Obesity is a public health issue linked to high morbidity and mortality among critically ill patients. There are approximately 15.5 million morbidly obese adults in the United States. The purpose of the project was to develop and implement an educational program using evidence-based protocols for bariatric care to educate nurses and caregivers regarding best practices when attending to obese patients. The practice-focused question examined whether learning about evidence-based bariatric care would improve the knowledge of nurses and caregivers caring for morbidly obese patients in an acute care setting. The theoretical foundation was Bandura'€™s self-efficacy theory. A questionnaire using a Likert scale was used to collect data from the 100 participants before and after the learning intervention. The selection criteria involved the inclusion of all nurses and caregivers working at the adult in-patient unit. A paired-samples t-test was used to evaluate levels of improvement in knowledge of the causes, treatment, management, and care of patients with obesity and the challenges in caring for morbidly obese patients. The findings indicated a statistically significant increase in participants'€™ knowledge of the causes (p < 0.000), treatment, management, and care of patients with obesity (p < 0.000) and the challenges involved in caring for morbidly obese patients after the learning intervention (p < 0.004). Thus, the implementation of an educational intervention may be effective in improving nurses'€™ knowledge of bariatric care. The implications of the project for social change involve the improvement in nurse'€™s knowledge of clinical guidelines, which can lead to increase in patient satisfaction, and improved overall health outcomes.

Introduction: Obesity during pregnancy is linked to many negative health effects for mothers and offspring. The majority of interventions with obese pregnant women based on physical activity have had limited success suggesting alternative approaches are needed. Sedentary behaviour is defined as waking activities that expend very low energy, 1.5 metabolic equivalents or below, while reclining, lying or sitting. Spending too much time sedentary has been identified as a risk factor for health, regardless of physical activity levels. We hypothesised that targeting sedentary behaviour may be a suitable alternative to reduce health risks during gestation among pregnant women who are morbidly obese (defined as body mass index, BMI > 40 Kg/m²). Aim and objectives: The aim was to explore sedentary behaviour among obese pregnant women and to propose an intervention to reduce the time obese pregnant women spend sedentary, through an active sitting exercise intervention. To conduct a systematic review of the literature to determine the proportion of time spent in sedentary behaviour among pregnant women, and the association of sedentary behaviour with pregnancy outcomes in mothers and offspring. To estimate total energy expenditure, and energy expended in sedentary activities in morbidly obese and lean pregnant women. To assess the feasibility of an active sitting exercise intervention for morbidly obese pregnant women, designed using a patient involvement in research method. Systematic Review: A systematic review of the literature reporting sedentary behaviour during pregnancy and its effects on pregnancy outcomes was conducted. Twenty six publications were included in the systematic review up until October 2015, and a further 18 were identified in the update completed in April 2018. Pregnant women spent at least 50% of their time in sedentary activities. Associations between increased time sedentary and higher risk of macrosomia, higher risk of pre-eclampsia, higher risk of developing gestational diabetes mellitus, and larger new-born abdominal circumference were observed, as the main findings. Most of included studies scored an intermediate quality, only two of the 44 studies scored a good quality. Cross-sectional study. A cross-sectional study was conducted, using the Pregnancy Physical Activity Questionnaire (PPAQ), and the Actical accelerometer, to assess energy expenditure, and energy expended in sedentary behaviour. Based on the PPAQ, women who were morbidly obese expended significantly more energy per day, as total expenditure, than lean pregnant women, which was confirmed by the Actical. During sedentary behaviour lean pregnant women expended significantly less energy than morbidly obese pregnant women, based on the PPAQ. No differences were observed between lean and morbidly obese pregnant women in the proportion of time spent in sedentary activities, nor in time sedentary. Exercise Intervention Design A patient involvement in research approach was used to design an active sitting exercise intervention for morbidly obese pregnant women. Twenty three women took part in the design of the intervention, enabling design of a final protocol including six exercises, to be performed in two sets of 10 repetitions. Active sitting exercise intervention An intervention based on active sitting exercises for morbidly obese pregnant women to reduce sedentary time was conducted to assess the feasibility. Thirty morbidly obese pregnant women were recruited of whom 20% completed the exercise intervention. The main reason not to complete the intervention was lack of time. Conclusion: A better understanding of sedentary behaviour is needed for the design of effective interventions to help to reduce the adverse effects of morbid obesity on pregnancy, especially as prevalence is growing. More time spent in light intensity activities rather than in sedentary behaviour may play a role as contributing to reduce those risks associated with obesity during pregnancy, and to reduce time spent sedentary. Participants have shown real interest in helping to design an effective exercise intervention. Involving and empowering participants in how to take care of themselves as part of the intervention helps to increase their commitment. Giving participants the tools to take care of their own health and their babies' should be considered as part of the intervention with very obese pregnant women. Providing the information in how and why exercise might help, and basing the intervention in giving participants easy and realistic tasks that they could do on their own and around their own environment, will help to increase their commitment. This appears to be a feasible and effective strategy.

Formation of atelectasis, defined as reversible collapse of aerated lung, often occurs after induction of anaesthesia with mechanical ventilation. As a consequence, there is a risk for hypoxemia, altered hemodynamics and impaired respiratory system mechanics. In certain situations, the risk for atelectasis formation is increased and its consequences may also be more difficult to manage. Anesthesia for bariatric surgery in morbidly obese patients and surgery requiring one-lung ventilation (OLV) with capnothorax are examples of such situations. In Paper I (30 patients with BMI &gt; 40 kg/m2 scheduled for bariatric surgery) a recruit­ment maneuver followed by positive end-expiratory pressure (PEEP) re­duced the amount of atelectasis and improved oxygenation for a prolonged period of time. PEEP or a recruitment maneuver alone did not reduce the amount of atelectasis. In paper II we investigated whether it is possible to predict respiratory function impairment in morbidly obese patients without pulmonary disease from a preoperative lung function test. Patients with mild signs of airway obstruction (reduced end-expiratory flow) in the preoperative spirometry developed less atelectasis during anaesthesia. In paper III we developed an experimental model of sequential OLV with capnothorax using electrical impedance tomography (EIT) that in real-time detected lung separation and dynamic changes in pulmonary ventilation and perfusion distributions. OLV to the left side caused a decrease in cardiac output, arterial oxygenation and mixed venous saturation. In paper IV we used our model of OLV with capnothorax and applied a CO2-insufflation pressure of 16 cm H2O. We demonstrated that a PEEP level of 12-16 cm H2O is needed for optimal oxygenation and lowest possible driving pressure without compromising hemodynamic variables. Thus, the optimal PEEP was closely related to the level of the capnothorax insufflation pressure. With insufficient PEEP, ventilation/perfusion mismatch in the ventilated lung and redistribution of blood flow to the non-ventilated lung occurred.

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