Cath Lab Digest

T he challenge of ostomy care and the very obese patient lies in the skill and planning required for successful physical, emotional, and spiritual recovery.¹ Many experts believe that from the onset, the obese patient having surgery is at a significant disadvantage because assessment is difficult, anesthesia is problematic, and technical procedures are more complicated.² Regardless, the number of obese patients requiring ostomy surgery is likely to rise, just as the prevalence of obesity is increasing. Once considered a high-risk group on which physicians avoided surgical intervention, currently 37% of surgical patients are obese and 17% are considered morbidly obese.³

Demographics

In the United States, an estimated 13 to 16 million people are morbidly obese to the extent that medical intervention, simply based on obesity-related comorbidities such as pain management, immobility, skin injury, respiratory issues, and embolic threats is needed.⁴ This is a dramatic increase from 40 years ago when only a quarter of Americans were considered overweight. Today, more than two-thirds of adults and 25% of children are overweight and 10% to 25% of adults are obese - ie, have a body mass index (BMI) >30. Obesity is costly emotionally and economically; Americans spend close to $33 billion annually in attempts to control or lose weight, while $117 billion is spent on obesity-related health problems. Despite pressure to control weight, Americans continue to gain weight, and the implication to caregivers is that their care is more complex, requiring diligent interdisciplinary assessment and intervention to prevent costly and predictable complications. The value of an interdisciplinary approach is that some obese patients having ostomy surgery will develop complications that impact outcomes and are best managed by a diverse group of clinical experts such as nurses, pharmacists, physicians, and occupational/physical therapists.

Preoperative Preparation

The preoperative period for the morbidly obese ostomy patient involves physical and emotional preparation. The wound ostomy continence nurse (WOCN), as a member of the interdisciplinary healthcare team, works closely with the ostomy patient as an important player in the patient's preoperative assessment and preparation. A stoma placement mark is especially necessary to long-term physical and emotional independence of the obese patient. The WOCN should take special care to place the mark away from folds or natural contours in an area visible by the patient and away from the belt line. A conference with the surgeon(s) may be necessary to determine what options are available to stoma placement. Arranging for a United Ostomy Association (UOA) volunteer visitor and having a discussion pertaining to the emotional and practical needs of the ostomy patient and his/her significant other(s) will further promote long-term adaptation. When planning for a UOA volunteer visitor, consider more than one visitor.

Like all patients, the very overweight patient will need comprehensive preoperative teaching, which includes breathing and coughing instruction and appropriate leg exercises.⁵ Breathing and coughing exercises are especially important to prevent atelectasis and congestion that can result from shallow respirations as a result of incisional pain, depressive analgesia, inactivity, and obesity itself.⁶ Demonstrating deep breathing and coughing exercises should include splinting the involved surgical area and use of the incentive spirometer. Patients need to be reminded that gentle splinting will not interfere with ostomy function.