Module 1 part 1: Vulnerability and Informed Consent Flashcards
List the reasons why a perioperative patient might be vulnerable
- pt requiring surgery are vulnerable d/t countless stressors and previous personal experience
- increased risk of harm and potential to develop actual and potential problems r/t anaesthesia and surgery
- surgical intervention exasperates sense of powerlessness and inc. vulnerability
- Anxiety impacts homeostatis within pt - need to recognize this
- STRESS resulting physical symptoms r/t inc. catecholamines, oxytocin, ADH and prolactin. Involves 3 stages
What are the 3 stages of stress response (A.R.E)?
1) Alarm stage: body initially exposed to stressor and resistance dec.
2) Resistance Stage: The body endeavours to adjust to stressor
3) Exhaustion Stage: The body’s adaptation energy is exhausted
Explain the process and affects of an ACUTE STRESS RESPONSE
- Hypothalamopituitary-adrenal axis activated. Various hormones secreted
- Acetylcholine activates adrenaline and noradrenaline secretion = improves cardiac and resp. fxn d/t HR inc. r/t inc. force of contraction
- Bronchioles dilate –> rate and depth of resp. inc–> improved blood flow to heart and skeletal muscle
- Adrenaline secretion –> inc. blood glucose d/t glycogen breakdown and gluconeogenesis + inhibiting insulin secretion
- Other response: sweating, pilo-erection of skin. dilated pupils, dec. GI fxn and urination.
- Psychological: uneasy, fearful, withdrawn, angry
Explain the process and affects of a Chronic STRESS RESPONSE
- reduction of susceptibility to pain and circulating endogenous analgesia (endorphins)
- Gluconeogenesis = evevated blood glucose
- Kidneys retain NA+ and H20 = inc. blood volume and BP
- inc. blood viscosity = inc. blood coagulation
- immune system suppression and inflammatory response
- burnout r/t emotional exhaustion and fatigue
Why might a periop pt be anxious?
- waiting, pain, fear of unknown, anaesthesia and surgery
- wmn more anxious than men
- includes 6 themes
What are the 6 themes r/t anxiety?
- preoccupation
- outcome concerns
- being unconscious
- loss of control
- dependence on others
- pain/discomfort
What is social vulnerability?
Involves an individuals demographic, cultural or economic data which may be relevant factors in the potential development of disease
- higher level of economic status and academic achievement –> inc. capacity to make informed choices within society regarding health issues
What are the variables that decrease a persons capacity to make informed choices and increase vulnerability?
- age
- gender
- income
- minority status
What are the social variables r/t to periop pt’s that increase a person’s vulnerability?
- age
- gender
- marital status
- earnings
- educational attainment
- religion
- race
- personal experience
What are the dimensions psychological vulnerability?
The emotional effects of anxiety or stress which may cause actual or potential harm to the individuals identity or self-esteem
- Internal and external locus of control
- Personal Traits
- Etic (external) and Emic (internal) perceptions of harm
What are the variable that may inc. a pt’s susceptibility to psychological vulnerability?
- removed from normal surroundings
- reduced personal capacity to cope
- manifests as feelings of hopelessness and anxiety –> distress
- depression and apathy leading to negative impact on postoperative recovery
- cultural issues
Periop stressors that contribute to psychological vulnerability
- needle phobia
- fear of not waking up from anaesthesia
- fear of waking during surgery
- loss of control
what is meant by “locus of control”?
locus of control is the degree to which people believe that they have control over the outcome of events in their lives, as opposed to external forces beyond their control
How does locus of control impact a periop pt?
The unknown perioperative environment itself diminishes self-control and this in
turn may compound the increasing sense of vulnerability that patients often experience
individuals have an innate desire to be involved in decision-making regarding
their care
Internal locus of control vs external locus of control affecting a person?
Internal: have a believe in their own ability to shape their destiny
External: believe that luck, fate and powerful others shape their destiny
What personal traits inc. a patients susceptibility to vulnerability?
- personal traits within the environment
- inborn characteristics
- acquired characteristics
- pt’s perception and their sense of control on their circumstances
- Autonomy: loss of independence, self-identity and self-determination
- Self-efficacy: ability to cope and recover from surgery
Inborn characteristics vs acquired characteristics that contribute to vulnerability?
inborn: genetic predisposition, personal temperament, susceptibility to disease, age, gender, and race
Acquired: life experience and responses to trauma and development of coping mechanisms
Etic (external) vs Emic (internal) perceptions of harm in periop environment?
Etic: anaesthesia, surgical procedure and technical theatre environment
Emic: Pt’s perception arising from previous and current life experiences
What holistic approach should be implemented for periop pt’s?
Patient-centered care
What is meant by physical vulnerability and does it relate to?
Is caused by the individual’s inability to resist further harm as heir existing condition has been compromised by disease or trauma
- relates to an individuals physiological state and the disease acquirement, development, morbidity and mortality
What is “technical environment”?
- electrical equipment
- noxious gases
- toxic and combustible materials
blood and it’s components
How is “Risk” defined?
A situation involving exposure to danger i.e risk of something happening or exposure to a person that is a threat to health
Actual vs Potential Vulnerability:
ACTUAL VULNERABILITY: the known circumstances rendering an individual susceptible caused by known periop stressors (needle phobia, fear of dying, loss of control etc)
POTENTIAL VULNERABILITY: Circumstances which may or may not cause vulnerability r/t the pt’s perception of the circumstances and state of mind within periop situation
What are the 3 themes in the concept of vulnerability (L.R.M)?
1) LABELS: The classification of patients into groups heightened awareness of existing
vulnerability within specific groups prior to surgical intervention and
alerted practitioners to utilise effective management strategies.
2) RECOGNITION: Physical and behavioural signs were identified, along with awareness of
the patient’s state of mind and the anxietal state caused by the
perioperative environment, the impending surgery and their own
perception of the situation.
3) MANAGEMENT(2 themes): In relation to the management of perioperative vulnerability, two main
themes were identified: PROFESSIONAL QUALITIES and STRATEGIES. When
dealing with perioperative vulnerability it was considered important that
practitioners had a range of skills including professional, communication
and personal alongside the value of presence. Knowledge and experience
was imperative, knowledge of their role, being confident and competent.
What are the 3 conditions that consent must include?
- be adequately informed
- capacity to make decisions
- free from coercion
What information is required for a pt. to make an informed decision?
- condition for which the care is proposed
- the reason
- risks and benefits
- Alternatives
- info is sufficient, specific and evidence-based
What is informed consent?
- the pt’s autonomous decision about whether to undergo sx
- must include voluntary and written consent from pt for nonemergent sx
Who’s responsibility is it to provide a clear and simple explanation of what the sx will entail, benefits vs risk, alternatives and possible complications?
The surgeons
In what circumstances is informed consent necessary?
- invasive procedures: surgical incision, biopsy, cystoscopy, paracentesis
- non-surgical that carries inc. risk
- involving radiation
What is voluntary consent?
VOLUNTARY CONSENT:
- given free w/o coercion
- 18 + yo
3 dimensions of vulnerability
social
psychological
physical
What is vulnerability?
The quality or state of being exposed to the possibility of being attached or harmed, either physcially or emotionally
Why do we need to know QNES?
- to reduce harm
- increase patient safety
What does the QNES include?
Informatics Safety Quality improvement Evidence Based Practice Teamwork and Collaboration Patient-centerd Care
Where did informed consent come from?
Nuremberg Trials
Who can provide informed consent?
- individual
- surrogate
- emancipated minor
Physician in an emergency
