from tunnels that extended upward from undermined areas, and muscle necrosis developed. The area beneath the pannus was open and draining. Multiple surgical sites in the abdomen were open and draining foul-smelling purulent drainage. Both lower extremities developed multiple areas of necrosis. (See Declining postoperative course: Photos tell the story.)

Despite medical and nursing interventions, Gary was visibly deteriorating. On day 61, everyone involved in his care, including his wife, met and decided to withhold all life-sustaining measures. He died soon after being removed from the ventilator.

As this case demonstrates, a good patient outcome may not be possible even with optimal management of nutrition, wounds, and infection by a competent, dedicated healthcare team. When the patient continues to deteriorate, as Gary did, keeping him comfortable and maintaining his dignity take the highest priority.

Hedy Badolato and Denise Dacey are dietitians. Connie Johnson is a wound care nurse. Kim Stevens and Jen Fox are staff nurses. Hatim Youssef is an intensivist. Scott Sinner is an infectious disease specialist.

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, Wound Care Advisor. All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.