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The most important consideration by far is to have one clinician in charge, a clinician whom the patient trusts and who is able to oversee multiple treatment approaches (see Somatoform Disorders, above) In acute problems, attention must be paid to metabolic imbalance, alcohol withdrawal, and previous drug use prescribed, recreational, or over-thecounter Adequate sleep and analgesia are important in the prevention of delirium When absolute behavioral control is urgently needed, agents such as propofol, dexmedetomidine, opioids, and midazolam have been used Many clinicians are attuned to the early detection of the surgery-prone patient Plastic and orthopedic surgeons are at particular risk Appropriate consultations may help detect some problems and mitigate future ones Postsurgical anxiety states can be alleviated by personal attention from the surgeon Anxiety is not so effectively lessened by ancillary medical personnel, whom the patient perceives as lesser authorities, until after the physician has reassured the patient Inappropriate use of as needed analgesia places an unfair burden on the nurse Patient-controlled analgesia can improve pain control, decrease anxiety, and minimize side effects Depression should be recognized early If severe, it may be treated by antidepressant medications (see Antidepressant Drugs, above) High levels of anxiety can be lowered with judicious use of anxiolytic agents Unnecessary medications tend to reinforce the patient s impression that there must be a serious illness or medication would not be required
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Prior desensitization can significantly allay anxiety about medical procedures A dry run can be done to reinforce the oral description Cooperation during acute problem periods can be enhanced by the use of appropriate reinforcers such as a favorite nurse or helpful family member People who are positive reinforcers are even more helpful during the intermediate phases when the patient becomes resistant to the seemingly endless procedures (eg, debridement of burned areas) Specific situations (eg, psychological dependency on the respirator) can be corrected by weaning with appropriate reinforcers (eg, watching a favorite movie on a videorecorder when disconnected from the ventilator) Behavioral approaches should be used in a positive and optimistic way for maximal reinforcement Relaxation techniques and attentional distraction can be used to block side effects of a necessary treatment (eg, nausea in cancer chemotherapy)
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A change in environment requires adaptation Because of the illness, admission and hospitalization may be more easily handled than discharge Reintegration into society can be difficult In some cases, the family is a negative influence A predischarge evaluation must be made to determine whether the family will be able to cope with the physical or mental changes in the patient Working with the family while the patient is in the acute stage may presage a successful transition later on Development of a new social life can be facilitated by various self-help organizations (eg, the stoma club) Sharing problems with others in similar circumstances eases the return to a social life, which may be quite different from that prior to the illness
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Prepare the patient and family for what is to come This includes the types of units where the patient will be quartered, the procedures that will be performed, and any disfigurements that will result from surgery Repetition improves understanding The nursing staff can be helpful, since patients
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The prognosis is good in all patients who have reversible medical and surgical conditions It is guarded when there is
CMDT 2008
Whooley MA Depression and cardiovascular disease: healing the broken hearted JAMA 2006 Jun 28;295(24):2874 81 [PMID: 16804154]
serious functional loss that impairs vocational, educational, or societal possibilities especially in the case of progressive and ultimately life-threatening illness
Ciechanowski P et al Influence of patient attachment style on self-care and outcomes in diabetes Psychosom Med 2004 Sep Oct;66(5):720 8 [PMID: 15385697] Hogarth DK et al Management of sedation in mechanically ventilated patients Curr Opin Crit Care 2004 Feb;10(1):40 6 [PMID: 15166848]
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