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The Complexities of Plus Size Management
Anita Rush
© Anita Rush 2015
THE COMPLEXITIES OF PLUS SIZE MANAGEMENT
Anita Rush MSc (Health Ergonomics) Dip Health Care Studies RGN
Clinical Nurse Specialist - Equipment email: [email protected]
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The Complexities of Plus Size Management
Anita Rush
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Introduction Plus Size refers to:- Mediatric
Bariatric
Guiding principles:-
Managing the foreseeable risk
Reduce the potential exposure hazards
Safety and harm free care
Integrated person centred approach
Education and communication
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Definition An organisational policy may define a bariatric person differently e.g.
• A person whose weight and dimensions are over the safe working load of routine equipment
• A person whose weight and size restricts their ability to access health and social care, due to:-
Limitations on movement and the ability to travel to local or specialist centres
Difficulty with access and egress to buildings
Inability to gain an accurate diagnosis
A reluctance to seek advice from health and social care professionals
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Prevalence within the local, UK and World Population
Estimated Number of Obese Men 2003 and 2010, by Region
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Human Consequences
Reduced mobility and functioning
Discrimination
Increased morbidity and mortality
Reduced body image
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NHS costs
£10 billion
2050
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Economic cost
£49.9 billion
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Body Shape - Somatotypes
Apple shaped:
Android
Pear shaped:
Gynoid
Proportional Bulbous Gluteal
Reproduced with the kind permission of National Back Exchange
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Organs affected
Source Peate. I 2005
Daily Mail 7 December 2010
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Balanced Decision Making
Health and Safety at Work Act 1974 miscellaneous regulations 2002 (HSE,1974)
Management of Health and Safety at Work Regulations 1999
Lifting Operations and Lifting Equipment Regulations 1998a
Provision and Use of Work Equipment Regulations 1998b
Manual Handling Operations Regulations 1992 3rd Edition (HSE 2004)
Human Rights Act 1998
Equality Act 2010 The Occupiers Liability Act 1957
Regulatory Reform (Fire Safety) 2005
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Manual Handling Operations Regulations 1992, as amended 2004
Requirements of Employers:
Avoid hazardous manual handling, so far as is reasonably practicable
Assess the risk, for tasks which can not be avoided
Reduce the risk, so far as is reasonably practicable
Review the risk assessment, in the light of any changes
Provide information on the weight of the load e.g. the person
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Numerical Guidelines for Lifting and Lowering (MHOR 1992) as amended 2004
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Human Rights Act 1998
Article 2 - Everyone’s right to life shall be protected by law
Article 3 - No one shall be subjected to torture or to inhumane or degrading treatment or punishment
Article 5 - Everyone has the right to liberty and security of person
Article 8 - Everyone has the right to respect for his private and family life, his home and his correspondence
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Effective inter-agency communication and working practices with all key stakeholders
A clear definition of a bariatric person and the necessary referral procedures
Clear responsibilities for Directors, Heads of Service, Care Managers and Advisors e.g. Tissue Viability, Back Care
An effective policy - approved, supported and financed by the organisation
Involvement of the patent and family at all stages of health or social care intervention
Provision of necessary equipment and staffing, in a timely manner
A holistic package of care, focusing on the physical, psychological and rehabilitation or treatment aims of the person
Review of the effectiveness of the care or treatment plan
A Person Centred Approach
Systems Approach
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Risk Assessment
The following are required to be assessed:
Task
Individual Capabilities of the handler(s)
Load i.e. Patient
Environment
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Risk assessment
Mobility assessment
Handling activities
Equipment provision
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Task • Increased exertion / force in moving and handling tasks
• Frequent and prolonged physical effort
• Excessive pushing or pulling forces e.g. Moving heavy duty equipment, turning in bed, lateral transfers
• Holding/manipulating limbs at a distance from the trunk e.g. Holding a leg during turning/leg ulcer dressings, holding abdomen to allow access for catheterisation
• Reaching forward e.g. for rolling, turning or lateral transfers; providing personal care on a wider bed
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Twisting or rotation of the lumbar spine – assisting to stand from a wider chair, catheterisation, personal care in bed, wound dressings
Risk of sudden movements – the weight of a distended abdomen suddenly moving during turning; sudden movements to stand / get in or out of bed
Exceptional circumstances – emergency evacuation during a fire, resuscitation, management of the falling or fallen client
Task
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Individual Capabilities
Experience and skill in moving plus size people
Knowledge and training in specialist equipment
Attitude to obesity
Ability to communicate effectively and work as a team
Height, reach and physical strength
Underlying health problems or pregnancy
Clothing and footwear, including protective equipment e.g. Gloves, lead aprons
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Load (Patient) • Accurate or estimated weight? (Research demonstrates a
20% variation)
• Shape, size and distribution of weight
• Presence of lymphoedema
• Neck circumference (Increased neck circumference is linked to metabolic syndrome and a predisposing factor to sleep apnoea (> 37cm for men and > 34cm for women)
• Ability to tolerate lying flat
• Ability to assist with movements and restrictions on movement due to distribution of weight / medical condition
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Load (Patient) Medical diagnosis
Skin integrity and classification of pressure ulcers
Site and level of pain
Patient and family expectations and previous experience of being moved
Treatment and rehabilitation goals
Clothing
Mental capacity and psychological needs
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Equipment Concerns
Equipment design
183kg no restrictions –
270kg with restrictions
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Patient Specific Constraints Linens Patient gown Abdominal binders BP Cuffs Pharmaceutical Dressings Ventilation Continence Catheters for Venous access Environments
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Bed Design
Bed width
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Expanding Bed
Chair beds
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Bed assessment (consider width)
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Head neck position in bed
Posterior scapula adipose deposits around the neck
Ramping improves the laryngeal view, arrange either a medium pillow, flat pad and/or neck roll under the patient’s head until an imaginary horizontal line can be drawn between the external ear and sternal notch space. This provides a supportive surface that ensures safe alignment of the head and neck
Hyperextension is an important position for airway management
Ramping Ear level with sternum. Reduces risk of difficult laryngoscopy, improves ventilation.
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Ramping with pillows
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Concluding: when evaluating beds and mattresses consider:-
Height and width of the bed Safe working load of the bed, to include mattress
weight and health staff caring for the patient Suitability of the bed design Width of the bed enables patient to be turned from
side to side Sustaining Tissue Viability pressure reducing,
reduction Working environment Length of the bed Weight Capacity of side rail support Bed Positioning
Otherwise unsafe practice can occur
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Seating
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Why Prescribe Riser Recliner Chairs? Plus Size persons sleeping surface 24 x7
Independent function
Aid Rehabilitation
Heavy Lymphatic legs
Decreases exertion
Cardiac management
To facilitate postural management
Tissue viability
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Consequences of inappropriate seating
non healing leg wounds
Wound exudate
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Seating Assessment Seat width
Seat depth
Weight capacity - is it:
static
moving
Foam should be high density to prevent compression
Ease of use stable and well balanced
Check arms are in reach
Surface texture facilitate the insertion of slide sheets or slings
Consider BS EN 1022:2005 and BS EN 12520:2010 (strength and stability)
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Consider the Following Approximately 75% of the body weight is taken through
the seated area
Weight of each leg may account for up to 15.7% of persons total body weight
(ref Chaffin D.B, Anderson GBJ, Martin BJ (1999) Occupational Biomechanics 3rd ed New York: J Wiley and Sons)
Knees and hips should be level
Majority of the weight should be over the Ischial tuberosities and buttocks.
Upper half of the posterior thighs with head in midline and balanced over the body
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The Complexities of Plus Size Management
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Potential Challenges Feet dangling in plantar flexion when sat in the chair in an upright
position (can’t bend knees)
Gluteal shelf
Low seat height required
Depth of chair (no head support)
Pannus putting pressure on groin area (non-healing tissue damage)
Cardiac management
Combat fatigue
Prescriber knowledge base
Chairs fit for purpose
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Plus Size Seating Assessment
Look at the body dynamics of the patient
Functional spatial requirements for the person
Where the chair is being used
Environmental constraints
Independent adjustments: (1,2,3,4 motor options)
Configurability of the chair, (i.e. can it be adjusted to meet the varying needs of the person)
Safe working load of all the functional movements
Height width and depth of chair
Arm rest width/height (comprising seat width/safe transfers)
Purpose it is being used for
Tissue Viability Properties i.e. seating leg elevation, tilt in space function
Weight of leg elevation if pannus and legs combined
Recyclability
Otherwise you can disable rather than enable
Hoist and Slings Design and Safety: Impact Weight
Accommodate the weight of a falling patient
As a rule of thumb, a falling patient is double their weight
Designing for Plus Size persons anything designed needs to consider the persons impact weight i.e. 25stone impact weight 50stone.
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The Complexities of Plus Size Management
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Increased Footprint
Storage
Width of room
Width of equipment
Corridors/opening/doors/transport
Home environment
Delivery transportation
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Circulation
Width can it go through doorways
Map route
Where are you going
Manoeuvrability
Number of staff required to move
Stability
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Hoist Design
Slings Types
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The Complexities of Plus Size Management
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Re-positioning/lifting Limbs
It has been identified that the weight of a person’s leg will be 15.7% of the total body weight and an arm 5.1%
(Chaffin et al 1999, Pheasant 1992)
e.g. For a person weighing 190kg, the leg weight would be 190 x 0.157 = 29.83kg
This does not take into account additional weight from conditions, such as lymphoedema
Leg Dressings
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Hoist and slings in evacuation
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Consider the following when using hoists and slings:
• Positioning of the sling • Safe working load of the hoist / sling • Width of the sling bar • Size of the sling: patients dynamics not only height and
weight but shape • Will the position of the patient enable safe transfer on and
off the bed • Does the patient have any ability to assist • Sustaining tissue viability with the use of slide sheets • Attachments • Working Environment. E.g. safe working load of the floor
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Cost Analysis Case study
Patient 216kgs discharge from hospital following a stroke. No potential for rehab and bedbound Care visits: 4 carers 4 times a day Equipment in place:
Overhead hoist Turning bed
Patients family unhappy with the different carers visiting and the intrusion into their family life Trialled motorised repositioning device worked well. Purchased device at a cost of £7,300 Outcome:
• One Carer visit twice a day • Annual saving to Social Services £116,800 • Family well being improved
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Repositioning Equipment
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Wendylett
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Pushing and Pulling of Loads
Slopes and rough surfaces increase the amount of force required to push/pull a load
Risks increase over longer distances and when frequency does not provide sufficient rest/recovery time
Obstacles can create risks by trying to avoid collision
Large amounts of effort increase risks
Repetitive pushing and pulling increases risk
Position of the hands are best placed between the waist and shoulder height
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Pushing Pulling Forces Guideline figure for starting or stopping
a load is a force of about 20kgs
Guideline figure for keeping a load in motion is a force of about 10kg
Guidance exists in relation to gradients (Manual Handling Operations
Regulations amended 2004)
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Equipment Provision
All equipment designed for Plus Size person is not alike – one size does not fit all
Use the appropriate equipment for your patients body dynamics
Are you competent to prescribe (if not ask the manufacturer/supplier (i.e. joint visit/training)
Remember majority of Plus Size person will require Specialist equipment
Access and Egress
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Space
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Factors to consider
Individual Factors Health and safety Space & Design
Equipment / Furniture
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Client
Family
Clinical
Hygiene
Community Environment
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Environmental Hazards
Constraints
Access and Egress
Safe working load of the floor
Stair lifts
Carpets
Furniture
Door openings
Corridors
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Associated Environmental Risk
When prescribing equipment for the home environment ensure that the following is considered
Floor weight limits
Weight of the equipment being used
Weight of the spouse/carer if they sit on the bed or kneel to undertake handling tasks
Weight of the mattress
Lift weight
Corridors
All need to be added to the weight limit calculation.
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General rule of thumb a ground floor
can take 2000kgs based on a 3 metre
square room
Upstairs will be less
Equation has to take into account the
joists, type of floor and size of room
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6 inches x 6 inches
Max: point load 1 square foot
Point load 375kgs most building are built to that as a minimum
400 kg person should not stand on one leg
99% of ground floor buildings are adequate
1st floor and above you should always seek advice
Consider the combined weight of the bariatric person, staff and equipment / furniture, for example: -
Weight of person 200kg
Weight of bed 285kg (bariatric bed 1080)
Weight of mattress 24kg
Weight of hoist +/-100kg (gantry)
Combined weight of 2 carers 200kg
Weight of armchair 100kg (Riser/Recliner)
Additional furniture +/-100kg
Total 1009kg
Weight Limit of Floors
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Bathroom Dimensions
Bathrooms Apart from inpatient bariatric bathroom facilities, bariatric patient-accessible bathrooms should also be
located in outpatient facilities and signposted with universal signage that is respectful and functional. The toilet design should also not have features that can lead to stigmatization.
Heavy-duty benches for bariatric patients to sit down during shower but with heavy-
duty grab bars in case /patient slips. Sinks located away from toilet and
Heavy-duty grab bars that look trendy and are functional
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Getting it right
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Key Messages Moving and handling bariatric people is complex and multi-factorial
Treat the person as an individual and with dignity and respect
Accurate assessment is essential
Obtain an accurate weight, wherever possible
Identify equipment which will maximise the ability of the person to assist
Reduce the risk of injury to all, to the lowest level reasonably practicable
Ensure there is a detailed handling plan
Seek specialist advice as required
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Emerging Bariatric Themes
Risk Management
Patient Led intervention
Appropriate Resources
Appropriate Equipment
Appropriate Environments
Education
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In Essence The right equipment can facilitate
Patient function
Increase independence
Eliminate some high-risk nursing tasks
Inappropriate equipment causes over-exertion injuries to staff
Regular heavy patient handling increases the risk of cumulative damage
(Pheasant 1997)
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Concluding
Bariatric Management is complex and multi-factorial.
Requires a Whole Systems Approach
Bariatric patients should be enabled not disabled
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THANK YOU
Anita Rush SRN Dip MSc Clinical Nurse Specialist Equipment
Email: [email protected]
Electronic copies of presentation are available upon request
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