The current and future nursing shortage has been a hot topic within the medical industry; it has even begun being featured in major publications and news outlets. Attrition within the field is growing steadily, as those committed long-term ages out of their careers, there simply aren’t expected to be enough people to replace them. Nurses are asked every single day to do more with less. But in addition, the condition and volume of patients are expected to increase and require more complex management in the future. Why? There are two forces driving that, an aging “Boomer” generation and, well, the weight of the world.

Weight gain isn’t a U.S. phenomenon; in fact, according to the World Health Organization, worldwide obesity has increased three-fold since 1975. Looking deeper into the numbers, weight gain by decade is on a steady incline based on a study by the CDC, looking at the average American weight by decade:

• 1960’s-70’s – 167 lbs
• 1980’s-90’s – 183 lbs
• 2000’s – 191lbs

Following this pattern, each American adult will have gained more than 45 pounds, pushing many into the category of “obese". In fact, according to the Department of Health and Human Services and the CDC, 42.4% of U.S. adults are currently obese, which is up from the 30.5% measured in 2000. That creates a problem for the healthcare system in general, but nurses very specifically. According to a study by the WHO, obese patients present with significantly increased levels of disease. Increased BMI (body bass index) is a significant risk factor for noncommunicable diseases such as:

• Cardiovascular diseases (mainly heart disease and stroke), which were the leading cause of death in 2012
• Diabetes
• Musculoskeletal disorders (especially osteoarthritis)
• Some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon).

In fact, the study concludes as BMI increases, the risk increases steadily for one or more of these potentially fatal diseases. Sadly, this isn’t just an adult issue; children are also experiencing steady increases in BMI, which, according to the WHO, is associated with the following:

• Premature death and disability in adulthood
• Breathing difficulties
• Increased risk of fractures
• Hypertension
• Early markers of cardiovascular disease
• Insulin resistance
• Psychological effects

And this list is (mostly) physical repercussions. Add to these issues the impact of bullying and social isolation, which not only impacts individuals as children but spills over into teen and adult years, manifesting in nearly every way imaginable, both physically and emotionally. But what is the weight of the world’s impact on nurses and nursing? As it turns out, the collective weight gain of the world greatly impacts both nurses as individuals and the required staffing levels that will potentially be needed to care for the same number of patients.

According to a recent Nursing World piece, the complexity of care and the number of individuals needed to support appropriate care and treatment is impacted by increased BMI statistics. Let’s take a brief look.

Skin Impact

• Tubes and catheters can burrow into the skin and soft tissue.
• To prevent skin issues, repositioning tubes, and catheters at least every two hours may be necessary. (Camden, 2006). This repositioning, however, is difficult for patients who are immobile.
• Excessive moisture accumulation in skin folds promotes bacterial, fungal, and viral growth leading to intertrigo and potential skin breakdown (Yosipovitch, DeVore, & Aerlyn, 2007).
• Obese patients often present with atypical pressure ulcers as the pressure within skin folds is sufficient to cause skin breakdown.
• Wound healing is problematic because the blood supply to adipose tissue is usually compromised, which diminishes oxygen and nutrients necessary to prevent breakdown and promote healing (Gallagher, 2005b).

Respiratory Impact

• Reduced expiratory reserve volume and functional residual capacity.?
• Studies also suggest that increased pulmonary blood volume leads to congestion which results in the thickening of the airway wall, thus reducing the size of the airway (Boran et al., 2007).
• Clinically, ten percent of morbidly obese patients have severe respiratory impairments, such as obesity hypoventilation syndrome (OHS), while over 50% have moderate or severe sleep apnea (Resta, Foschino-Barbaro, & Legari, 2001).
• If resuscitation measures become necessary, and cardiopulmonary resuscitation (CPR) is needed, a Doppler may be used to hear blood flow through the carotid artery to determine the efficacy of compressions. Placing a backboard under the patient may pose a threat to caregiver safety because once resuscitation efforts are successfully completed, the board must be removed to prevent serious skin consequences from occurring.
• During an emergency intubation, it may be challenging to visualize anatomic landmarks, such as vocal cords, in a morbidly obese patient.
• Even in a non-emergency situation, safe airway management may require more planning. Tracheostomy tubes may be too short for use in the presence of a very thick neck.

Altered Drug Absorption

• Excess body fat might alter drug absorption, depending on the medication.
• The dosage of some medications is calculated using the patient’s actual body weight, while the dosage of other medications is based on ideal body weight. Trying to remember which drug falls into which category is nearly impossible.
• Standard 1 to 1 ½ inch needles may not be able to penetrate past adipose tissue in a patient with a thick layer of fatty tissue. A longer needle may be necessary.

Intravenous Access

• Intravenous (IV) access can also be challenging in obese patients. (If it takes more than two attempts to start a peripheral IV, and there is no other reason not to consider using a peripherally-inserted central catheter (PICC) or midline catheter).

Immobility

• Most very overweight patients are at risk for specific hazards of immobility. Common immobility-related complications include skin breakdown, cardiac deconditioning, deep vein thrombosis, muscle atrophy, urinary stasis, constipation, pain management problems, and depression.
• Immobility also contributes to pulmonary complications such as atelectasis and pneumonia.
• The obese patient is more inclined to develop these complications during an extended hospitalization.
• Specific tasks such as moving and lifting immobile patients can seem overwhelming without proper mentoring and equipment. Ceiling lifts with properly fitted lifting and turning bands; portable lifts that aid in standing or walking an unsteady patient; a sliding board, slip, or inflatable transfer device; and more can be invaluable to nurses who are trained on their proper usage.

All of the complications listed above mean additional complexity of care, additional staffing needs, and additional equipment required. Of course, it also means that nurses will have more taxing duties physically because larger patients create a higher risk of potential injury to nurses responsible for moving, repositioning, and caring for their hour-to-hour needs. Hospitals and doctor’s offices must be encouraged to purchase the additional equipment required to safely manage and care for the realities of today's and tomorrow’s patients and nurses. With the current and future anticipated nursing shortages, our nation’s medical community simply cannot afford to lose a single nurse to unnecessary injury or permanent disability. After all, the weight of the world is truly on their shoulders.