need the group's advise

[Guest guest]

We have a patient with the following

history: 51 year old female CHF, pneumonia, asthma, hyperlipidemia, DM,

HTN, anemia, nephrotic syndrome, obstructive sleep apnea, anasarca, gastritis,

CKD, chronic pain syndrome, IBS, DVT, Fe deficiency anemia, psychotic behaviors,

and noncompliance. Ht 5'2 " Wt 165 kg. BMI 67.1 Patient does not participate

in minimal ADL's. She will not lift a wash cloth to wash her face. She

soils the bed and when asked what she would do at home she states " I

just go in my pants and have my husband clean me up " She is frequently

here. PT works with her every admission. She is noncompliant with her renal

diet when she is here and will play one staff member against another to

try to obtain additional food. She is currently on 1500 kcal, 60

gram protein, 2 gm Na, 3 gm K and 1200 ml fluid restriction secondary to

her chronic renal disease- nondialysed. Despite diuretic therapy she continues

to gain weight. The nephrologist is satisfied with her current status and

believes she maybe dry at the moment so 165 kg would be her dry weight.

Her weight has increased 6 kg since September 2006. She has been instructed

approximately six times over the past three years on several different

diets by three different dietitians. I have documented that she is

not a candidate for bariatric surgery due to her history of noncompliance

with dietary intervention and failure to participate in basic ADL's. Although

we realize some of her medical conditions may improve if she were to lose

weight., we seriously doubt she will be compliant. My questions are this:

Would you refer this patient for bariatric

surgery?

If you would refer her, what type of

surgery would you refer her for? Lap band vs Roux en y

Is she really even a candidate for a

lap band? Is there a cut off BMI for the lap band?

Is there anything you would suggest

this patient do prior to having surgery?

If you would not refer this patient,

what would you document?

Do you have any additional recommendations?

Thanks for your assistance in advance.

Rita , RD, LD/N

Clinical Nutrition Manager

Memorial Hospital of Tampa

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