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1 Decreasing cooperation as the patient sees improvement and compliance are not compelled 2 Readjustment problems with family, job, and society
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1 Intensive care unit psychosis The stressful ICU environment may be a cause of delirium Critical care unit factors include sleep deprivation, increased arousal, mechanical ventilation, and social isolation Other causes include those common to delirium and require vigorous investigation (see Delirium, above) 2 Pre- and postsurgical anxiety states Such problems are common and commonly ignored Presurgical anxiety is very common and is principally a fear of death (many surgical patients make out their wills) Patients may be fearful of anesthesia (improved by the preoperative anesthesia interview), the mysterious operating room, and the disease processes that might be uncovered by the surgeon Such fears frequently cause people to delay examinations that might result in earlier surgery and a greater chance of cure The opposite of this is surgery proneness, the quest for surgery to escape from overwhelming life stresses Polysurgery patients may be classified as having factitious disorders Dynamic motivations include the need to get medical care as a way of getting dependency needs met, the desire to outwit authority figures, unconscious guilt, or a masochistic need to suffer Frequent surgery may also be related to a somatoform disorder, particularly body dysmorphic disorder (an obsession that a body part is disfigured) More apparent reasons may include an attempt to get relief from pain and a lifestyle that has become almost exclusively medically oriented, with all of the risks entailed in such an endeavor Postsurgical anxiety states are usually related to pain, procedures, and loss of body image Acute pain problems are quite different from chronic pain disorders (see Chronic Pain Disorders, this chapter); the former are readily handled with adequate analgesic medication (see 5) Alterations in body image, as with amputations, ostomies, and mastectomies, often raise concerns about relationships with others 3 Iatrogenic problems These usually pertain to medications, complications of diagnostic and treatment procedures, and impersonal and unsympathetic staff behavior Polyphar-
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1 Anxiety Anxiety about return to the posthospital environment can cause regression to a dependent position Complications increase, and staff forbearance again is tested Anxiety occurring at this stage usually is handled more easily than previous behavior problems 2 Posthospital adjustment Adjustment difficulties after discharge are related to the severity of the deficits and the use of outpatient facilities (eg, physical therapy, rehabilitation programs, psychiatric outpatient treatment) Some patients may experience posttraumatic stress symptoms (eg, from traumatic injuries or even from necessary medical treatments) Lack of appropriate follow-up can contribute to depression in the patient, who may feel that he or she is making poor progress and may have thoughts of giving up Reintegration into work, educational, and social endeavors may be slow Life is simply much more difficult when one is disfigured, disabled, or disenfranchised
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The symptoms that occur in these patients are similar to those discussed in previous sections of this chapter, eg, delirium, stress and adjustment disorders, anxiety, and depression Behavior problems may include lack of cooperation, increased
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complaints, demands for medication, sexual approaches to nurses, threats to leave the hospital, and actual signing out against medical recommendations The underlying personality structure of the individual is a major factor in coping styles (eg, the compulsive individual increases indecision, the hysterical individual increases dramatic behavior)
CMDT 2008
Differential Diagnosis
Delirium and dementia (including cases associated with HIV infection and drug abuse) must always be ruled out, since they often present with symptoms resembling anxiety, depression, or psychosis Personality disorders existing prior to hospitalization often underlie the various behavior problems, but particularly the management problems
Complications
Prolongation of hospitalization causes increased expense, deterioration of patient-staff relationships, and increased probabilities of iatrogenic and legal problems The possibility of increasing posthospital treatment problems is enhanced
frequently confide a lack of understanding to a nurse but are reluctant to do so to the physician Denial of illness is frequently a block to acceptance of treatment This too should be handled with family members present (to help the patient face the reality of the situation) in a series of short interviews (for reinforcement) Dependency problems resulting from long hospitalization are best handled by focusing on the changes to come as the patient makes the transition to the outside world Key figures are teachers, vocational counselors, and physical therapists Challenges should be realistic and practical and handled in small steps Depression is usually related to the loss of familiar hospital supports, and the outpatient therapists and counselors help to lessen the impact of the loss Some of the impact can be alleviated by anticipating, with the patient and family, the signal features of the common depression to help prevent the patient from assuming a permanent sick role (invalidism) Suicide is always a concern when a patient is faced with despair An honest, compassionate, and supportive approach will help sustain the patient during this trying period
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