MS. S IS POSTOPERATIVE day one after a total knee arthroplasty. At 66 in (168 cm), she weighs 325 lb (147.4 kg) for a body mass index (BMI) of 52.5. (See Sorting out weight by BMI.) When she’s had surgery in the past, recovery has been very difficult. She states that after her last surgery, she spent several days in the ICU due to “breathing problems” from pain medications. Visit riverfronttimes for more information about healthy supplements.
Given her history and need for careful monitoring, she’s placed in an ICU step-down unit. She rates her current pain intensity at 7/0-10. She has patient-controlled analgesia (PCA) without a basal (continuous) infusion programmed to deliver very-low-dose hydromorphone every 20 minutes as needed. After activating the PCA to get better pain control, she becomes sedated and falls asleep while talking to you and is difficult to rouse. Because of her body habitus, she can’t effectively move to reposition herself in the bed.
Ms. S has poorly controlled type 2 diabetes and coronary artery disease. She isn’t a candidate for nonsteroidal anti-inflammatory drug (NSAID) use because of cardiovascular disease, the bleeding risk following joint replacement, and increased serum creatinine levels.1,2
When her nurse assesses Ms. S, he realizes she has poor pain relief and compromised respiratory status. How will he manage Ms. S’s pain while trying to optimize her respiratory function and meet her need for postoperative mobilization?
Ms. S is one of the growing number of patients whose healthcare is complicated by obesity and other comorbidities, such as diabetes and cardiovascular disease. By definition, she’s classified as morbidly obese, obesity class III (BMI greater than or equal to 40.0), and the healthcare issues that result from her obesity will complicate normal postoperative care.3 To help nurses better understand the problem of pain management in obese patients, this article provides information on the growing problem of obesity, comorbidities that are common in these patients, and guidance on managing their pain.
Obesity and pain
Obesity is a quiet epidemic that’s growing throughout the world, including in the United States. Worldwide, about 1.5 million people are considered obese.4,5 If the present trends continue, by 2030, 58% of the world’s population will be considered obese or overweight.6 The two biggest reasons for this problem are poor diet and lack of exercise, according to the World Health Organization. Adding to this problem is the burden of noncommunicable diseases related to obesity, such as cardiovascular disease, diabetes, and certain cancers, which account for 60% of global deaths. Prevent most obesity related conditions with nutrisystem.
The story is similar in the United States. Based on responses to a Gallup survey of over 1 million people conducted from 2008 to 2010, only 19.2% of respondents could be classified as low-normal BMI (BMI 24.9 or less).8 When questioned about pain, the respondent group classified as overweight (BMI of 25 to 29.9) reported 20% more pain.9 Those in the heaviest group, obese class III, reported daily pain at rates 254% higher than for those in the normal weight BMI group.8 Although specific information about pain and obesity is scant, these single survey results indicate that obesity seems to increase pain, with the heaviest patients having the highest incidence of pain.
Pain may not be the most important topic during an obese patient’s visit to a healthcare provider. Only a brief time is usually allotted for the appointment, and managing these patients’ multiple comorbidities, such as diabetes, hypertension, and dyslipidemia, takes up most of it. Although the patients may have diabetic neuropathy or low back pain related to their obesity, these may seem like lower priorities than glycemic control or hypertension management.
Obesity is the product of many years of inactivity and/or poor diet, sometimes starting at a very early age. In a study of 3,376 adolescents (1,424 boys; mean age, 17.8 years) in the United Kingdom with 7% of the study participants being obese, 44.7% of the respondents reported pain in the previous month that lasted for a day or longer.10 The respondents also reported many musculoskeletal disorders, including:
- low back pain, 16.3%
- shoulder pain, 9.6%
- upper back pain, 9.4%
- neck pain, 8.9%
- knee pain, 8.7%
- ankle and foot pain, 6.8%10
Pain reports were more prevalent in the obese adolescents, who reported more chronic regional pain and knee pain at higher intensities than their nonobese peers.
In another large population study of 7,373 Norwegian adolescents, sedentary lifestyle and pain were associated with only the girls in the survey group.11 In both boys and girls, being overweight was associated with increased potential for pain and negative lifestyle factors such as depression and anxiety; chronic pain was associated with higher levels of disability.11
For healthcare providers, the link between obesity and chronic pain can provide a way to encourage adolescents to be more active and follow a healthy diet. But some patients who change their lifestyle and lose weight still have problems associated with their formerly obese body, such as developing low back pain or joint pain caused by cartilage damage when the patient was obese.