The patient: the reason for your existence

Chapter 7


The patient: the reason for your existence



Chapter objectives


After studying this chapter, the learner will be able to:


• Describe Maslow’s hierarchy of needs.


• Describe some characteristics of diversity in a patient population.


• List the key elements of a patient-centered approach.


• Describe how the patient may perceive care.



Key terms and definitions



Body mass index (BMI) 


Calculation that divides body weight in kilograms by height in meters squared (kg/m2).


Comorbidity 


More than one disease entity in an individual.


Domestic violence 


Abuse perpetrated in the home or living arrangement. Can be physical, psychological, verbal, or nonverbal.


Homeostasis 


A balance of systems within a person that sustains life in a disease-free state.


Paradigm 


Model used as a foundation for a conceptual framework.


Perception 


Use of the senses, cognition, and awareness to evaluate the collective stimuli of the environment.


Perpetrator 


Person who is suspected of committing a crime against another person.


Polypharmacy 


The use of multiple medications, either prescribed or self-administered.


Stress 


Internal perception of and response to stimuli in a positive or negative manner.


Victim 


Person who has been injured by the effects of the environment or suffered abuse by another person.



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The patient as an individual


Patients are the reason for the existence of the health care team. They look to the perioperative team to fulfill their diverse needs during the preoperative, intraoperative, and postoperative phases of care (Fig. 7-1). The patient is always the center of attention, not just when under the OR spotlight. A patient may be defined as an individual recipient of health care services.


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FIG. 7-1 The OR from the patient’s perspective.

Extremes of age (pediatric and geriatric) and comorbid disease entities require individualization of the plan of care. To meet a patient’s requirements and expectations effectively, personnel should have knowledge of the patient’s needs, problems, and health considerations. From a perioperative perspective, understanding the effect a surgical procedure has on a patient’s lifestyle is important. Characteristics that individualize patients include, but are not limited to, the following:



Homeostasis is a consistent internal environment maintained by the patient’s adaptive capabilities, and it has a physiologic and a psychological component. From a physiologic aspect, the patient’s body strives to maintain equilibrium within normal limits through control mechanisms located in the endocrine glands and in the reticular formation in the brainstem. This stability depends partly on the structural integrity of the body, the adequacy of its functions, and environmental influences.


Psychological homeostasis is based on emotional acceptance and a rational understanding of events that influence health and wellness. Fear and anxiety are common stressors that alter a patient’s psychological response to the health care system.



Patients’ basic needs


Needs are factors that must be controlled or redirected to restore altered function. Nursing diagnoses are based on knowledge and understanding of a patient’s needs and how to fulfill them. The surgical patient faces a threat to the needs identified by humanistic psychologist and motivational theorist Abraham Maslow (1908-1970): physical, security, psychosocial, emotional, and spiritual.8



Hierarchy of needs


In following Maslow’s concept of a motivational hierarchy of needs to set priorities for care (Fig. 7-2), the basic lower level (physiologic needs) essential for survival must be met first. Satisfaction of the higher level needs for safety and security, belonging and acceptance, self-esteem, and self-actualization can then be met. Health care personnel should be concerned with a total picture of the patient’s needs and consider all of them. Additional information about Maslow’s hierarchy of needs can be found at http://psychology.about.com/od/theoriesofpersonality /a/hierarchyneeds.htm.


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FIG. 7-2 Maslow’s hierarchy of basic needs as related to surgical patient needs during perioperative care.

In illness, needs can be influenced by factors such as location of the pathologic condition, type of surgical procedure, and effectiveness of therapy. Also, priorities may change with changing situations. Preoperatively, anxiety and nutritional status are addressed. Intraoperatively, the team concentrates on the patient’s physiologic needs for oxygen and circulation and the prevention of shock and infection. Postoperatively, team members must prevent complications and encourage patient self-actualization. If the patient’s needs are not met satisfactorily, undesirable consequences can occur.



Patients’ reactions to illness


To meet a patient’s needs, the health care team should be sensitive to the patient’s feelings about the illness. A patient’s reactions influence his or her behaviors and the staff’s behavioral responses. An understanding of the patient’s basic methods of coping is helpful to the caregiver in developing the plan of care (Table 7-1).



TABLE 7-1


Common Coping Mechanisms


















































Mechanism Meaning Objective Assessment Example
Denial Rejects responsibility; unable or unwilling to accept the truth Stammers; may or may not make eye contact; seems to be making excuses “I do not have lung cancer.”
Displacement Shifts blame to a weaker substitute Is submissive to power figures but critical and oppressive to subordinates “My doctor never tells me anything. The laboratory must be wrong.”
Identification Acts like an admired hero or villain Shows outward signs of indecisiveness and low self-esteem “My sister and I both feel ill. We both have the same disease, I’ll bet.”
Projection Attributes unacceptable behavior to others Acts suspicious of others; assumes a defensive posture “The cigarette manufacturer enticed me to smoke.”
Rationalization Justifies behavior with plausible statements May be defensive or smug; trying to save face; can become hostile “I became ill only because cancer runs in my family.”
Reaction formation Acts differently than he or she feels inside Is confused, irrational; has mood swings; may seem overly conscientious and moral “These are not tears of sadness; they are tears of joy because I will be dead soon.”
Regression Reverts back to a more primitive state of being May assume closed, fetal position; has crossed arms and legs; looks downward, cries; has prolonged silences “I want my mother.”
Repression Blocks unacceptable thoughts and feelings Has a blank stare, a questioning look; no in-depth discussions “I don’t remember what my diagnosis is. Why am I here?”


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Behavior


Health and human behavior are interdependent and often age-dependent. Regardless of age, individuals with physiologic problems experience some emotional change that influences their behavior. Patients react to a new interpersonal environment according to their learned behavioral patterns. The following are basic facts about behavior:



Behavior should be evaluated in light of the person’s specific situation and pertinent social forces such as family, culture, and environment. Patients respond to crises or personal threats in different ways. Some persons face suffering and surgical intervention with extreme courage, dignity, and fortitude. Others may revert to extreme fear or helplessness, even when faced with a relatively safe procedure.8


Overt behavior is not necessarily consistent with one’s feelings but often reflects them most accurately. Patients often express frustration and fear behaviorally in an effort to cope with environmental stimuli.



Adaptation


In 1984, theorist Sister Callista Roy proposed adaptation as a conceptual model for nursing. Any deviation from a person’s normal daily pattern of living necessitates adaptation through innate or acquired defenses. Adaptation may involve physiologic or psychological changes. Her paradigm as it applies to perioperative patient care includes the following:



Both the mind and the body must adapt successfully for the patient to recover. Adaptation requires energy, ingenuity, and persistence. The adaptive process includes physiologic or psychological changes that constitute an attempt to counteract stimuli so the individual can continue to function. If something interferes with this adaptation, the effects can be detrimental. Adaptation to illness includes the following three stages:



Adaptation may be rapid or slow, depending on the nature of the stimuli and on the patient’s culture, learned responses, and developmental needs. Adaptations may be sensory, motor, or sensorimotor. The extent of adjustment needed is contingent on the type of illness, the magnitude of disability, and the patient’s personality. More information about Roy’s adaptation theory can be found online at http://currentnursing.com/nursing_theory/Roy_adaptation_model.html.



Stress


Stress can be defined as a physical, chemical, or emotional factor that causes tension, and it may be a factor in disease causation. It is the result of a perceived threat and is manifested by changes in physiologic and psychosocial behavior. Stress tolerance depends on the individual and on the stressor—its intensity, duration, and type (either localized or generalized, such as pain).


Stressful factors can originate from within the individual or from the external environment. Intrinsic factors, or those that originate within a patient, include the following:



• Hereditary or genetic factors, such as competency of the hormonal or enzymatic system.


• Nature of the illness or disease process. This may be influenced by nutritional or immunologic status.


• Severity of the illness or the presence of a stigma.


• Previous personal experiences with illness. Chronic illness has a disruptive effect on lifestyle.


• Age. Children feel threatened, whereas adolescents resent an interruption of activities and are painfully aware of body changes. Older people think about infirmity and death.


• Intellectual capacity. Misconceptions can lead to a knowledge deficit about the disease. Impaired cognitive function creates an inability to understand or comprehend.


• Disturbed sensorium. Hearing or sight loss intensifies a stressful experience.


• General state of personal well-being.


Extrinsic factors originate from external sources and include the following:



• Environment. The physical and social environment of the hospital is not the same as that of the home.


• Family role and status. Expectations and authoritative relationships affect lifestyle, attitudes, and communications.


• Economic or financial situation.


• Religion. Beliefs influence attitudes and values toward life, illness, and death. For example, Jehovah’s Witnesses do not permit transfusion of whole blood or blood components. Orthodox Jews must follow dietary laws in any environment. The fatalistic attitudes derived from some religious beliefs give a person little control over his or her environment and can render a patient passive and apathetic.


• Cultural background, education, and social class. These factors are closely related to a patient’s emotional responses and living habits. Significant cultural elements such as food habits, daily living patterns, hygiene, family organization, child care, and orientation to the past, present, and future should be analyzed in relation to culture. An ethnic community is really a larger family. Roles taught by a cultural group influence the mores, beliefs, and social interactions of its members. Also, responses to pain may vary according to cultural or ethnic background. Some groups commonly show an exaggerated emotional response, whereas other groups believe concealing suffering and feelings is more appropriate.


• Social relationships. Family, significant others, and friends help satisfy the need for reassurance and provide a sense of being cared about.


Stress is both physiologic and psychological. It can adversely affect appetite and bodily functions such as digestion, metabolism, and fluid and electrolyte balance. The secretion of adrenocortical hormones delays wound healing and decreases resistance to infection. In addition, the patient’s emotional needs come to the surface during times of markedly increased stress, which mobilizes defense mechanisms for fight or flight. The patient’s ability to adapt depends in part on effective intervention.


Anticipatory apprehension, although normal to some degree, may diminish critical thinking and decision-making abilities and may initiate an exaggerated response. Patients feel vulnerable when threatened with the loss of body parts, bodily function, or life. The strangeness of the OR itself—its noises, odors, and equipment—represents an unfriendly environment.



Patients’ perceptions of care


Studies have shown that a patient’s perception is based on expectations of high-level care. The patient’s belief system defines what he or she considers to be good care. Perceptions of caring behaviors vary according to the degree of illness, type of procedure, level of cognition, and setting. Most patients believe that proficient and efficient perioperative care includes assistance with pain control, warmth, comfort, and a safe environment. The caregiver is also perceived as a patient advocate and a communication link with the family or significant others.


Research has revealed that preoperatively a patient needs information about the surgical procedure, how it will be performed, and the type of anesthetic to be used. Intraoperatively, the patient assumes a passive role, entrusting care to the perioperative team.


Before administration of the anesthetic, the patient may be acutely aware of the surroundings and activities. Patients surveyed indicate that during this segment of intraoperative care they want to know what is happening as it takes place and desire reassurance from the circulator at their side. Patients expect the perioperative nurse to remain in physical proximity and act promptly in an emergency.


During and after the administration of the anesthetic, the patient places a strong sense of confidence in the team as a whole and has expectations of competence and efficiency. The professional nurse is considered a main source of protection during this period of vulnerability.


Postoperatively, patients expect the perioperative nurse to monitor their condition closely and to provide pain relief as needed. In continuation of the passive role, patients perceive the nurse as caring, protective, and efficient. Patients respond favorably to the following:




Family/significant others


A discussion of the patient is not complete without specific mention of the patient’s family or others significant in his or her life. Illness often creates an emotional and financial burden on the family. They may experience considerable anxiety over the outcomes of surgery, the feelings of isolation, and the disruption of lifestyle. A family’s reaction to illness and perception of care is as individualized as the patient.


Families need preoperative instruction to prepare for the postoperative outcomes and rehabilitation. They also need to be kept informed of the patient’s progress during the surgical procedure and recovery period. Time passes more slowly during waiting periods, and family members may fear something has gone wrong if the wait is longer than anticipated. Some family members may prefer to wait at home or at work. The surgeon should contact a spouse, family member, or significant other when the surgical procedure is over.


Discussions with anyone other than the patient concerning condition or personal information require the patient’s permission as part of the Health Insurance Portability and Accountability Act (HIPAA) requirements concerning patient privacy. Details can be found at www.hhs.gov/ocr/privacy/.



The patient with individualized needs


The debilitated, chronically ill, or age-extreme patient has an increased difficulty in combating the stress of surgery and anesthetic agents. Other problems or health considerations that predispose the patient to intraoperative or postoperative complications include substance abuse or other serious subclinical conditions not revealed during the preoperative assessment.


Preoperative diagnostic and laboratory studies assist in establishing diagnoses and in pinpointing areas of deficiency. Surgical intervention is often postponed until a physiologic situation is improved or controlled (e.g., high blood pressure is lowered; cardiac dysrhythmias are corrected). Preoperative therapy may be indicated to control diabetes, reduce obesity, or treat infection to decrease the risk of complications.


Patients of various ages and stages of development have different needs, and the ways of meeting these needs vary. A family-centered approach to care is valuable. Family cooperation is essential for communication with, interpretation for, and assistance with patients, particularly geriatric patients.



The patient with sensory impairment or physical challenge


Some patients come to the perioperative environment with conditions unrelated to the surgical problem. Sensory and physically challenged patients commonly have increased anxiety and need a highly individualized plan of care; these patients also have the potential for a problematic postoperative recovery.




Language barrier


A language barrier can be a complex challenge. Anxiety increases in proportion to one’s inability to communicate in a stress-producing situation. The inability to understand or to express oneself verbally is frustrating, and the patient’s behavior may reflect feelings of inadequacy or insecurity.


Nonverbal body language through eye contact, pleasant facial expressions, and a gentle touch can comfort the patient who speaks a different language. Every effort should be made to obtain an interpreter to assist the patient and the health care team; many hospitals use interpreters for the ethnic groups within the community.


Some patients are reluctant to share confidential medical information with a relative or friend. The interpreter should be trusted and accepted by the patient and should be sensitive to the needs of the surgeon and caregivers. The patient needs to be adequately informed before giving consent for a surgical procedure and must provide permission for release of information concerning the procedure.



Hearing impairment/deafness


Hearing impairment varies from inner ear conduction changes that occur during the aging process and affect the distinction of some high-frequency consonant sounds to congenital profound sensorineural deafness. Conductive or sensorineural deafness may result from disease or injury to the ear at any age.


The degree of impairment determines whether the patient communicates through sign language, has a hearing-assistive cochlear implant, has a hearing aid, or reads lips. Written information is always helpful, provided the patient is literate. Pictograms work well with most patients. An interpreter can assist with patients who use sign language.


The following steps should be observed when communicating with a patient who has a hearing impairment:



1. Make sure the room is quiet and well lit, with minimal distractions. Deaf patients may perceive extraneous sounds as buzzing or air-rushing. Deafness can be manifest in many degrees. Care is taken not to approach so quietly that the patient becomes startled.


2. Look directly at the patient. Speak clearly and slowly in a moderate tone of voice, with visible but not exaggerated lip movements. Facial expressions, touch, and body gestures can help communicate feelings and instructions.


3. Greet the patient without wearing a facemask and attract the patient’s attention before speaking. Make eye contact.


4. Be sure the patient understands and responds appropriately to questions.


5. To help explain your actions, show the patient any equipment (e.g., a safety strap) before placing it on him or her.


6. Allow the patient to wear a hearing aid in the perioperative environment, if possible. Try to know what type of device the patient uses and how to adjust the controls if it should start humming during the procedure.



Visual impairment/blindness


Like deafness, blindness can be a part of the aging process or a congenital anomaly. Cataracts are a common cause of the loss of visual acuity; this condition may be inherited but is more often associated with aging. Vision is affected by the shape of the eye, other structural factors, and diseases and injuries.


Patients who are blind feel insecure in a strange environment; therefore, the following steps should be observed when communicating with them:



A visually impaired patient should be permitted to wear spectacles in the perioperative environment as much as possible. If a general anesthetic is used, the spectacles should be sent to the postanesthesia care unit (PACU) so they are available when the patient wakes up. Contact lenses must be removed before administration of a general anesthetic because they may dry on the cornea or become dislodged.



Physical challenge


Patients who are physically challenged need a highly individualized plan of care. Physical problems such as contractures or pressure sores may make positioning the patient on the operating bed difficult. Patients with spastic muscle motion as in cerebral palsy need additional personnel around the operating bed for safety during transfer or the random body movement could cause the patient to fall.


Creative supports and positioning aids are needed, and additional assistance may be necessary to move the patient safely. Use alternating pressure pads, such as gel pads, as available. Exposure of the surgical site may be difficult to achieve.


Millions of people have some form of arthritis. Children with juvenile rheumatoid arthritis have many systemic problems as a result of the disease process, which continues into adulthood. The onset of this autoimmune disease can occur at any age and can result in stiffness, swelling, and deformity of the joints of the hands, feet, and neck; inflammation of blood vessels; and tissue damage to organ systems. Joints need solid but padded support. Long-term treatment with nonsteroidal antiinflammatory drugs (NSAIDs) or corticosteroid therapy may affect bleeding intraoperatively and wound healing postoperatively.


Paralyzed patients, such as those with spinal cord injury, are unable to move. Patients with lack of voluntary muscle control, such as with cerebral palsy, must be protected from falls or injuries during transport or transfer. These patients have decreased tactile sensitivity to heat and cold, so they must be protected from burns and hypothermia.



Impairment of cognitive function


Communicating with patients who have impaired cognitive function is sometimes difficult. Cognitive functions are based on intelligence and the ability to think, learn, remember, and solve problems.


Explanations about procedures and the environment may seem confusing and frightening to these patients. Verbal communication should be attempted at the patient’s level of understanding and response. Simple phrases and soft vocal tones can be reassuring. Some patients benefit from the presence of a significant other.


Patients with an autistic spectral disorder have a variety of cognitive levels. Understanding the individual characteristics of the patient’s condition is useful during communications with the patient.7,9 More information concerning autistic spectral disorder can be found at www.nichd.nih.gov/health/topics/asd.cfm. Cooperation during the surgical procedure may be hard to attain, and preoperative sedation may be necessary.



The patient with alteration of nutrition


Decreased intake and increased metabolic demands create nutritional problems in surgical patients. Drug therapy and procedure activities affect nutritional status; this should be considered when planning for a patient’s nutritional needs.4 Table 7-2 describes the effects that certain drugs have on nutrition. The preoperative assessment may reveal risk factors associated with alterations of nutrition. Patients undergoing procedures of the mouth, face, head, and neck may have mechanical difficulty taking adequate nutrition.




Malnutrition


Malnutrition in the surgical patient is caused by an inadequate intake or use of calories and protein preoperatively and/or postoperatively. The discrepancy between the intake of essential nutrients and the body’s demand for them creates a state of impaired functional ability and structural integrity.4


Surgical patients are commonly kept without food preoperatively for safe anesthetic administration and postoperatively to prevent nausea and vomiting. Patients who are undernourished have less than 70% to 80% of ideal body weight (IBW) and suffer greatly from the lack of caloric intake. As a result of malnutrition, the patient may experience the following:



1. Poor tolerance of anesthetic agents



2. Altered wound healing potential



3. Decreased serum electrolyte levels associated with anorexia, bulimia, alcoholism, and other chronic metabolic disturbances



4. Increased susceptibility to infection from immunologic incompetence, with a total lymphocyte count less than 1500/mm3


5. Sequential multisystem organ failure



6. Increased risk of morbidity and mortality


Serum blood tests help determine nutritional status and include total proteins, albumin/globulin ratio, and BUN level. Body weight is also significant. The average adult patient needs a minimum of 1500 calories daily to prevent body protein catabolism.


Hypermetabolic states can double that requirement to 3000 calories daily. If caloric intake is less than body requirements, protein is converted into carbohydrates for energy. Protein synthesis then becomes insufficient for restoration of body tissues. Box 7-1 describes conditions that place a patient at risk for protein deficiency and malnutrition.



BOX 7-1   Factors That Increase a Patient’s Risk for Protein-Based Nutritional Deficit




Depleted reserves of essential elements must be replenished to replace tissue loss and expedite wound healing. Protein deficiency impairs collagen formation, thereby delaying the healing process. Water-soluble vitamins C and B complex are important for tissue repair and nervous system function. The fat-soluble vitamins A, D, E, and K are important for neurovascular activities.


The patient’s depleted nutritional status lowers host resistance by impairing lymphocyte and neutrophil production. A definite relationship has been shown between hypoproteinemia and proliferative postoperative infection. Wound healing is impaired.



Metabolism


Metabolism is the phenomenon of synthesizing foodstuffs into complex elements and complex substances into simple ones in the production of energy. It involves two opposing phases:



Metabolic disorders such as diabetes and the stress response of traumatic injury can complicate the outcome of a surgical intervention. Hormonal responses to physical stress involve both anabolic and catabolic effects on the body, with catabolism being the predominant effect. The degree of metabolic reaction may depend greatly on the body’s reserve of labile protein. The patient’s preoperative nutritional state, the type and extent of the surgical procedure, and the effect of the surgical procedure on the patient’s ability to digest and absorb nutrients affect immediate postoperative metabolism.


Catabolic responses are augmented by preoperative fasting, cathartic preparation, adrenocortical responses to tissue trauma during the procedure, blood loss, and alterations in fluid and electrolyte balance. Patients with burns, traumatic injury, absorptive disorders, or toxemia need careful nutritional replacement because they usually have a severe protein deficit. Hydration and renal function are closely observed and monitored in the perioperative environment.


Drugs also can have an adverse affect on metabolic balance. Broad-spectrum antibiotics limit a disease process, but in association with dietary inadequacy, they can cause vitamin K deficiency in older patients by inhibiting the intestinal bacteria that produce that vitamin. Drug detoxification or excretion may be altered in patients with impaired kidney or liver function, leading to possible drug overdose.



Nutritional supplements


Dietary management is used to correct metabolic and nutritional abnormalities before the surgical procedure. In some patients, special nutritional supplements are indicated to build up or compensate for a permanent metabolic handicap. Enteral feedings help maintain the integrity of the gastrointestinal mucosa.4 Successful therapy is indicated by weight gain, a rise in plasma albumin, and a positive nitrogen balance. A chemically defined elemental diet may be administered via the following routes:




The patient with diabetes mellitus


Diabetes mellitus is an endocrine disorder that affects glucose metabolism and the production of insulin in the beta cells of the pancreas. Insulin is a hormone that helps break down carbohydrates. If insulin is not produced in sufficient quantities or is of poor quality, carbohydrates are not metabolized and are excreted in the urine as glucose. Glucose molecules are large and damage the cellular structure of the renal tubules of the kidneys.1,2


Usually genetic in origin, diabetes mellitus can be triggered in predisposed individuals by environmental stress. Management of the surgical patient with diabetes depends on the type and control of the disorder, which is one of three types:



1. Type 1: Insulin-dependent diabetes mellitus (IDDM). The pancreas produces little or no insulin, thus necessitating regular administration of insulin via injection. Onset may be at any age but usually occurs in juveniles (adolescents ages 12 to 16 years) and adults up to age 40 years.


2. Type 2: Non–insulin-dependent diabetes mellitus (NIDDM). The pancreas produces varying amounts of insulin. Onset may be at any age but usually occurs after age 40 years in obese persons. Blood glucose levels are controlled by diet and the administration of oral antihyperglycemics.


3. Diabetes mellitus associated with other conditions or syndromes. Impaired glucose tolerance may be the result of pancreatic or hormonal disease, drug or chemical toxicity, abnormal insulin receptors, or other genetic syndromes. The diabetes may be latent, asymptomatic, or borderline.


Stress caused by physical and emotional trauma, infection, or fever raises blood glucose levels and stimulates the pituitary and adrenal glands. The pituitary gland secretes adrenocorticotropic hormone (ACTH), which stimulates the production of glucocorticoids. These glucocorticoids in turn increase gluconeogenesis, the formation of glucose by the liver from noncarbohydrate sources. The resultant extra glucose enters the bloodstream.


Coincidentally, the adrenal glands secrete epinephrine, which accelerates the conversion of glycogen in the liver to glucose and also raises the level of blood sugar. More insulin is needed to metabolize this additional blood sugar. The primary goal in controlling diabetes is to maintain a stable internal environment, thereby averting a metabolic crisis. Extreme care must be taken to prevent the following:



1. Hyperglycemia and ketonuria



2. Ketoacidosis and acetonuria



3. Hypoglycemia and hypoglycemic shock



Prevention of these states depends on the following:



The preoperative assessment of patients with the potential for impaired glucose metabolism includes laboratory testing for fasting and postprandial blood glucose levels, urinalysis, complete blood count, BUN values, and serum electrolyte determinations. A chest x-ray study and electrocardiogram (ECG) also are advisable.



Common complications


The balance between caloric intake and glucose metabolism is disrupted during the perioperative experience. Patients with type 2 diabetes usually withstand a surgical intervention without crisis. Intraoperative metabolic control may be more difficult in patients with type 1 diabetes who have marked unpredictability and greater extremes in blood sugar levels. Lengthy major surgical procedures with extensive tissue trauma present the greatest challenge to regulation. Patients with diabetes are prone to the following:



• Dehydration and electrolyte imbalance


• Infection


• Inadequate circulation from neurovascular disease, which causes deficient tissue perfusion (Fig. 7-3)


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FIG. 7-3 Outcomes of tissue injury in the OR.

• Hypertension


• Hyperlipidemia that affects both coronary and peripheral arteries; peripheral edema can lead to gangrene


• Delayed wound healing as a result of increased protein breakdown or compromised circulation; glycogenesis, the breakdown of glycogen to glucose in the liver, diverts protein from tissue regeneration


• Neuropathy or nervous system disorders, which cause motor and sensory deficit


• Nephropathy, which affects small blood vessels in the kidneys


• Retinopathy, which affects small vessels in eyes, and blindness


• Neuropathic musculoskeletal disease; severe bone destruction may cause neuropathic fractures


• Neurogenic bladder, which causes incontinence; urinary tract infections are common


Diabetes causes many bodily changes that increase in frequency with duration of the disease. Physiologic dysfunctions, as listed in Table 7-3, make a person with diabetes a potentially high-risk patient.



TABLE 7-3


Physiologic Dysfunctions in Patients at High Risk with Diabetes and Obesity








































































































Diabetes Mellitus Obesity
INTEGUMENTARY SYSTEM
Skin that may be dry, itchy Hirsutism in women
Loss of fat from adipose tissue Excess subcuticular fat
Injuries that heal slowly Injuries that heal slowly
MUSCULOSKELETAL SYSTEM
Neuropathic skeletal disease with bone destruction Osteoarthritis
Leg pain, neuropathy Chronic back pain
Muscular wasting Strain on joints and ligaments
  Joint pain
  Diminished mobility
CARDIOVASCULAR SYSTEM
Increased heart rate Myocardial hypertrophy
Predisposition to coronary artery disease High blood pressure
Predisposition to thrombophlebitis Arteriosclerosis
Peripheral edema Venous stasis
  Varicose veins
RESPIRATORY SYSTEM
Predisposition to infection Shortness of breath
  Decreased tidal volume
  Decreased lung expansion
RENAL SYSTEM
Nephropathy Vascular changes in kidneys
Increased excretion Decreased intestinal mobility
Neurogenic bladder Predisposition to liver and biliary disease
GASTROINTESTINAL SYSTEM
Secretion of glucose by liver  
NEUROLOGIC SYSTEM
Neuropathy  
Sensory impairment  
Retinopathy and blindness  
ENDOCRINE SYSTEM
Poor or nonexistent insulin production Predisposition to diabetes mellitus
Poor metabolic control Pituitary abnormalities
Increased production of cortisol by adrenal glands under stress Poor metabolic control
Electrolyte imbalance Dysfunctional uterine bleeding

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Apr 6, 2017 | Posted by in GENERAL SURGERY | Comments Off on The patient: the reason for your existence

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