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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

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

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)

Functions | Pricing | Pricing Control | Define Condition Types | Maintain Condition Types [V/06]

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

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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

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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