Nursing Diagnoses

What exactly is a "nursing diagnosis"? Isn't the doctor the one who diagnoses people? Well, yes. The term "nursing diagnosis" can be a little misleading, and indeed, was very confusing to me when I first started nursing school. A nursing diagnosis is not the same thing as a medical diagnosis - it is not the formal labelling of a patient's condition. That's a physician's job - to assess the patient and figure out what the problem is. The nurse's job is to assess the patient and figure out what practical problems they may face. For example, if a patient has a history of dizziness and is taking a medication that makes them sleepy, a possible nursing diagnosis would be "at risk for falls". This is not a medical diagnosis, but rather a statement of a problem the patient may face that the nurse can intervene in and work to prevent or relieve. It's basically a way for nurses to critically consider how they will care for their patients, and what interventions should take priority.

A nursing practice guideline found here offers a list of possible nursing diagnoses for an obese patient. Five of these nursing diagnoses are below:

• Imbalanced nutrition: more than body requirements
• Knowledge deficit
• Ineffective Health Maintenance
• Activity intolerance (related to impaired mobility)
• Sedentary Lifestyle

 The chart below further explores the first nursing diagnosis.

Nursing diagnosis: Imbalanced nutrition: more than body requirements
Actual or potential problem	Actual problem. For this hypothetical patient, it has already been demonstrated that they consume more calories than their metabolism requires. A potential problem would be described in a nursing diagnosis as “at risk for _____”
What is the problem related to?	This may be related to several issues which we have already discussed. Imbalanced nutrition may be related to deficient knowledge, cultural habits, and limited access to fresh foods.
Plan and desired outcome	Discuss the patient’s current dietary habits. Educate the patient concerning their body’s metabolic needs, how this relates to losing weight (decreasing calorie intake prompts the body to metabolize fats for energy), and how to use a tool like the MyPlate Food Tracker to assess and maintain a balanced diet. Desired outcome is gradual, consistent loss of weight (about 1-2 pounds per week) through a balanced and calorie-limited diet.
Nursing intervention	Provide the education and conversation discussed above, as well as encouragement and continued support during this difficult lifestyle change. Promote enrollment in a cooking class to increase patient’s confidence in preparing healthy meals. Offer information on any local weight loss support groups, particularly ones focusing on proper nutrition.

 

 

 

Nursing Interventions

Nurses have two main roles in treating obesity - education and support. Education might consist of discussions of the potential impact of obesity on health, a safe calorie restricted diet, guidelines for exercise, recommendations for assessing personal hydration, reasonable expectations for a weight loss timeline, and access to resources for additional support or counsel. Support addresses the psychosocial aspects of obesity - patients must feel accepted and not disrespected by their health care providers. As a sort of chronic disease, obesity requires long-term treatment and frequent check-ups. This is not a one-stop visit sort of thing, it requires coordination of care and initiative to maintain contact with patients.

Another important role for nurses is to assess the patient's situation - how they perceive their own weight and health (and how others close to them perceive these things), what their habits are, how they go about their daily life, and if they are impaired in any way by their weight. From this initial assessment, the nurse may be able to begin considering interventions to work with the patient's specific needs - for instance, if a patient recognizes that they binge eat when they are emotionally distressed, the nurse may work to redirect that habit to something less harmful, like calling a friend to talk or doing a calming mental exercise. Or the nurse may discover that a patient doesn't exercise because they have poor vision and fear tripping in their living environment. The nurse may arrange for an optometrist appointment to update glasses prescriptions, and a home visit to assess the safety of the home.

Another significant role of nurses in fighting obesity is preventing it. Every patient that a nurse sees is an opportunity for education in the importance of maintaining overall health through appropriate diet and exercise. Even small steps in the right direction make a big difference.

Of course, none of this is straightforward or easy, otherwise obesity would likely not be the problem that it is. Nurses can participate in research of the issue to promote better understanding of how obesity can be treated and how it may be prevented.

Lewis, S. L. (2014). Obesity. In Harding M. M. (Eds.), Medical-Surgical Nursing - Assess and Management of Clinical Problems. (pp. 906 - 922). St. Louis, Elsevier.

Treatment.

"How can I lose weight?" It seems to be the central question of the last few decades in the much of the Western world. Weight loss theories are everywhere in the media - online, on TV, in the news, on talk shows, in magazines, on library bookshelves, in doctors' offices, at Subway. There's always a new diet or workout or magic pill to try. There are entire TV series dedicated to watching people lose extreme amounts of weight.

 

There are currently three central strategies for combating obesity - weight loss through diet and exercise (lifestyle changes) first and foremost, then medication, then surgery.

 Lifestyle Changes
The National Heart, Lung, and Blood Institute has several recommendations for weight loss through diet and exercise. The recommended healthy rate of weight loss is 1-2 pounds per week.

• Calorie restriction - the number of calories consumed usually needs to be reduced by 500-1000 calories per day. For women, this usually means 1000-1200 calories per day, and for men this usually means 1200-1600 calories per day. An important part of this is portion control - this means eating one piece of toast rather than three.
• Food choices - avoid saturated and trans fats, cholesterol, and excess sodium (these are found in red meats, egg yolks, and processed foods). Choose low fat dairy products (yogurt, milk, and cheese), proteins (lean meats, fish, beans), whole grains (oatmeal, whole grain bread and pasta), and plentiful fresh or frozen fruits and vegetables.
• Physical Activity - to lose weight, it is recommended to exercise at moderate intensity for 300 minutes each week. This exercise can be broken up into 10 minute chunks.
• Change Leisure habits - Reduce the amount of leisure time spent watching TV or on the computer.
• Reward success - set small goals (losing the first ten pounds, eliminating soda, making it to the gym every day for a week) and reward them as you meet them. The reward should not be food, but rather something like a massage, a day trip, or watching a good movie.

One good tool for considering which foods to eat is the USDA "My Plate". It provides some visual perspective on portion size and food groups.

 

ChooseMyPlate.com also has a feature called the SuperTracker, which allows you to enter in all the food you eat in a day and then visually shows your what your diet is in relation to recommended daily food intake. It is based on the standard guideline of 2000 calories per day, but still provides good feedback on whether you're actually eating enough vegetables or not, or if that granola bar is really as healthy as it claims to be. I used the SuperTracker tool to track my food intake for several weeks as a part of a nutrition class, and was surprised to discover that I generally eat too much sodium and not enough whole grains or vegetables.

 

Regardless of the recommendations, it is an immense challenge to lose weight. In order for weight loss to be permanent, there must be a lifestyle change. This is why fad diets fail - they cause intense amounts of weight loss because they are so extreme, but they aren't sustainable in the long run, and so people return to their previous habits and gain the weight back. It is incredibly difficult to change one's lifestyle permanently, especially if your family or culture functions differently than your goal. As I mentioned earlier, food has great cultural and personal significance for many people. I can't eat my mom's molasses cookies without thinking of Christmas and all the happy times associated with it. They are more than just fat and sugar and empty calories - they are a memory that I can participate in every time I eat them. When all the treasured family recipes are heavy in fat and sodium and light on fresh produce, it can feel like treachery to tweak the recipe or try something new. This is why social support is so significant in weight loss, and why obesity is so much larger than just a medical problem - it is a social problem, affected by many interwoven systemic causes.

 

Medications

There are several approved medications available for weight loss. They are usually not prescribed unless the patient has tried lifestyle changes for at least six months without significant weight loss. It's also important to note that these medications are to be used in addition to lifestyle changes. There is no magic pill that will cause maintainable weight loss without changes in nutrition and exercise. One category of weight loss drugs works by blocking the enzyme that allows for fat to be digested, effectively reducing the calories that the body absorbs. Another class of drugs works on receptors in the brain to reduce appetite. All medications have side effects, and must be prescribed and monitored by a doctor.

 

Surgery

The final medical intervention for obesity is surgery. This is reserved for people with extreme obesity (with a BMI of 40 or higher) or moderate obesity with significant health consequences like sleep apnea or diabetes. Reasonable attempts and lifestyle changes like diet and exercise are required before surgery will be considered.

 

 





 The basic function of weight loss surgery is to reduce the size of the stomach or the amount of food the stomach can hold, forcing people to eat less, more frequently, and more slowly. Surgery is usually effective, but can have serious side effects.

Signs and Symptoms

Signs are the effects of disease that a health care worker can note in their assessment (bruising, body shape, blood sugar, lung sounds, heart rate, etc). Symptoms are the patient's experience of a disease, and what they can report to a health care professional (pain, shortness of breath, changes in appetite or mood, difficulties moving, etc).

The central signs of obesity are body shape and BMI, as I discussed in a previous post. The patient's experience is usually not so straightforward. Weight gain is generally very slow, and so people may not realize how much their weight has increased until the day that they can't button their jeans anymore.

This video does a nice job of demonstrating how different things might be if significant weight gain was instant. An extra ten or twenty pounds makes a more noticeably significant impact when people don't have weeks and months to get used to the change.

 

 

Another result of obesity that can have an even more significant impact on people than just having to find bigger clothes is a sense of social stigmatization. Overweight is not the cultural standard of beauty - in fact, underweight often is. With new diets always surfacing, frequent news reports on America's obesity epidemic, and the judging glances of strangers, it is easy to understand how heavy social burden is that obese and overweight people carry. This symptom of obesity must not be overlooked. 

Diagnosis

Obesity is usually diagnosed with a simple calculation of Body Mass Index (BMI). The equations used to calculate BMI and more visual BMI chart are below:

http://fatweightlossguide.com/wp-content/uploads/2012/07/bmi-formula.png

http://kah.net.in/images/bmi%20chart.jpg

 



A BMI between 18.5 and 24.9 is categorized as normal. Less than 18.5 is underweight, greater than 25 is overweight, and greater than 30 is obese. A BMI that is greater than 40 (the top right part of the chart) is morbid obesity (Lewis, 2014, pp. 906).

 

As I discussed in my first post, BMI does not always accurately represent a person's body fat content or health risks. A muscular athlete usually weighs more than a normal person of their height, and so their BMI may indicate that they are overweight or obese. My father's BMI would classify him as obese, but he has low to normal blood pressure and is in good health. BMI may underestimate obesity in elderly people, because they have decreased overall body mass. Despite these inaccuracies, BMI is still the most used categorization of body weight.

 

Other measures of obesity-associated health risks include waist circumference and waist-to-hip ratio. Both of these measures reveal the distribution of fat in the body. Visceral fat in the abdominal cavity is increases health risks more than subcutaneous fat. Simple assessment of body shape can often reveal distribution of fat - gynoid (pear) shape is associated with a better prognosis than android (apple) shape (Lewis, 2014, pp. 907-908).

 

Children have a slightly different categorization of weight. "Overweight status is defined as an age- and gender-specific body mass index (BMI) between the 85th and 94th percentile based on the 2000 Centers for Disease Control and Prevention Growth Charts for the United States. Obesity is defined as an age- and gender-specific BMI at or above the 95th percentile for children of the same age and sex" (Hockenberry, 2015, pp. 728).

 

Lewis, S. L. (2014). Obesity. In Harding M. M. (Eds.), Medical-Surgical Nursing - Assess and Management of Clinical Problems. (pp. 906 - 922). St. Louis, Elsevier.

 

Hockenberry, M. J. (2014) Health Problems in the Adolescent. Wong's Nursing Care of Infants and Children. (pp. 727 - 737). St. Louis, Elsevier.

 

 

Etiology & Pathophysiology

...that is to say, why does obesity exist & how does it work?

The physiologic causes of obesity (etiology) are somewhat straightforward, but why obesity exists in such large scale is not yet understood. At its most basic level, obesity is an energy imbalance - the body is not burning as much potential energy (metabolism & exercise) as it consumes (food), and so that energy is stored (as fat). When this imbalance persists for a long time, fat stores eventually become much larger than the body needs.

There are two types of obesity - primary and secondary. Primary obesity is the most common form - it occurs when someone consumes many more calories than their body uses. Think of it as too much energy available. Secondary obesity occurs because the body doesn't use enough energy in its daily functioning. This isn't necessarily related to someone just not exercising, though of course that would make the problem worse. Secondary obesity can be caused by abnormal metabolism function (as in hypothyroidism), defects in a chromosome, or a problem with the central nervous system (Lewis, 2014).

Because primary obesity represent the majority of cases, that is what I will focus on. There are many factors to consider as to why people become obese.

One component is genetic - based on their inherited genes, some people are much more likely to become obese.

http://www.acneeinstein.com/wp/wp-content/uploads/2012/05/acne-genes.jpg



 

Genetics impact how our body stores and uses energy. In more ancient times, genes that promoted energy storage were favorable - this increased the chances of surviving famines. In modern American culture, the great abundance and cultural significance of food makes a genetic predisposition to storing energy unfavorable. "Estimates of obesity as an inherited problem are more than 50%" (Lewis, 2014). However, unless these genes cause a form of secondary obesity, it is likely that genetics alone only increase susceptibility to obesity - behavior (diet and exercise habits) still play a significant role (CDC, 2012).  

 

The environment also has an impact on obesity's development. Food, especially processed foods, is easily accessible and very visible in the Western world.

 

http://sphweb.bumc.bu.edu/otlt/MPH-Modules/PH/NutritionModules/Dietary_Self_Assessment/PortionDistortion.png

 



Portion sizes have increased, and empty calories are readily available at every gas station and food mart. Often these processed foods are cheaper to buy in bulk than fresh foods, and so people with lower income may resort to eating less nutritious foods to save money. Neighborhoods may be unsafe for outdoor activity, and transportation to grocery markets that sell fresh foods may not be reliable. Many jobs are sedentary, and much free time is spent watching TV or on social media.

 

There are cultural and social elements that promote overconsumption of foods. Food is symbolic - the average American cannot look at a Thanksgiving spread and think only of nutritional value. It is associated with family, reward, celebration, comfort, home.

 

 

These pleasurable associations with food can result in overeating in times of stress or discomfort. "When overeating develops at an early age and continues into adulthood, one's ability to sense fullness (satiety) is compromised. Whether triggered by specific food or by the wide variety of choices, some people consume more food than their bodies need. The lack of hunger that drives eating has been termed "mindless eating" and leads to consumption of unnecessary calories and increase in body weight" (Lewis, 2014, pp. 910).

 

Finally, there are hormones and signaling proteins called peptides which play a role in appetite. Ghrelin is made by the stomach after it has been empty for a while, prompting hunger. Ghrelin levels decline when food is in the stomach. In obesity, ghrelin levels do not decline with food intake, and so the body doesn't have the sensation of fullness when it normally would. Leptin is made by fat cells, and suppresses hunger. In obesity, leptin levels are actually increased, meaning that obese people likely have a resistance to leptin and can no longer feel its effects (Lewis, 2014, pp. 909)

 

As fat cells increase in size and number to the point of obesity, the body faces many increased health risks. These include heart disease, sleep apnea, asthma, high blood pressure, type 2 diabetes, chronic kidney disease, and many other health problems. I will discuss these in greater length in a future blog post.

 

Lewis, S. L. (2014). Obesity. In Harding M. M. (Eds.), Medical-Surgical Nursing - Assess and Management of Clinical Problems. (pp. 906 - 922). St. Louis, Elsevier.

Centers for Disease Control and Prevention. (2014). Overweight and Obesity - Data and Statistics. [Graphic Illustrations]. Retrived from http://www.cdc.gov/obesity/data/prevalence-maps.html

 



Epidemiology

Epidemiology might be a rather intimidating word, but it just means the study of how often and where a certain disease happens. Researchers keep track of this information for everything from malaria to whooping cough to concussions, then using the data to assess patterns or trends (whether certain locations are more affected, or a certain disease is occurring more often).

The Centers for Disease Control (CDC) is a very important organization that gathers and manages the majority of this information in the United States.

 

 

This animation shows adult obesity rates from 1985-2010. There is a clearly apparent trend of increasing obesity rates. In just a 25 year span, this country has gone from most states have rates lower than 15% to all states having rates above 20%, often even more than 30%. 

 

This CDC chart gives a picture of where we are now - the rates of self-reported obesity in American adults from 2011-2013. None of the states had rates of less than 20%. In the orange and red states, approximately one out of every three adults is obese. It's important to remember that this is obesity rates - the rates of overweight adults are even higher.

Obesity in Hispanic Adults

Obesity African Adults 

 Obesity in Non-Hispanic White Adults



The CDC's data reveals that there are disparities between obesity rates when the results are analyzed by race. Non-Hispanic White adults (on the bottom) have generally lower rates of obesity than Hispanic Adults (on the top) and African Americans (in the center).  There are also trends relating lower income people with higher rates of obesity. There are several key factors that may explain these disparities, but we'll save that discussion for another blog entry.

 

Obesity is associated with many increased health risks, including:

• Type 2 Diabetes - over 80% of people with Type 2 Diabetes are obese or overweight (Lewis, 2014, p. 910).
• Hypertension - high blood pressure
• Coronary Artery Disease - this disease is associated with significantly increased risk of heart attack
• Sudden Cardiac Death
• Cardiomyopathy - defects in the heart muscle cells
• Right-sided heart failure
• Mentrual Irregularities
• Infertility
• Sexual Dysfunction
• Sleep Apnea
• Asthma
• Pulmonary Hypertension - high blood pressure in the lungs
• Arthritis
• Chronic low back pain
• Cancer - "About 20% of cancers in women and 15% in men are attributable to obesity" (Lewis, 2014, p. 911)

Because of these many increased health risks, the risk that someone who is obese will die is increased by 50-100%, compared with someone who is a normal weight (Lewis, 2014, p. 910). These health risks can also lead to a decreased quality of life - when people are obese, they may not be able to live life as they wish to in the moment.

 

Obesity is a significant, complicated dilemma, and it requires serious attention.

Braqdy, Heather. (2013). Watch the Country Get Fatter in One Animated Map. [Gif]. Retrived from http://www.slate.com/articles/news_and_politics/map_of_the_week/2013/04/obesity_in_america_cdc_releases_gif_of_epidemic_over_time.html

Lewis, S. L. (2014). Obesity. In Harding M. M. (Eds.), Medical-Surgical Nursing - Assess and Management of Clinical Problems. (pp. 906 - 922). St. Louis, Elsevier.

Centers for Disease Control and Prevention. (2014). Overweight and Obesity - Data and Statistics. [Graphic Illustrations]. Retrived from http://www.cdc.gov/obesity/data/prevalence-maps.html