COMMENT 7

 
There are numerous health risks associated with obesity. These   include hypertension, type 2 diabetes mellitus, cardiovascular   disease, cancer, gallstones, osteoarthritis, and sleep apnea.
Weight gain increases vascular resistance and activates the   angiotensin system, elevating blood pressure. Obesity increases   insulin resistance and glucose intolerance, causing diabetes.   Increases in blood volumes, high cholesterol levels, and oxygen   demands strain the heart causing cardiovascular disease. Numerous   studies have shown that abdominal obesity doubles the risk of breast   and colon cancer. Gallstones are 2.7 times more likely in patients   with a BMI of over 40kg/m². Osteoarthritis occurs as extra mass   causes deterioration of weight-bearing joints. Lastly, extra abdominal   weight puts pressure on the diaphragm, inhibiting the lung’s   ability to expand, causing sleep apnea (Ali & Crowther,   2005). As can be seen, obesity places patients at risk for   otherwise preventable diseases. Mr. C. already exhibits many of these   based on his clinical presentation. He is overweight and complaining   of sleep apnea. He has elevated triglycerides at 312 mg/dL and a low   HDL or ‘good cholesterol’ level of 30mg/dL, which puts him   at risk for heart disease. He is already hypertensive. He is also   likely diabetic with an elevated fasting blood glucose at 146   mg/dL. Per the American Society for Metabolic and Bariatric   Surgery (ASMBS), qualifications for bariatric surgery are as follows:   BMI ≥ 40, BMI ≥35 and at least one or more obesity-related   co-morbidities, or an inability to achieve a healthy weight loss   sustained for a period with prior weight loss efforts (ASMBS,   2017). Based on the clinical information presented within the   case study, Mr. C.’s BMI is 45.4 which is over the requirements   for bariatric surgery. He also possesses multiple co-morbidities, such   as hypertension and sleep apnea that would qualify him for surgery.   However, without knowing more about his lifestyle, it would be   difficult to determine if he is truly a candidate. Per the ASMBS   guidelines, he needs to have attempted prior weight loss without   success. Nursing needs to document in detail his previous weight loss   attempts, as well as his willingness for change. Many patient   experience non-compliance after surgery, such as unhealthy snacking or   skipping exercise that impairs weight loss (Elkins et al., 2005), so   it is important nursing evaluate and educate Mr. C., avoiding possible   conflicts after his surgery. His hypertension also needs to be better   controlled prior to surgery to avoid complications.
Mr. C. eats at 7:00am, noon, 6:00pm, and a snack at 10:00pm. Based   on his eating habits and the medications prescribed, the most   therapeutic medication regiment for Mr. C. may be as follows:
Mylanta at 10:00am, 3:00pm, and 9:00pm, which   are three hours after all his meals. With his currently meal schedule,   his bedtime dose is also his 9:00pm dosing.
Sucralfate should be given at 6:00am, 11:00am,   and 5:00pm, or 1 hour before his meals. He also needs a bedtime dose   at 10:00pm.
Ranitidine should also be given at bedtime, 10:00pm.
This schedule may be a little confusing for Mr. C. to begin with. I   would introduce it slowly, perhaps starting with just Sucralfate and   Ranitidine, and then introduce Mylanta as to not overwhelm him.   I’d also recommend he move up the time of his bedtime snack to   maybe 8:00pm or 9:00pm as eating right before bed can trigger reflux.   Plus, I would also make sure his snack is light and his meals do not   contain any acidic or spicy food.
Using the clinical data presented, we can evaluate Mr. C.’s   functional health patterns:
Health-perception – health   management: Mr. C. has taken a step towards wellness   with his interest in bariatric surgery. He also states that he has   been trying to control his blood pressure with sodium restrictions.   These are positives in his health perception and management pattern.   He is acknowledging there is an issue with his health and weight and   is looking to better himself. However, there appears to be multiple   knowledge deficits regarding diet, exercise, and surgical intervention   that need to be clarified.
Nutritional – metabolic: Mr. C. is   overweight with a BMI of 45.4. His cholesterol levels are outside of   normal ranges, indicating a poor nutritional intake of high fat foods.   His fasting glucose is elevated, putting him at risk for diabetes. He   says he is restricting his sodium intake, which is a step in the right   direction, but he is still hypertensive. Mr. C. needs education to   help him make healthy food choices and have his sodium restriction   further evaluated.  I would also want to see a   HgBA1C. Elimination: Although there is no   mention of elimination in the study, nursing should be looking at his   bowel pattern as obesity puts patients at risk for various GI cancers,   gallstones, abdominal pains, and other issues (Ali & Crowther,   2005). Activity-exercise: Mr. C. works what   sounds like a sedentary job in the catalog telephone center and make   no mention of exercise in his assessment. Obesity can also cause   decreased activity tolerance and shortness of breath, especially if he   is fatigued from poor sleep. Nursing needs to discusses exercises   expectations with Mr. C., especially for after his   surgery. Sleep-rest: Mr. C. has sleep apnea due   to his weight. This can lead to fatigue and activity intolerance.   Nursing should consider the possibility of him needing a BiPap until   he has lost enough weight and should discuss this with the patient and   physician. Cognitive-perceptual: It is unknown   if Mr. C. has any cognitive or perceptual deficits. It should be   mentioned that diabetes can cause perceptual deficits, especially   within the realms of vision and tactile stimuli. Although he is still   young, and his fasting blood sugar was not extremely elevated, nursing   should assess him for the presence of diabetic neuropathy or   retinopathy (Jarvis, 2012). Self-perception –   self-concept: Mr. C. has acknowledged that he is overweight   by considering bariatric surgery. He also mentions that he has always   been overweight since he was a child. Although there is no mention of   it within the case study, nursing should evaluate him for anxiety or   depression related to his weight, as well as self-esteem and ways to   improve upon it. I would not be surprised to hear he was teased about   his weight as a child. Those interactions can greatly affect   self-concept as an adult. Role-relationship:   There is no mention of family, roommates, or any support system. Given   that he is a single young man, he likely lives alone based on the   information provided. Nursing needs to further assess his support   system. Post-surgical care may be especially difficult without anyone   to assist him. Temporarily losing independence while he recovers after   surgery may also be difficult. If he needs time off work, for example,   there is no further financial support. These are concerns that need to   be addressed.Sexuality – reproductive: Mr.   C. is single. He does not appear to have children. Being overweight   may have impacted his ability to find a partner, as well as his sexual   function and self-confidence. These are things that would be worth   further discussing with him. Coping – Stress   tolerance: Again, he does not mention having a support   system. This will impact his ability to manage any stress   post-surgery, as well as decrease his overall motivation for wellness.   Also, he mentions having gain 100lbs in the past 2-3 years. Nursing   should evaluate if something has triggered his weight gain, such as   stress eating due to a traumatic incident.
There are numerous problems that can be identified within the scenario.
Hypertension (Actual): Mr. C.’s blood pressure   is 172/96. This puts him as risk for myocardial or cerebral damage.   His weight causes excess vascular resistance, increased blood volume,   and increased oxygen damage to tissues (Ali & Crowther, 2005). He   is trying to control the hypertension through dietary restrictions but   it does not appear to be enough. Nursing should work with him closely   to evaluate his intake, as well as discuss with his physician the   possibility of being prescribed an antihypertensive.
Sleep Apnea (Actual): He also has sleep   apnea.Mr. C.’s abdominal weight is putting pressure on his   diaphragm, impairing his ability to breath at night (Ali &   Crowther, 2005). Although the symptoms will likely improve once he   begins to lose weight, in the meantime it may be beneficial to consult   for a sleep study and a BiPap. This will allow his body to oxygenate   and rest at night, giving him more energy for the day.
Obesity (Actual): Perhaps the most obvious problem is   Mr. C.’s weight. He is 68 inches tall or 5 feet 8 inches. He   weighs 135.4kg or roughly 298.5 lbs. Using that information in a BMI   calculator from the Centers for Disease Control and his BMI is 45.4.,   making him obese (CDC, 2015). Being obese puts him at risk for   numerous health issues.
Osteoarthritis (Potential): Mr. C.’s   excess weight puts pressure on his weight-baring joints. This causes   the joints to become frayed and thin, eventually wearing down.   Although he may not complain of joint pain now, he will likely develop   it in the future. For every kilogram increase in weight, the risk of   developing osteoarthritis is increased by 9-13% (Ali & Crowther,   2005). This means Mr. C. has an over 200% risk of developing osteoarthritis.
Sexual Dysfunction (Potential): Mr. C’s   weight could lead to future sexual dysfunction. Although he is   currently single, he may want to seek a partner or have children in   the future. Obesity has been linked to lower levels of testosterone,   erectile dysfunction, and overall sexual dysfunction in men (Ostbye,   2011). There is also concern for stigmatization and discrimination.   Mr. C.’s weight could impact his relationships in the future.
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