5 replies to this topic

[aussie-margaret]

Hi,
I have not seen a patient this size before in my nursing career (21 years) - a woman from a nursing home - a diabetic who reportedly weighs 178 kilos , probably more, which I think is close to 400 lbs.

The patient has multiple medical problems as you can imagine,
I have not seen it, but has a large Pressure area sinus and a large area around it, looking like it could break down. I am working nights, so thankfully don't have to do the dressing.

Now last night this patient proved impossible to do anything for. THe patient is on a air mattress and a hover-mat to be moved, but even with 4 nurses and a wardsman, could not be moved much. THe patient is so large she cannot physically be turned on the bed from side to side as the pt touches either side of the bed she is so huge, and all we could do last night was get a couple of pillows under one side to try to get some pressure of the bottom. And the patient won't help in any way, either.

Asked the morning in-charge about a wider bed, and they are available ( I have never seen one used), but as this is an old hospital, it can't be gotten out of the room in an emergency, as the doorways are smaller, so the in-charge did not think it was feasable.

I know that Australians are following Americans in obesity, so can you share some tips in managing this type of patient that you cannot physically do anything for due to the size, and you know that the pressure area problems are likely to worsen as you cannot turn the patient. The patient came from the local nursing home with the pressure area, so it seems they could not cope either.

The last one I saw with a sizeable pressure area - relatives had tried to care for the woman at home without success - died from sepsis. THis patient has MRSA as well as all the other medical problems, and the smell from the wound is disgusting.

the staff want this patient reviewed and written up as 'not for resusitation'.

What can you write in the progess notes, and how can you document that it is almost impossible to do anything due to the size of the patient and there simply is not enough room on the bed to turn the patient.
The night supervisor reckoned the specialist wanted to take the pt to theatre to debride the pressure area, but the pt would have to be done at a larger hospital with better facilities (who are not going to be exactly thrilled about getting a patient like this transferred I am sure), and that no anaethetist would touch this patient anyway. I can't even imagine how a pt this size would be managed on the operating theatre table.

Any suggestions about how to protect oneself legally in a situation like this

thanks

[ladybugj]

first, document everything! attempted to turn patient with 4 nurses, 1 wardsman and hoyer lift; note the bed leaves little room to turn pt, larger bed would be ideal, but question if it would be safe in the case of an emergency. next contact your social worker, case management and ethics committee regarding the issues of bed, wound care and continued care. consulting the psychologist may be a help to the patient as she may be suffering from depression, dimentia or some other psychological disorder contributing to her size. as for her being "dumped" to another, larger, hospital...last i thought, we were suppose to be in this profession for the patient's benefit. it will not be easy or even pleasant to care for her, but if it is in her best interest it is what needs to be done.

the best i can offer for australians following americans in the fight with obesity is prevention and education. this poor lady may not have the opportunity, ability or will to recover, but to counsel other patients seen heading in that direction, getting early intervention will save someone else.

good luck and keep us posted

[NawlinsGirl]

Ladybug is right, intervention from all aspects is going to be crucial for this lady and last but not least excellent documentation is going to be essential. Ive seen a patient that weighed more than 600 lbs in the MICU at the facilty I use to work. They obtained a bed called the "Big Boy Bed". It gave her the room she needed and the bed assisted in turning her plus it had a special mattress to prevent further breakdown. For whatever reason people get to this point, it could be medical or psychological , we have an obligation to do whatever we can to take care of them. Its not easy ,but all we can do is our best as in any patient we come in contact with.

[3boyzmom]

Document, document, document all the efforts you make to care for the patient. As far as transferring the patient to another facility, it's not dumping if you are transferring to a facility that can provide a higher level of care than you can. If your building can't accommodate the Big Boy bed due to door widths, etc., it's possible that it's in the patient's best interests to transfer her.

Chances are you aren't going to miraculously impact the patient to lose weight and become fit and healthy. But all you can do is the best you can do, and we have to just keep on doing it even when it seems futile.

[aussie-margaret]

update

I was on days off but heard

patient's pressure area broke down further
patient deteriorated
transferred to High Dependency and later died

[3boyzmom]

That is sad. Sounds like the cards were stacked against her, though.