Morbid obesity and spinal cord injury: a case study.

With obesity on the rise in the United States, most nurses will probably encounter the unique challenges that result from the pathophysiological changes in this population. The combination of morbid obesity and any other disease process or injury create complex medical management issues for caregivers during hospitalization and after discharge. Complications of spinal cord injury are intensified with obesity. Prevention and treatment of secondary complications require nursing practice to go above and beyond the standards of care. This paper clearly illustrates the nursing challenges by focusing on the experience of caring for a morbidly obese person who sustained a C5-6 spinal cord injury. Complications unique to this patient, as well as adjustments in care, will be discussed with a main focus on the acute rehabilitation phase. Ms. Z. is a 24-year-old female who worked as a home health aide. One cold winter day, as she was driving to a client's house, she lost control of her truck and struck another vehicle. The result of Ms. Z.'s accident was a C5-6 complete spinal cord injury (SCI), which would be complicated by her weight of more than 400 pounds. When the accident occurred, Ms. Z. was not wearing a seatbelt and had not worn one since age 12 because they did not fit. In fact, it is reported that obesity is associated with decreased seat belt use (Lichtenstein, Bolton & Wade, 1989). It took an hour to extricate Ms. Z. from the truck. She was then flown via Mayo One life support helicopter to our Type I Emergency Trauma Unit/Center. There she received methylprednisolone 4.8 gm i.v./1 hour followed by 22 cc/hr or 5.4 mg/kg over 23 hours. After medical personnel made assessments, they sent her to the operating room for cervical fusion. Ms. Z.'s obesity complicated positioning, X-ray, draping, and all facets of the operative procedure. Ms. Z. was in the intensive care unit (ICU) for six weeks, where she faced more complications that included: prolonged ventilator dependence; right upper lobe collapse; three episodes of asystole after being turned; a midback adipose fold wound; and urinary tract infections. Members of the rehabilitation team (physicians, nurses, physical therapists, occupational therapists, and a psychologist) became involved in her care at the beginning of her ICU stay. Early intervention by the rehabilitation team was essential to provide Ms. Z. with collaborative care and to eventually ensure an adequately prepared transition to the rehabilitation unit while maintaining continuity of care. Innovative planning for Ms. Z.'s transition to rehabilitation and mobilization included careful selection of beds, wheelchairs, and lifts to accommodate her weight and body size.