BOSTON—Treating patients with cancer who are morbidly obese presents unexpected challenges according to Vita Norton, RN, BSN, OCN, and Michelle Howard, RN, BSN, of Mass - achusetts General Hospital in Boston. Data indicate that obesity significantly increases the risk of endometrial and ovarian cancers and is associated with worse outcomes.
In a poster, Norton and Howard presented the case of a 60-year-old woman weighing 525 lb who underwent major surgery for adenocarcinoma of the uterus (stage IA, grade 2), followed by vaginal brachytherapy. She had multiple comorbidities, including type 2 diabetes mellitus, hypertension, and restrictive lung disease; and her medical history included papillary thyroid cancer and debridement for lymphedema-related cellulitis.
She was hospitalized multiple times after diagnosis for partial small bowel obstructions and infections. Following an admission for diffuse abdominal pain, she spent 4 days on the surgical unit. Bedbound, the patient needed a Foley catheter to address urinary incontinence. On day 4, she was transferred to the gynecologic oncology unit, which was equipped with a bariatric bed with an assist-to-stand feature; a heavy-duty transfer lift; a bariatric wheelchair and shuttle chair; and a bariatric commode.
The patient’s impaired mobility and urinary incontinence resulted in poor skin integrity. The skinfolds of obese patients are susceptible to bacterial, fungal, and viral activity that breaks down the skin and causes infections. She could not reposition herself or get out of bed, and complications of her lung disease left her unable to tolerate being upright. Nevertheless, she insisted the staff remove the catheter, which caused pain. As a result, she urinated on herself over the next 24 hours, accelerating skin breakdown.
For the skin to heal, her mobility needed to improve to where she could use the commode. She also needed to be repositioned every 2 hours, as is common with obese patients, to prevent skin erosion and pressure sores and administer perineal care, a process requiring 4 to 5 staff members.
Several obstacles arose in caring for this patient, requiring the interdisciplinary team to collaborate on a care plan. They wanted to move her to the bathroom using the bariatric shuttle chair or wheelchair, but her short legs could not reach the floor so she could stand. She fell when using the standing feature, and the staff decided this was unsafe. Nor could they use the inflatable slide board, because even belting her in provided insufficient stabilization. They tried using the mechanical transfer lift, with 5 staff members moving her to the sling, but she found the sling painful. Her girth prevented her from fitting comfortably in the wheelchair or the shuttle chair, and she could not reach the shuttle chair’s foot supports. Both were intolerably painful.
The patient asked to use a standard hospital bed, which is closer to the ground. The staff medicated her before moving her to the lift and then the wheelchair. With coaching on how to rise from the wheelchair and help from 2 canes, a nurse, and a physical therapist, she stood and walked safely to the standard bed.
She could then move from the bed to the bathroom on her own. Its firmer mattress let her reposition herself and sit up unassisted. Skin integrity rapidly improved, allowing the patient to return home after 2 days, rather than to a rehabilitation center as indicated in the initial care plan.
The authors noted that “bariatric technology is not always the solution.” Resolving this patient’s issues required close cooperation with other staff and listening actively to the patient’s concerns, as well as being flexible and thinking critically.
As obesity rates climb in the United States, with more than 35.5% of women considered obese in 2009, and as our population ages, oncology nurses will likely encounter more obese or morbidly obese patients. Awareness of and sensitivity to their concerns are critical. The relationship with the patient must take priority, with a care plan tailored to the patient’s unique needs (Sidebar). As new assistance devices become available, facilities and practices should take a proactive approach in preparing to care for more morbidly obese patients.
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