NRS 410V Week 5 Discussion Question, Case Scenario

Case Scenario

Mr. C., a 32-year-old single man, is seeking information at the outpatient center regarding possible bariatric surgery for his obesity. He reports that he has always been heavy, even as a small child, but he has gained about 100 pounds in the last 2–3 years. Previous medical evaluations have not indicated any metabolic diseases, but he says he has sleep apnea and high blood pressure, which he tries to control with sodium restriction. He current works at a catalog telephone center.

Objective Data

1. Height: 68 inches; Weight 134.5 kg
2. BP: 172/96, HR 88, RR 26
3. Fasting Blood Glucose: 146/mg/dL
4. Total Cholesterol: 250mg/dL
5. Triglycerides: 312 mg/dL
6. HDL: 30 mg/dL

Critical Thinking Questions

What health risks associated with obesity does Mr. C. have? Is bariatric surgery an appropriate intervention? Why or why not?

Mr. C. has been diagnosed with peptic ulcer disease and the following medications have been ordered:

1. Magnesium hydroxide/aluminum hydroxide (Mylanta) 15 mL PO 1 hour before bedtime and 3 hours after mealtime and at bedtime.
2. Ranitidine (Zantac) 300 mg PO at bedtime.
3. Sucralfate/Carafate 1 g or 10ml suspension (500mg / 5mL) 1 hour before meals and at bedtime.

The patient reports eating meals at 7 a.m., noon, and 6 p.m., and a bedtime snack at 10 p.m. Plan an administration schedule that will be most therapeutic and acceptable to the patient.

1. Assess each of Mr. C.'s functional health patterns using the information given. (Hint: Functional health patterns include health-perception – health management, nutritional – metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception – self-concept, role-relationship, sexuality – reproductive, coping – stress tolerance.)
2. What actual or potential problems can you identify? Describe at least five problems and provide the rationale for each.

Some health risks associated with Mr. C’s obesity are increased BP (hypertension), sleep apnea, elevated cholesterol, elevated triglycerides and possible start of diabetes (due to increase glucose levels) (Lewis, 2011). Mr. C needs to lose weight or he will be a diabetic and have cardiovascular disease. It is clear that with the glucose levels being what they are, he is already pre-diabetic already. Mr. C needs to lose weight to prevent himself from becoming diabetic and to decrease his hypertension. Mr. C would benefit from have bariatric surgery, since his is already morbidly obese. If he were to lose weight, he could decrease his chance from becoming a diabetic and or having possible heart attack. There is a high reduction in mortality rates with bariatric surgery. There is a significant improvement in those diseases that are caused or worsened by obesity, including: blood pressure, diabetes, and heart disease, and stroke (ASMBS, 2016). There is still a need for Mr. C to undergo some counseling to help change his lifestyle. Mr. C has gained 100 pounds within 2-3 years; there is clearly a need to educate Mr. C on good eating habits and better lifestyle choices.

Mr. C’s medication schedule should be as follows:

6:00am – Sucralfate/Carafate

7:00am – Breakfast

10:30am – Mylanta and Suralfate/Carafate

12:00pm – Lunck

3:00pm – Mylanta

5:00pm – Sucralfate/Carafate

6:00pm – Dinner

9:00pm – Mylanta and Sucralfate/Carafate

10:00pm – Snack

11:30pm – Bedtime – Zantac, Mylanta, and Sucralfate/Carafate

When assessing Mr. C’s functional health patterns, it is important to look at the following:

Health – Pereption – Health – Management: It is very clear that Mr. C is at risk for serious diseases. Mr. C needs to be educated on a good/healthy diet. I believe that Mr. C would benefit from counseling to help him with better lifestyle choices.

Nutritional – Metabolic – Mr. C would benefit from a healthier diet that would include vegetables, proteins, whole grains and including portion control to help maintain a healthier weight and better LDL’s, HDL’s and triglycerides.

Elimination – Mr. C would benefit from being educated on increasing water intake and fiber in his diet to help promote elimination. This would help to keep Mr. C on a more regular bowel movement schedule.

Activity –Exercise – It currently sounds like Mr. C is not including any exercise or activity in his daily life. I would be best that Mr. C is setup on a exercise program that starts out slowly and gradually increased as he becomes more accustom to exercising. This would help Mr. C with his cholesterol issues/problems, to help decrease them.

Sleep – Rest – Mr. C is currently having sleep apnea already. If he were to decrease his weight and become more active, I believe that this would help Mr. C to get into a better sleep habit and possibly help his sleep apnea. If this does not help, then Mr. C would need to get a C-PAP machine to help eliminate this problem.

Cognitive – Perceptual – Mr. C is able to understand that he has gotten himself into a bad situation and now he is seeking help to decrease his weight in hopes of becoming healthier.

Self – Perception – Self Concept – Mr. C stated that he has been overweight his whole life, this indicated that he has always felt abnormal. It is possible that Mr. C feel depressed and/or has negative feeling about himself. This is a good reason for Mr. C to have some counseling. Being overweight your whole life becomes a habit/pattern. It is very important to break this pattern or habit and start new healthier habits to promote health. Otherwise, Mr. C can have all the surgical procedures he wants and it will never change, he will always be prone to becoming overweight again.

Role/Relationship: Mr. C is not currently in a relationship. There is no indication of family support.

Sexuality/Reproductive: Mr. C views himself as being overweight his whole life and he is not currently in a relationship. If Mr. C completed this surgery and started living a healthier lifestyle, he may build his confidence up and feel as if he would be in a relationship now.

Coping/Stress Tolerance: Mr. C has been overweight his whole life, this also indicated that he has not had good coping skills. If Mr. C would undergo counseling, this would also be a section that could be investigated further to help Mr. C buildup better coping skills in dealing with stress in a more positive ways other than eating as a way of dealing with stress.

There are some Actual and potential problems that Mr. C is facing.

Acutal:

Diabetes – fasting glucose of 147, this indicates that Mr. C is pre-diabetic or already has diabetes. Further test would be needed, like an A1C to indicate a longer period of time to show what the blood sugar has been doing.

Sleep apnea

Hypertension

SOB

Potential:

Heart Attack – Due to Mr. C’s cholesterol and hypertension, he is at risk for heart attack.

Stroke – Due to Mr. C’s cholesterol, he is at risk for stroke.

CAD – Mr. C is at risk for CAD due to his cholesterol, hypertension and diabetes.

Kidney disease – due to diabetes this will affect the kidney function over time.

Death – If Mr. C does not lose weight then he is at risk of dying early in life with all the issues stated above. 

References:

American Society for Metabolic and Bariatric Surgery. (n.d.). Retrieved November 08, 2016,

            from https://asmbs.org/

Lewis, S. M. (2011). Medical-surgical nursing: Assessment and management of clinical

            problems. St. Louis, MO: Elsevier/Mosby.

Advantages and disadvantages of gastric bypass:

Advantages

1.       Produces significant long-term weight loss (60 to 80 percent excess weight loss)

2.       Restricts the amount of food that can be consumed

3.       May lead to conditions that increase energy expenditure

4.       Produces favorable changes in gut hormones that reduce appetite and enhance satiety

5.       Typical maintenance of >50% excess weight loss

Disadvantages

1.       Is technically a more complex operation than the AGB or LSG and potentially could result in greater complication rates

2.       Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron, calcium, and folate

3.       Generally has a longer hospital stay than the AGB

4.       Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance

Here are some advantages and disadvantages to the sleeve gastrectomy procedure:

Advantages

1.      Restricts the amount of food the stomach can hold

2.      Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. Weight loss of >50% for 3-5+ year data, and weight loss comparable to that of the bypass with maintenance of >50%

3.      Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB)

4.      Involves a relatively short hospital stay of approximately 2 days

5.      Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety

Disadvantages

1.      Is a non-reversible procedure

2.      Has the potential for long-term vitamin deficiencies

3.      Has a higher early complication rate than the AGB

Adjustable Gastric Band

The Adjustable Gastric Band – often called the band – involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band, and the rest of the stomach below the band.

Advantages

1.      Reduces the amount of food the stomach can hold

2.      Induces excess weight loss of approximately 40 – 50 percent

3.      Involves no cutting of the stomach or rerouting of the intestines

4.      Requires a shorter hospital stay, usually less than 24 hours, with some centers discharging the patient the same day as surgery

5.      Is reversible and adjustable

6.      Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedure’s

7.      Has the lowest risk for vitamin/mineral deficiencies

Disadvantages

1.      Slower and less early weight loss than other surgical procedures

2.      Greater percentage of patients failing to lose at least 50 percent of excess body weight compared to the other surgeries commonly performed

3.      Requires a foreign device to remain in the body

4.      Can result in possible band slippage or band erosion into the stomach in a small percentage of patients

5.      Can have mechanical problems with the band, tube or port in a small percentage of patients

6.      Can result in dilation of the esophagus if the patient overeats

7.      Requires strict adherence to the postoperative diet and to postoperative follow-up visits

8.      Highest rate of re-operation

Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Gastric Bypass

The Biliopancreatic Diversion with Duodenal Switch – abbreviated as BPD/DS – is a procedure with two components. First, a smaller, tubular stomach pouch is created by removing a portion of the stomach, very similar to the sleeve gastrectomy. Next, a large portion of the small intestine is bypassed.

Advantages

1.      Results in greater weight loss than RYGB, LSG, or AGB, i.e. 60 – 70% percent excess weight loss or greater, at 5 year follow up

2.      Allows patients to eventually eat near “normal” meals

3.      Reduces the absorption of fat by 70 percent or more

4.      Causes favorable changes in gut hormones to reduce appetite and improve satiety

5.      Is the most effective against diabetes compared to RYGB, LSG, and AGB

Disadvantages

1.      Has higher complication rates and risk for mortality than the AGB, LSG, and RYGB

2.      Requires a longer hospital stay than the AGB or LSG

3.      Has a greater potential to cause protein deficiencies and long-term deficiencies in a number of vitamin and minerals, i.e. iron, calcium, zinc, fat-soluble vitamins such as vitamin D

4.      Compliance with follow-up visits and care and strict adherence to dietary and vitamin supplementation guidelines are critical to avoiding serious complications from protein and certain vitamin deficiencies

References:

American Society for Metabolic and Bariatric Surgery. (n.d.). Retrieved November 08, 2016,

            from https://asmbs.org/