AORN JOURNAL
MARCH 1991, VOL. 53, NO 3
Surgical Outpatient Concerns WHATEVERYPERIOPERATIVE NURSESHOULD KNOW Linda M. Caldwell, RN
0
utpatient surgery has been a growing phenomenon in the health care field for nearly two decades. In some states, the number of outpatient operations performed now exceeds those done on inpatients, and this growth is expected to continue at least through the 1990s.’ Studies of stress related to hospitalization and to specific medical procedures have generated much literature,* however, no studies have identified what patients find stressful about having outpatient surgery. Compared to other topics such as stress or coping, there has been very little formal research on any aspect of outpatient surgery, despite the increase in volume of this type of surgery. A recent research study examined stress and coping by patients who underwent outpatient surgery and how preferences for information and self-care may influence preoperative stress and coping.’ Data was collected by interviews and questionnaires. Seventy-six adult patients, having outpatient surgery for the first time at a large teaching hospital in northern New England, participated in the qualitative part of this study. For the interview, subjects signed consent forms and were asked, “What is it that has concerned you, or is concerning you, most about having this surgery on an outpatient basis?” Six broad areas of concern were identified from their responses. This article summarizes those concerns, which is the qualitative portion of the research study.
Professional Care
C
oncerns about professional care focused on the availability and continuity of care following discharge, as well as the competence of the surgical team. Many of the concerns about availability and continuity of care were interrelated in this sample because many patients traveled long distances from rural areas. These concerns were expressed in comments related to the development of postopera-
Linda M . Caldwell, RN, DNSc, is an associute professor of nursing at Curry College, Milton, Mass. She received her bachelor of science d e g r e e in nursing f r o m N o r t h e a s t e r n University, Boston; her master of science d e g r e e i n nursing f r o m B o s t o n College, Chestnut Hill,Mass; and her doctorate in n w s ing porn Boston University.
The author acknowledges Carole A. Shea, PhD, for her help with data analysis. 761
AORN JOURNAL
MARCH 1991, VOL. 53,NO 3
Some patients expressed concern about not having enough information, while others felt that they had too much information. tive complications and the distance of the patient’s home from the hospital. Other patients were concerned not with availability of care but with continuity. Several patients were concerned that they would have to see an unfamiliar physician if something went wrong. Concerns about the quality of professional care were expressed both directly and indirectly. Some patients stated this area of concern directly in such comments as . . . as long as this works . . . , “. . .just so it’s done right . . . ,” or . . . as long as nothing goes wrong . . . I hope they get what they’re looking for and that everything will be all right.” Several patients, in response to the question of what was concerning them, stated how much they trusted their physicians or the health care teams. Because this was not the question asked, it appeared that an implied or indirectly stated concern was present. “
”
“
Information
I
nformational concerns varied. Some patients expressed concern about not having enough information, while others felt that they had too much information. Several patients stated that they did not know enough to ask the right questions. This was somewhat expected because the entire sample consisted of patients undergoing outpatient surgery for the first time. Comments such as “this is all new to me,” “I don’t know what to expect,” or “I don’t know the questions to ask” reflected this concern. Other patients stated that they did not want to know more about the surgical experience. They believed too much information would make them nervous. Perceptions of excessive information were mentioned several times in relation to informational brochures and consent forms. One woman said that her main concern was signing the consent form. She said she 762
wondered about the statement on the form that states the surgery center is not responsible, “It’s like absolving them in case I die.” Some authors question the value of extensive information in consent forms.4 It appears that, at least for some patients, extensive information induces stress. Difficulty in following preoperative instructions was another area of information concern. In particular, the instruction not to eat or drink preoperatively was problematic. One patient said, “Not eating when you are home is hard, especially once you realize you can’t.’’
The Pi-ocess of Surgery
P
atients had concerns about the process of surgery including the surgical procedure itself, the preoperative waiting, the fear of being discharged too soon, and the very common fear of anesthesia. Concerns about waiting may have been somewhat biased in this study. Patients who were included were, by definition, those who had to wait. It required 20 to 30 minutes to collect all the data from each patient. Therefore, only those patients who were expected to have a wait were approached. Many patients, however, waited longer than 30 minutes. One women expressed her concern about the wait as . . . you have to come in so early, I’ll spend two hours waiting and I’ll worry and think a lot in that time.” Another woman stated, . . . waiting two and a half to three hours is tough it really has made me anxious.” A related concern was the time available for care and recovery postoperatively. One patient was concerned that he would be rushed after his surgery. He said, “My surgery is late and this place is only open until a certain time.” Fear of anesthesia was very common; 30.3% of the patients listed anesthesia as one of their “
“
AORN JOURNAL
MARCH 1991, VOL. S 3 , NO 3
Many patients were worried about the effect of surgery on their ability to carry out their usual daily activities.
oncerns about health outcomes centered primarily on fear of the unknown. Fears of recurrence, the possibility of malignancy, and the probability of additional surgery based on the findings of the present surgery were all mentioned as sources of worry. These concerns were expressed in comments such as “ . . . what will they find?”, “I want them to say, there is nothing wrong, go home, you are healthy,” and “My fear is that they will find something, and I’ll have to have another operation.” Almost half of the sample (43.5%) were uncertain about malignancy before the surgical procedure, so the worry about unknown health outcomes was expected.
being dependent on others, and being unable to care for dependents. Many patients were concerned about the effect of the surgery on their ability to carry out their usual daily activities. Surgical complications and pain were areas of concern and were related in statements such as “If I feel well enough to go home afterwards that is great, but if there are complications I would be more than willing to stay,” or “I’m worried about the pain, that maybe I can’t deal with it at home.” The subjects in this study were primarily young females and they frequently expressed concern about the care of their children after discharge. “I worry about taking care of the kids when I get home . . . usually you stay a day or so until you feel ready . . . I’m not sure how I will manage with them if I don’t feel so great.” The effect of outpatient surgery on their functioning at home also was mentioned. ‘‘It’s not as relaxing going home; you see messes and want to pick them up, but you probably can’t.’’ These concerns relate to the inability to carry out normal role function and therefore are appraised as stressful. Other patients were concerned about being at home alone. One elderly patient said, “I’m not sure there will be people around afterward and that could be a problem. People aren’t very helpful. I tried to get a ride back but I couldn’t, now I’llhave to take a taxi.” Having social support has been identified as anxiety reducing.s Lack of this option, particularly if it is a usual coping strategy, would contribute to the stress of a situation. Additionally, loneliness in itself may be stressful.h
Recover-y Process
Personal Vulnerability
concerns. Several patients mentioned a prior unpleasant experience as an inpatient as the basis of their concern. Others were fearful because of the novelty of the experience for them. One man said, “I’m scared. I’m not used to going to sleep when it’s not bedtime . . . the anesthesia, I’ve never felt that experience before . . . will I wake up after the operation and be sick, and can I eat? I’ve never been put to sleep . . . this is all new.” Local anesthesia generated its own type of concern, illustrated by statements such as “If I were knocked out it would be easier to deal with,” “I talked to the anesthesia guy last week but there is no guarantee that he will be the one today,” and “I want something to knock out my mind as well as my body.”
Health Outcome
C
T
h e recovery process worried s o m e patients. Their fears included fear of pain and complications after discharge,
M
any patients directly stated that they were worried, anxious, scared, or nervous. Several subjects who were hav-
d 763
MARCH 1991, VOL. 53, NO 3
AORN JOURNAL
The perception that surgery is minor may lead some patients to the conclusion that recovery should occur quickly. ing gynecologic surgery also expressed feelings of anger or embarrassment about the type of surgery. An example of this emotion is contained in this statement: “When I wake up I’ll feel angry. 1’11 feel violated and mutilated because of the nature of the surgery . . . the whole thing is humiliating, not being in control . . . the doctors and nurses will take over. . . it’s a violation of me to have a D&C.”
The Nurses’ Role
M
any of these concerns are common to all surgical patients, whether they are having their surgery on an inpatient or an outpatient basis. For example, fear of malignancy or anesthesia and concerns about professional competence or personal vulnerability may be fears common to any surgery. Other concerns may be directly related to the surgery being performed on an outpatient basis. Availability and continuity of care in the postoperative period may be of more concern to surgical outpatients than to patients who are hospitalized for surgery. Helping patients identify resources available to them postoperatively, both at the surgical center and in their own communities, may help decrease this concern. Scheduling and waiting are problems that are probably difficult to change. Delays may be unavoidable because cases may be added to the OR schedule, or some cases may take longer than anticipated. Patients should be told to anticipate a wait for surgery and could be directed to bring something with them (eg, deck of cards, knitting). Other concerns specific to the outpatient setting include the fear of being discharged too soon from the surgical unit. Once discharged, the fear of being isolated from care may arise, particularly if the patient’s home is far away. The unit where this research was carried out 766
remained open until the last patient was ready for discharge-even if it meant nurses stayed after the usual closing time. Patients, however, still identified being discharged too soon as an area of concern, particularly if their surgery was scheduled late in the day. Reinforcing the fact that patients are not discharged until they are physically ready to go home may help relieve this worry. Resuming normal activities and coping with recovery may be more problematic for outpatients. Because outpatients are immediately discharged to their usual environments, they may feel pressured to resume normal activities. In contrast, inpatients have some recovery time during which their normal roles are expected to be abandoned. Talking with the outpatient and his or her family may identify ways to decrease this worry. Even though it was not mentioned as a problem, patients frequently perceived surgery as minor because it was done on an outpatient basis. This perception did not appear to be a concern of patients, but it was mentioned frequently enough to be a concern to nursing. Many patients made statements such as “going home makes me feel safer,” “it must be an easy procedure if I can go home afterward,” and “outpatient gives me the idea that it’s minor and the risks are lower.” Because patients perceive surgery as minor, it may lead them to the conclusion that recovery should occur quickly. This belief may give rise to apprehension when it takes longer for the patient to recover than he or she had anticipated. Research has found that the negative effects of even light anesthesia can be measured two or more days postoperatively; this is more time than either patients or physicians anticipated.’ Nurses should be aware of this perception and correct any misunderstandings during preoperative teaching without causing
MARCH 1991, VOL. S3, NO 3
undue apprehension or alarm.
Summary
J
ust asking the patient what he or she is concerned about may help. The vast majority of patients in this study listed multiple concerns when asked. Very few hesitated or had to take time to think about the question or their answer. Give them your time and listen. C
Notes 1. Massachusetts Hospital Association, “Outpatient majority,” Mass. Health Care 2 (February 1988) 5 ; A McCreary, “Ambulatory surgery,” Evening Express (Portland, Maine) 36; J E Davis, “The future of major ambulatory surgery,” Surgical Clinics qf North America 67 (August 1987) 893-901. 2. B J Volicer, “Patients’ perceptions of stressful events associated with hospitalization,” Nursing Research 23 (May/June 1974) 235-238; B J Volicer, “Stress factors in the experience of hospitalization,” in Communicating Nursing Research, ed M V Batey, 8 (Boulder, Colo: Western Interstate Commission for Higher Education, 1977) 53-67; J A Gurklis, E M Menke, “Identification of stressors and use of coping methods in chronic hemodialysis patients,” Nursing Research 37 (July/August 1988) 236-239; J A Carr, M J Powers, “Stressors associated with coronary bypass surgery,” Nursing Research 3.5 (July/August 1986) 243-246; K S Baldree, S P Murphy, M J Powers, “Stress identification and coping patterns in patients on hemodialysis,” Nursing Research 3 1 (March/April 1982) 107-1 12. 3. L M Caldwell, “Preferences for information and self care, stress and coping with outpatient surgery: A descriptive correlational study,” Dissertation Abstracts International 50 (Doctoral dissertation, Boston University, 1988) 1850B. 4. L M Wallace, “Psychological preparation as a method of reducing the stress of surgery,” Journal of Human Stress 10 (Summer 1984) 62-69. 5. L M Wallace, “Communication variables in the design of pre-surgical preparatory information,” British Joiirnal of Clinical Psychology 25 (May 1986) 111-118. 6. R S Lazarus, A DeLongis, “Psychological stress and coping in aging,” American Psychologist 38 (March 1983) 245-254. 7. Wallace, “Psychological preparation as a method of reducing the stress of surgery,” 62-69.
AORN JOURNAL
Osteoporosis Fractures Are Preventable Pain, disability, and death from fractures due to postmenopausal osteoporosis are preventable if physicians detect women at risk and start treatment early, according to an international panel of experts. Osteoporosis causes more than 1.3 million fractures each year in the United States and the cost of treating these fractures is more than $10 billion a year. Early detection and treatment can reduce these costs significantly, according to a news release from the Third International Symposium and Consensus Development Conference held in Copenhagen, Denmark, in October 1990. Antiresorptive agents limit the amount of bone loss in postmenopausal women. The most common preventative agent is estrogen replacement therapy. Estrogen can reduce hip and wrist fractures if given for at least five years early in menopause. Another class of antiresorptive agents called bisphosphonates reduces the likelihood that women will develop “dowager’s hump. ” The panel concluded that estrogen therapy also provides cardiovascular benefits in addition to preventing bone loss. It also concluded that high calcium intake will not blunt the accelerated bone loss that occurs at the onset of menopause, but it is necessary to maintain peak bone mass throughout life. The experts concluded that fluoride stimulates the production of bone-building cells and increases bone mass but its effect on fracture incidence is controversial. They agreed that clinical investigations of parathyroid hormone to increase total bone mass should be continued. The panel urged increases in research to enhance understanding of the causes of osteoporosis and called for additional methods to accurately diagnose bone loss and restore healthy bone. The meeting was sponsored by the European Osteoporosis Foundation, The US National Osteoporosis Foundation, and the US National Institute of Arthritis and Musculoskeletal and Skin Disease. 161
MARCH 1991, VOL. 53, NO 3
Surgical Outpatient Concerns WHATEVERYPERIOPERATIVE NURSESHOULD KNOW Linda M. Caldwell, RN
0
utpatient surgery has been a growing phenomenon in the health care field for nearly two decades. In some states, the number of outpatient operations performed now exceeds those done on inpatients, and this growth is expected to continue at least through the 1990s.’ Studies of stress related to hospitalization and to specific medical procedures have generated much literature,* however, no studies have identified what patients find stressful about having outpatient surgery. Compared to other topics such as stress or coping, there has been very little formal research on any aspect of outpatient surgery, despite the increase in volume of this type of surgery. A recent research study examined stress and coping by patients who underwent outpatient surgery and how preferences for information and self-care may influence preoperative stress and coping.’ Data was collected by interviews and questionnaires. Seventy-six adult patients, having outpatient surgery for the first time at a large teaching hospital in northern New England, participated in the qualitative part of this study. For the interview, subjects signed consent forms and were asked, “What is it that has concerned you, or is concerning you, most about having this surgery on an outpatient basis?” Six broad areas of concern were identified from their responses. This article summarizes those concerns, which is the qualitative portion of the research study.
Professional Care
C
oncerns about professional care focused on the availability and continuity of care following discharge, as well as the competence of the surgical team. Many of the concerns about availability and continuity of care were interrelated in this sample because many patients traveled long distances from rural areas. These concerns were expressed in comments related to the development of postopera-
Linda M . Caldwell, RN, DNSc, is an associute professor of nursing at Curry College, Milton, Mass. She received her bachelor of science d e g r e e in nursing f r o m N o r t h e a s t e r n University, Boston; her master of science d e g r e e i n nursing f r o m B o s t o n College, Chestnut Hill,Mass; and her doctorate in n w s ing porn Boston University.
The author acknowledges Carole A. Shea, PhD, for her help with data analysis. 761
AORN JOURNAL
MARCH 1991, VOL. 53,NO 3
Some patients expressed concern about not having enough information, while others felt that they had too much information. tive complications and the distance of the patient’s home from the hospital. Other patients were concerned not with availability of care but with continuity. Several patients were concerned that they would have to see an unfamiliar physician if something went wrong. Concerns about the quality of professional care were expressed both directly and indirectly. Some patients stated this area of concern directly in such comments as . . . as long as this works . . . , “. . .just so it’s done right . . . ,” or . . . as long as nothing goes wrong . . . I hope they get what they’re looking for and that everything will be all right.” Several patients, in response to the question of what was concerning them, stated how much they trusted their physicians or the health care teams. Because this was not the question asked, it appeared that an implied or indirectly stated concern was present. “
”
“
Information
I
nformational concerns varied. Some patients expressed concern about not having enough information, while others felt that they had too much information. Several patients stated that they did not know enough to ask the right questions. This was somewhat expected because the entire sample consisted of patients undergoing outpatient surgery for the first time. Comments such as “this is all new to me,” “I don’t know what to expect,” or “I don’t know the questions to ask” reflected this concern. Other patients stated that they did not want to know more about the surgical experience. They believed too much information would make them nervous. Perceptions of excessive information were mentioned several times in relation to informational brochures and consent forms. One woman said that her main concern was signing the consent form. She said she 762
wondered about the statement on the form that states the surgery center is not responsible, “It’s like absolving them in case I die.” Some authors question the value of extensive information in consent forms.4 It appears that, at least for some patients, extensive information induces stress. Difficulty in following preoperative instructions was another area of information concern. In particular, the instruction not to eat or drink preoperatively was problematic. One patient said, “Not eating when you are home is hard, especially once you realize you can’t.’’
The Pi-ocess of Surgery
P
atients had concerns about the process of surgery including the surgical procedure itself, the preoperative waiting, the fear of being discharged too soon, and the very common fear of anesthesia. Concerns about waiting may have been somewhat biased in this study. Patients who were included were, by definition, those who had to wait. It required 20 to 30 minutes to collect all the data from each patient. Therefore, only those patients who were expected to have a wait were approached. Many patients, however, waited longer than 30 minutes. One women expressed her concern about the wait as . . . you have to come in so early, I’ll spend two hours waiting and I’ll worry and think a lot in that time.” Another woman stated, . . . waiting two and a half to three hours is tough it really has made me anxious.” A related concern was the time available for care and recovery postoperatively. One patient was concerned that he would be rushed after his surgery. He said, “My surgery is late and this place is only open until a certain time.” Fear of anesthesia was very common; 30.3% of the patients listed anesthesia as one of their “
“
AORN JOURNAL
MARCH 1991, VOL. S 3 , NO 3
Many patients were worried about the effect of surgery on their ability to carry out their usual daily activities.
oncerns about health outcomes centered primarily on fear of the unknown. Fears of recurrence, the possibility of malignancy, and the probability of additional surgery based on the findings of the present surgery were all mentioned as sources of worry. These concerns were expressed in comments such as “ . . . what will they find?”, “I want them to say, there is nothing wrong, go home, you are healthy,” and “My fear is that they will find something, and I’ll have to have another operation.” Almost half of the sample (43.5%) were uncertain about malignancy before the surgical procedure, so the worry about unknown health outcomes was expected.
being dependent on others, and being unable to care for dependents. Many patients were concerned about the effect of the surgery on their ability to carry out their usual daily activities. Surgical complications and pain were areas of concern and were related in statements such as “If I feel well enough to go home afterwards that is great, but if there are complications I would be more than willing to stay,” or “I’m worried about the pain, that maybe I can’t deal with it at home.” The subjects in this study were primarily young females and they frequently expressed concern about the care of their children after discharge. “I worry about taking care of the kids when I get home . . . usually you stay a day or so until you feel ready . . . I’m not sure how I will manage with them if I don’t feel so great.” The effect of outpatient surgery on their functioning at home also was mentioned. ‘‘It’s not as relaxing going home; you see messes and want to pick them up, but you probably can’t.’’ These concerns relate to the inability to carry out normal role function and therefore are appraised as stressful. Other patients were concerned about being at home alone. One elderly patient said, “I’m not sure there will be people around afterward and that could be a problem. People aren’t very helpful. I tried to get a ride back but I couldn’t, now I’llhave to take a taxi.” Having social support has been identified as anxiety reducing.s Lack of this option, particularly if it is a usual coping strategy, would contribute to the stress of a situation. Additionally, loneliness in itself may be stressful.h
Recover-y Process
Personal Vulnerability
concerns. Several patients mentioned a prior unpleasant experience as an inpatient as the basis of their concern. Others were fearful because of the novelty of the experience for them. One man said, “I’m scared. I’m not used to going to sleep when it’s not bedtime . . . the anesthesia, I’ve never felt that experience before . . . will I wake up after the operation and be sick, and can I eat? I’ve never been put to sleep . . . this is all new.” Local anesthesia generated its own type of concern, illustrated by statements such as “If I were knocked out it would be easier to deal with,” “I talked to the anesthesia guy last week but there is no guarantee that he will be the one today,” and “I want something to knock out my mind as well as my body.”
Health Outcome
C
T
h e recovery process worried s o m e patients. Their fears included fear of pain and complications after discharge,
M
any patients directly stated that they were worried, anxious, scared, or nervous. Several subjects who were hav-
d 763
MARCH 1991, VOL. 53, NO 3
AORN JOURNAL
The perception that surgery is minor may lead some patients to the conclusion that recovery should occur quickly. ing gynecologic surgery also expressed feelings of anger or embarrassment about the type of surgery. An example of this emotion is contained in this statement: “When I wake up I’ll feel angry. 1’11 feel violated and mutilated because of the nature of the surgery . . . the whole thing is humiliating, not being in control . . . the doctors and nurses will take over. . . it’s a violation of me to have a D&C.”
The Nurses’ Role
M
any of these concerns are common to all surgical patients, whether they are having their surgery on an inpatient or an outpatient basis. For example, fear of malignancy or anesthesia and concerns about professional competence or personal vulnerability may be fears common to any surgery. Other concerns may be directly related to the surgery being performed on an outpatient basis. Availability and continuity of care in the postoperative period may be of more concern to surgical outpatients than to patients who are hospitalized for surgery. Helping patients identify resources available to them postoperatively, both at the surgical center and in their own communities, may help decrease this concern. Scheduling and waiting are problems that are probably difficult to change. Delays may be unavoidable because cases may be added to the OR schedule, or some cases may take longer than anticipated. Patients should be told to anticipate a wait for surgery and could be directed to bring something with them (eg, deck of cards, knitting). Other concerns specific to the outpatient setting include the fear of being discharged too soon from the surgical unit. Once discharged, the fear of being isolated from care may arise, particularly if the patient’s home is far away. The unit where this research was carried out 766
remained open until the last patient was ready for discharge-even if it meant nurses stayed after the usual closing time. Patients, however, still identified being discharged too soon as an area of concern, particularly if their surgery was scheduled late in the day. Reinforcing the fact that patients are not discharged until they are physically ready to go home may help relieve this worry. Resuming normal activities and coping with recovery may be more problematic for outpatients. Because outpatients are immediately discharged to their usual environments, they may feel pressured to resume normal activities. In contrast, inpatients have some recovery time during which their normal roles are expected to be abandoned. Talking with the outpatient and his or her family may identify ways to decrease this worry. Even though it was not mentioned as a problem, patients frequently perceived surgery as minor because it was done on an outpatient basis. This perception did not appear to be a concern of patients, but it was mentioned frequently enough to be a concern to nursing. Many patients made statements such as “going home makes me feel safer,” “it must be an easy procedure if I can go home afterward,” and “outpatient gives me the idea that it’s minor and the risks are lower.” Because patients perceive surgery as minor, it may lead them to the conclusion that recovery should occur quickly. This belief may give rise to apprehension when it takes longer for the patient to recover than he or she had anticipated. Research has found that the negative effects of even light anesthesia can be measured two or more days postoperatively; this is more time than either patients or physicians anticipated.’ Nurses should be aware of this perception and correct any misunderstandings during preoperative teaching without causing
MARCH 1991, VOL. S3, NO 3
undue apprehension or alarm.
Summary
J
ust asking the patient what he or she is concerned about may help. The vast majority of patients in this study listed multiple concerns when asked. Very few hesitated or had to take time to think about the question or their answer. Give them your time and listen. C
Notes 1. Massachusetts Hospital Association, “Outpatient majority,” Mass. Health Care 2 (February 1988) 5 ; A McCreary, “Ambulatory surgery,” Evening Express (Portland, Maine) 36; J E Davis, “The future of major ambulatory surgery,” Surgical Clinics qf North America 67 (August 1987) 893-901. 2. B J Volicer, “Patients’ perceptions of stressful events associated with hospitalization,” Nursing Research 23 (May/June 1974) 235-238; B J Volicer, “Stress factors in the experience of hospitalization,” in Communicating Nursing Research, ed M V Batey, 8 (Boulder, Colo: Western Interstate Commission for Higher Education, 1977) 53-67; J A Gurklis, E M Menke, “Identification of stressors and use of coping methods in chronic hemodialysis patients,” Nursing Research 37 (July/August 1988) 236-239; J A Carr, M J Powers, “Stressors associated with coronary bypass surgery,” Nursing Research 3.5 (July/August 1986) 243-246; K S Baldree, S P Murphy, M J Powers, “Stress identification and coping patterns in patients on hemodialysis,” Nursing Research 3 1 (March/April 1982) 107-1 12. 3. L M Caldwell, “Preferences for information and self care, stress and coping with outpatient surgery: A descriptive correlational study,” Dissertation Abstracts International 50 (Doctoral dissertation, Boston University, 1988) 1850B. 4. L M Wallace, “Psychological preparation as a method of reducing the stress of surgery,” Journal of Human Stress 10 (Summer 1984) 62-69. 5. L M Wallace, “Communication variables in the design of pre-surgical preparatory information,” British Joiirnal of Clinical Psychology 25 (May 1986) 111-118. 6. R S Lazarus, A DeLongis, “Psychological stress and coping in aging,” American Psychologist 38 (March 1983) 245-254. 7. Wallace, “Psychological preparation as a method of reducing the stress of surgery,” 62-69.
AORN JOURNAL
Osteoporosis Fractures Are Preventable Pain, disability, and death from fractures due to postmenopausal osteoporosis are preventable if physicians detect women at risk and start treatment early, according to an international panel of experts. Osteoporosis causes more than 1.3 million fractures each year in the United States and the cost of treating these fractures is more than $10 billion a year. Early detection and treatment can reduce these costs significantly, according to a news release from the Third International Symposium and Consensus Development Conference held in Copenhagen, Denmark, in October 1990. Antiresorptive agents limit the amount of bone loss in postmenopausal women. The most common preventative agent is estrogen replacement therapy. Estrogen can reduce hip and wrist fractures if given for at least five years early in menopause. Another class of antiresorptive agents called bisphosphonates reduces the likelihood that women will develop “dowager’s hump. ” The panel concluded that estrogen therapy also provides cardiovascular benefits in addition to preventing bone loss. It also concluded that high calcium intake will not blunt the accelerated bone loss that occurs at the onset of menopause, but it is necessary to maintain peak bone mass throughout life. The experts concluded that fluoride stimulates the production of bone-building cells and increases bone mass but its effect on fracture incidence is controversial. They agreed that clinical investigations of parathyroid hormone to increase total bone mass should be continued. The panel urged increases in research to enhance understanding of the causes of osteoporosis and called for additional methods to accurately diagnose bone loss and restore healthy bone. The meeting was sponsored by the European Osteoporosis Foundation, The US National Osteoporosis Foundation, and the US National Institute of Arthritis and Musculoskeletal and Skin Disease. 161
