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Obesity
Description
Obesity is an excessively high amount of body fat or adipose tissue. Obesity is a major health problem because it increases the risk of numerous other diseases such as diabetes and cancer.
Currently, more than 35% of adults in the United States are obese. The highest prevalence of obesity occurs between ages 40 and 59 for women and after 60 years of age for men.
Obesity in adulthood is often a problem that begins in childhood or adolescence. Nearly one third of children and teens are currently obese or overweight.
The most common measure of obesity is the body mass index (BMI). BMI is calculated by dividing a person’s weight (in kilograms) by the square of the height in meters.
■ Individuals with a BMI less than 18.5 kg/m2 are considered underweight, whereas those with a BMI between 18.5 and 24.9 kg/m2 reflect a normal body weight. A BMI of 25 to 29.9 kg/m2 is classified as being overweight, and those with values at 30 kg/m2 or above are considered obese. The term severely (morbid, extreme) obese is used for those with a BMI greater than 40 kg/m2.
■ The incidence of the adult American population with a BMI greater than 25 kg/m2 is over 68%.
Pathophysiology
The cause of obesity involves significant genetic/biologic susceptibility factors that are highly influenced by environmental and psychosocial factors.
Most obese people have primary obesity, which is excess calorie intake over energy expenditure for the body’s metabolic demands. Others have secondary obesity, which can result from various congenital anomalies, chromosomal anomalies, metabolic problems, or central nervous system lesions and disorders.
The two major consequences of obesity are due to the sheer increase in fat mass and the production of adipokines produced by fat cells. Adipocytes produce at least 100 different proteins. These proteins, secreted as enzymes, adipokines, growth factors, and hormones, contribute to the development of insulin resistance and atherosclerosis.
Environmental factors include greater access to prepackaged and fast foods, larger portion sizes, lack of physical activity and sedentary recreation, and high-calorie foods that may be more accessible to those of low socioeconomic status.
There is a 20% to 40% increase in mortality for both men and women who are overweight in midlife. Many problems occur in obese people at higher rates than people of normal weight, including cardiovascular disease, respiratory problems, cancer, diabetes mellitus, and musculoskeletal, gastrointestinal, and liver problems.
Diagnostic studies
Collaborative care
A multifaceted approach needs to be taken, with attention to nutritional therapy, exercise, behavior modification, and for some, medication or surgical intervention. Stress healthy eating habits and adequate physical activity as lifestyle patterns to develop and maintain.
Drug therapy
Medications should be part of a comprehensive weight-reduction program that includes reduced-calorie diet, exercise, and behavior modification. Drugs that increase energy expenditure (e.g., ephedrine) are not recommended or approved by the Food and Drug Administration for weight loss.
Drugs will not cure obesity, and individuals must understand that without substantial changes in food intake and increased physical activity, they will gain weight when drug therapy is stopped. Teach patients about administration, and how the drugs fit into the overall weight loss plan. Discourage the purchase of over-the-counter diet aids except for Alli.
Surgical therapy
Bariatric surgery is a surgical procedure that is used to treat obesity. Criteria for bariatric surgery include having a BMI of 40 kg/m2 or a BMI of 35 kg/m2 with one or more severe obesity-related medical complications (e.g., hypertension, type 2 diabetes mellitus, heart failure, sleep apnea).
The Roux-en-Y gastric bypass (RYGB) procedure is a combination of restrictive and malabsorptive surgery. This surgical procedure is the most common bariatric procedure performed in the United States and is considered the gold standard among bariatric procedures.
Cosmetic surgeries may be used to reduce fatty tissue and skinfolds. These procedures include a lipectomy (adipectomy) to remove unsightly adipose folds and liposuction for cosmetic purposes.
Nursing management
Goals
The overall goals are that the patient with obesity will modify eating patterns, participate in a regular physical activity program, achieve weight loss to a specified level, maintain weight loss at a specified level, and minimize or prevent health problems related to obesity.
Nursing interventions
Together with other members of the health care team, you have a major role in planning for and managing the care of an obese patient. It is essential that you have a nonjudgmental approach in helping patients manage their problems related to obesity.
Preoperative care for gastric surgery includes planning for special needs of an obese patient, such as the availability of a larger sized BP cuff, hospital gown, bed, and chair. Consider how the patient will be weighed, transported through the hospital, and turned. Instruct the patient in the proper coughing technique, deep breathing, use of an incentive spirometer, and methods of turning and positioning to prevent pulmonary complications after surgery.
Postoperative care focuses on careful assessment and immediate intervention for cardiopulmonary complications, deep vein thrombosis, anastomosis leaks, and electrolyte imbalances. Facilitate patient respiratory efforts (elevating the head of the bed, turning, coughing, deep breathing); monitor for wound infection, dehiscence, and delayed healing; promote early ambulation; and monitor nasogastric (NG) tube patency. The transfer from surgery may require many trained staff members.
Obstructive sleep apnea
Description
Obstructive sleep apnea (OSA), also called obstructive sleep apnea–hypopnea syndrome, is characterized by partial or complete upper airway obstruction during sleep. Apnea is the cessation of spontaneous respirations lasting longer than 10 seconds. Hypopnea is a condition characterized by shallow respirations (30% to 50% reduction in airflow).
Pathophysiology
■ Apnea and arousal cycles occur repeatedly, as many as 200 to 400 times during 6 to 8 hours of sleep.
Clinical manifestations
Manifestations of sleep apnea include frequent arousals during sleep, insomnia, excessive daytime sleepiness, and witnessed apneic episodes. The patient’s bed partner may complain about the patient’s loud snoring. Other symptoms include morning headaches, personality changes, and irritability.
Diagnostic studies
Nursing and collaborative management
Conservative treatment
Conservative home treatment for mild sleep apnea (5 to 10 apnea/hypopnea events per hour) includes sleeping on one’s side rather than the back, elevating head of the bed, and avoiding sedatives or alcoholic beverages 3 to 4 hours before sleep. Because excessive weight worsens sleep apnea, refer patient to a weight loss program if indicated.
Continuous positive airway pressure (CPAP) by mask is often used for patients with severe symptoms (more than 15 apnea/hypopnea events per hour). With CPAP, the patient applies a nasal mask attached to a high-flow blower (see Fig. 8-5, Lewis et al.: Medical-Surgical Nursing, ed. 9, p. 109). CPAP reduces apnea episodes, daytime sleepiness, and fatigue.
Surgery
If conservative measures fail, surgery may be done. Two common procedures are uvulopalatopharyngoplasty and genioglossal advancement and hyoid myotomy. Radiofrequency ablation may also be used.
Oral cancer
Description
There are two types of oral cancer: oral cavity cancer, which starts in the mouth, and oropharyngeal cancer, which develops in the part of the throat just behind the mouth (called the oropharynx). Head and neck squamous cell carcinoma (HNSCC) is a term for cancers of the oral cavity, pharynx, and larynx and accounts for 90% of malignant oral tumors. Carcinoma of the lip has the most favorable prognosis of any oral tumor because these cancers are usually diagnosed earlier.
Pathophysiology
Although the definitive cause of oral cancer is unknown, it has a number of predisposing factors, including a diet low in fruits and vegetables, prolonged exposure to sunlight, tobacco use (cigar, cigarette, pipe, snuff), and frequent alcohol consumption. Human papillomavirus (HPV) contributes to 25% of oral cancer cases. HPV-associated oropharyngeal cancer is associated with multiple sexual partners, especially multiple oral sex partners.
Clinical manifestations
Common manifestations include:
Patients may also report nonspecific symptoms such as chronic sore throat, sore mouth, and voice changes. Some patients with oral cancer have an asymptomatic neck mass. Later symptoms of oral cancer are pain, dysphagia (difficulty swallowing), and difficulty in moving the jaw (e.g., chewing and speaking).
Cancer of the lip usually appears as an indurated, painless lip ulcer. The first sign of tongue cancer is an ulcer or area of thickening. Soreness or pain of the tongue may occur, especially on eating hot or highly seasoned foods.
Diagnostic studies
Collaborative care
Management usually consists of surgery, radiation, and/or chemotherapy. Surgery remains the most effective treatment. Many surgeries are radical procedures involving extensive resections. Some examples are hemiglossectomy (removal of one half of the tongue), glossectomy (removal of the entire tongue), and radical neck dissection (wide excision of the lymph nodes and their lymphatic channels). A tracheostomy (see Tracheostomy, p. 732) is commonly done with radical neck dissection.
Chemotherapy and radiation are used together when there are positive margins, bone erosion, or positive lymph nodes (see Chemotherapy, p. 694, and Radiation Therapy, p. 730). Chemotherapeutic agents used include 5-fluorouracil (5-FU), methotrexate, cisplatin (Platinol), carboplatin (Paraplatin), paclitaxel (Taxol), docetaxel (Taxotere), cetuximab (Erbitux), and bleomycin (Blenoxane).
■ Brachytherapy with implantations of radioactive seeds may be used to treat early-stage oral cancer.
Palliative treatment may be the best management when the prognosis is poor, the cancer is inoperable, or the patient decides against surgery. If it becomes difficult for the patient to swallow, a gastrostomy may be performed to provide adequate nutritional intake, and frequent suctioning will be necessary when swallowing becomes difficult.
Nursing management
Goals
The patient with carcinoma of the oral cavity will have a patent airway, be able to communicate, have adequate nutritional intake to promote wound healing, and have relief of pain and discomfort.
Nursing diagnoses
Nursing interventions
You have a significant role in early detection and treatment of oral cancer. Identify patients at risk (users of tobacco products, alcoholism, poor dental care, pipe smokers) and provide information regarding predisposing factors.
Preoperative care for the patient who is having radical neck dissection involves consideration of the patient’s physical and psychosocial needs with a special emphasis on oral hygiene. Explanations and emotional support are of special significance and should include postoperative measures relating to communication and feeding.
Postoperative care for a radical neck dissection focuses on the maintenance of a patent airway, including tracheostomy care and observing for signs of respiratory distress. See Head and Neck Cancer, p. 264, for further discussion and teaching.
Osteoarthritis
Osteoarthritis (OA), the most common form of joint (articular) disease in North America, is a slowly progressive noninflammatory disorder of the diarthrodial (synovial) joints. Currently 27 million Americans are affected by OA, with the numbers expected to greatly increase as the population ages.
OA is not considered to be a normal part of the aging process, but aging is one risk factor for disease development. Cartilage destruction can actually begin between the ages of 20 and 30 years, and the majority of adults are affected by age 40. Few patients experience symptoms until after age 50 or 60 years, but more than half of those older than 65 years of age have x-ray evidence of the disease in at least one joint. After 55 years of age, women are more often affected than men.
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