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Abstract |
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 Top Abstract Current Trends in Surgery...Postoperative ComplicationsUnique Nursing Considerations...ConclusionsReferences |
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Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
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). Obesity is associated with increased risks for mortality and morbidity and with certain health conditions3,4 (Table 2). In addition, otherwise healthy persons who are obese are at risk for mild kidney damage and some loss of renal function.5
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| Obesity has doubled from 15% to 31% in the past 20 years.
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Morbid obesity, also called medically complicated obesity and clinically severe obesity, is defined as a BMI of 40 or greater or a BMI of 35 or greater plus a weight-related comorbid condition. The exact cause of obesity is unknown; however, it is considered multifactorial, including genetic, metabolic, environmental, social, behavioral, and psychological factors.
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Current Trends in Surgery for Patients With Morbid Obesity |
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TopAbstractCurrent Trends in Surgery...Postoperative ComplicationsUnique Nursing Considerations...ConclusionsReferences |
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| Surgical intervention is the only method proven to have long-term effects on morbid obesity.
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Understanding the normal anatomy of the gastrointestinal tract is crucial to appreciate and recognize the surgical alterations performed. The small bowel is about 400 to 700 cm long (mean 550 cm) and is composed of the duodenum, jejunum, and ileum (Figure 1). Three broad categories of bariatric operations are done: restrictive, malabsorptive, and combined restrictive and malabsorptive.
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), the stomach is stapled vertically, creating a 10- to 30-mL proximal gastric pouch; the outlet "stoma" is secured with a prosthetic band. This operation may be open or laparoscopic; patients have an initial (but short-lived) loss of 40% to 60% of their excess weight.7,8
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), an implantable, adjustable silicone band is laparoscopically placed around the top part of the stomach, thereby effectively forming a small proximal gastric pouch. The size of the pouch can be adjusted by using a port tunneled from the band to the subcutaneous tissue on the anterior part of the abdomen to change the degree of inflation of a balloon within the band lining. Weight loss with the BioEnterics LAP-BAND system (INAMED Health, Santa Barbara, Calif) has been mixed; the results in Europe and Australia differed from results in the United States.9
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), was devised.
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Combined restrictive and malabsorptive operations have been performed since the 1960s. Roux-en-Y gastric bypass is the gold standard and is currently the most commonly performed bariatric operation in the United States.13 In this operation (Figure 5), a small proximal gastric pouch (volume <30 mL) is created, the jejunum is divided about 50 cm distal to the ligament of Treitz, the distal limb of the jejunum is brought up, and a gastrojejunostomy is created with the gastric pouch. The proximal limb of jejunum is then anastomosed to the distal jejunum at a measured length (length of the Roux limb) from the gastrojejunostomy, which may range from 75 to 100 cm.
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In 2004, laparoscopic techniques were used in approximately 10% of bariatric operations.16 The popularity of these techniques is increasing; currently an estimated 50% of operations are performed laparoscopically. Such minimally invasive approaches are expected to increase because the trend is toward minimal-access approaches in all types of surgery. The advantages of laparoscopic surgery are reduced wound complications, such as infection and incisional hernia; less pain; shorter hospital stays; and faster recovery times. The disadvantages include the technical difficulty involved, with a steep learning curve for the surgeon, and a potential increase in postoperative complications.
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Postoperative Complications |
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TopAbstractCurrent Trends in Surgery...Postoperative ComplicationsUnique Nursing Considerations...ConclusionsReferences |
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) are due to patients’ comorbid conditions and can be classified as early or late. Early postoperative complications occur within the first 30 days after the operation; late postoperative complications occur thereafter.
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Anastomotic leak is the most serious complication after bariatric surgery and the most common cause of death.4 Clinical signs and symptoms are often subtle, making diagnosis difficult. Patients with a leak may have increasing pain in the back or the left shoulder, abdominal pain, pelvic pain, and substernal pressure. Additional clinical signs include hiccups, restlessness, and unexplained tachycardia. Unexplained tachycardia is of particular concern (pulse rate that remains >120/min after the first 12 hours following the operation); this finding can indicate a leak, peritonitis, or gastric dilatation.4 Similarly, unexplained oliguria is also suggestive of an anastomotic leak.
Rhabdomyolysis is a rare complication after bariatric surgery. It is caused by skeletal muscle necrosis due to prolonged muscle compression and ischemia.18 Risk factors include the duration of the surgery, the position of the patient during surgery, and obesity. Numbness or muscle pain in the buttock, hip, or shoulder area is suggestive of rhabdomyolysis. Myoglobinuria may occur, as indicated by brown urine. An increase in the serum level of creatine kinase greater than 5000 U/L that peaks at 48 to 72 hours after operation is a confirming indication of rhabdomyolysis.19 Early diagnosis of this condition can prevent further complications, such as oliguric acute renal failure. Interventions to prevent rhabdomyolysis should include frequent changes in the patient’s body position both during and after the surgery, padding of gluteal and other pressure areas, limiting surgical time, and aggressive replacement of fluid after the procedure to maintain intravascular volume.
| Anastomotic leak is the most serious complication and the most common cause of death after bariatric surgery.
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Vomiting and diarrhea occur primarily in as many as 50% of patients after restrictive procedures. These problems may be short-term as the patients adapt to the new anatomy. Moreover, postprandial (after a meal) diarrhea is suggestive of dumping syndrome. Dumping syndrome, the body’s response to ingested sugars entering the small intestine directly without dilution by gastric secretion, is a common complication with bypass surgeries, occurring in 70% to 75% of patients.4 Dumping syndrome is a result of rapid gastric emptying that allows large volumes of hyper-osmolar chyme into the small bowel. This phenomenon initiates a sensation of nausea, fullness, and pain. Shifts of large amounts of fluids from the intravascular space to the intestinal lumen occur as hypertonic contents are equilibrated osmotically, resulting in tachycardia and lightheadedness.4
Additionally, patients may experience cramps and diarrhea from the stimulation of a postprandial release of peptide hormones due to the rapid entry of nutrients.4,20 Dumping syndrome typically disappears 12 to 18 months after surgery. Patients who have BPD-DS may experience voluminous and malodorous stools (steatorrhea), flatus, body odor, and bloating syndrome.
Late Complications
The most common late postoperative complication after open bariatric surgery is an incisional hernia. Incisional hernias are caused by increased tension at the wound edge due to excess adipose tissue and increased intra-abdominal pressure. The extent of an incisional hernia is related directly to the size of the initial incision. Incisional hernias occur in about 15% of patients after open bariatric surgery, a finding that explains the interest in minimal-access techniques.
Nutritional deficiencies are the second most common late postoperative complication. Vitamin deficiencies occur because of the inability to mobilize fat stores for energy; the body uses protein instead, leading to protein malnutrition. Deficiencies in iron, calcium, and vitamin B12 occur because of the bypass of the primary absorption sites of these substrates, usually after gastric bypass or a BPD. Additional causes of nutritional deficiencies include intractable vomiting and intolerance to nutrient-rich foods.4
Another late postoperative complication is cholelithiasis.21 Rapid weight loss after bariatric surgery is a contributing factor to the formation of gallstones. The exact mechanism leading to the formation involves a decrease in the solubility of cholesterol within the bile during the period of acute weight loss; bile stasis and biliary sludge lead to the development of gallstones. Patients who have gallstones or evidence of any gall-bladder abnormality should undergo a cholecystectomy at the time of bariatric surgery.4
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Unique Nursing Considerations for Patients After Gastric Bypass |
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TopAbstractCurrent Trends in Surgery...Postoperative ComplicationsUnique Nursing Considerations...ConclusionsReferences |
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Level of Care
Patients need to be triaged appropriately according to the level of nursing care required for their specific needs. Many patients are sent directly to a surgical general care area after the operation; however, admission to an intensive care unit is common after bariatric surgery. Patients with comorbid conditions such as sleep apnea, severe asthma, or congestive heart failure may spend several days in an intensive care unit for cardiopulmonary monitoring.4 Placement in an intensive care unit, an intermediate or progressive care area, or a general care area may be determined before, during, or after surgery, depending on a patient’s history, type of operation, and response to anesthesia and other medications. Immediate critical care issues are airway, breathing, and circulation.
Airway Management
Airway management is complicated in patients with short, thick necks and poor neck extension. The emphasis in initial care should be avoidance of situations that may compromise the airway and precipitate the need for intubation. The effects of residual anesthesia, as well as administration of analgesics and sedatives, are important, and patients should be monitored for respiratory depression.
Obstructive sleep apnea and hypoventilation syndrome are common problems in bariatric patients. Decreases in lung and chest wall expansion due to excess weight result in a buildup of carbon dioxide (PaCO2 >45 mm Hg) in the bloodstream. Patients become sleepy or fall asleep frequently and experience periods of apnea and the resultant hypoxia. Anesthetics and other intraoperative and postoperative medications may exacerbate these conditions, induce hypoxia, and put patients at a markedly increased risk for arrhythmias. Furthermore, a persistent somnolent state makes an inclusive physical assessment difficult.
Endotracheal intubation, if needed, requires adjustments in body position because of abdominal adiposity. Patients may be placed in a reverse Trendelenburg position in which the head is higher than the pelvis (not a jackknife position) during intubation. The reverse Trendelenburg position is used to limit the push of abdominal contents on the diaphragm. The effect of gravity causes a decrease in preload to the heart. Use of the reverse Trendelenburg position may improve oxygenation in patients with morbid obesity.22,23 This position also may decrease cardiac output, a situation that may partially counteract the beneficial effect of the position on oxygenation.23 Interestingly, in a study24 of hemodynamic changes during laparoscopic gastric bypass procedures, patients placed in the reverse Trendelenburg position had a decrease in central venous and pulmonary artery wedge pressure but no significant decrease in cardiac index.
Another procedure that enhances the laryngoscopic view and improves success of intubation is placing obese patients in a "ramped" position rather than in a standard "sniff " position. The ramped position is achieved by placing blankets under the upper part of the body to align the sternum to the external auditory meatus.25
In addition, short sternomental distances require careful measurements for depth of insertion of endotracheal tubes. Furthermore, palpable landmarks are difficult to find or are lost because of the size of obese patients. Because of difficulty in positioning the head into an intubation angle and possible redundant tissues in the airway, a fiber-optic laryngoscope may be needed to intubate the trachea. If time permits, awake fiber-optic intubation with topical anesthesia may be a prudent approach, especially if difficulty in intubation is anticipated. An emergency tracheostomy tray should be readily available. An intubating laryngeal mask airway or esophageal/tracheal double-lumen airway can be life-saving in emergent airway situations. A chest radiograph should always be obtained to confirm the position of the endotracheal tube.
Once intubation is achieved, the tube must be tied or taped securely. The method chosen to secure the tube varies depending on many variables, such as the shape of the head or face, skin integrity, fluid status, and sedation level. The skin around and under the ties or tape should be frequently assessed for breakdown. The depth of insertion of the endotracheal tube should be monitored frequently to ensure that the tube has not been dislodged.
Additionally, cricothyroidotomy and tracheostomy may be difficult in gastric bypass patients because of loss of landmarks and excessive neck fat. A standard tracheostomy tube may be too short and curved, resulting in easy dislodgement or occlusion. The use of an adjustable-length tracheostomy tube (8–15 cm) can be beneficial in maintaining the airway.26
Appropriate sedation to both preserve a safe airway and keep patients in a wakeful state is a challenge. Respiratory therapists are a resource for problems in airway management. The expertise of an anesthetist or an anesthesiologist may be required for management of patients who are difficult to intubate.
Mechanical ventilation may be prolonged after bariatric surgery because of suboptimal lung mechanics and weaning time. Tidal volumes set on the ventilator should be based on ideal body weight, not actual body weight. Although no preferred mode of ventilation (assist-control ventilation, intermittent mandatory ventilation, or continuous positive airway pressure) has been established, the addition of positive end-expiratory pressure may be beneficial to improve oxygenation in obese patients.23 Monitoring, however, is required because positive end-expiratory pressure may decrease venous return and cardiac output in patients who already are compromised.17 Extra caution needs to be taken when considering extubation of a bariatric patient because of the problems just discussed.
Pulmonary Care
Preoperative screening for pulmonary function will help determine proper pulmonary care during the initial postoperative period after gastric bypass. A standard pulmonary assessment is a challenge when the chest wall is enveloped by thick layers of adipose tissue. For example, x-rays may not penetrate well through the thick adipose tissue. Alternative methods may be needed for proper assessment. Techniques of monitoring that are less affected by adipose tissue will need to be relied on, such as arterial catheters for blood pressure monitoring, arterial blood gas analysis for oxygenation status, Doppler recordings for peripheral pulse assessment, and ventilator pressure readings to assess compliance.
Daytime sleepiness or other indications of sleep apnea (fitful sleeping, morning sleepiness and/or headaches) warrant the use of continuous positive airway pressure or bilevel positive airway pressure.17 Patients who use continuous positive airway pressure or bilevel positive airway pressure at home are instructed to bring their own equipment for these procedures to use in the hospital setting. Use of such equipment will help overcome airway obstruction and improve oxygenation immediately after extubation.
In order to reduce intra-abdominal pressure on the diaphragm and improve tidal volumes, the head of the bed should be elevated 30° to 45°, preferably in a reverse Trendelenburg position rather than in a jackknife or Kraske position; the latter position may actually increase the diaphragmatic pressure and lead to a decrease in tidal volume. Bariatric patients are at an increased risk for atelectasis and aspiration pneumonia. Patients should be encouraged to cough, take deep breaths, and use incentive spirometry as soon as they are awake.
| To improve tidal volume, the head of the bed should be elevated 30° to 45° in a reverse Trendelenberg position.
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Cardiovascular Management
Increases in total blood volume and resting cardiac output are characteristics of patients with morbid obesity; stroke volume is the factor that increases (cardiac output = stroke volume x heart rate).27 Even though cardiac output is increased, deficient left ventricular contractility and decreased ejection fraction may be present.27 In addition, increases in the mass, wall thickness, and chamber size of the left ventricle result in left ventricular dilatation and hypertrophy.28,29 Patients with these increases tend to have increased preload and reduced effectiveness of ventricular contraction, a situation that leads to inadequate toleration of fluid loading.
| Even though cardiac output is increased, deficient left ventricular contractility and decreased ejection fraction may be present.
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Awake hypercapnia and hypoxemia have been associated with pulmonary hypertension and right-sided congestive heart failure (cor pulmonale).30 The primary mechanism of acute pulmonary hypertension is hypoxia related to pulmonary vasoconstriction. The results of research in which pulmonary hypertension is compared with obstructive sleep apnea are challenging to interpret because of diverse controls for existing heart and lung illnesses and varied definitions of pulmonary hypertension (>20 mm Hg vs 25 mm Hg). On the basis of a review of 12 studies, Atwood et al31 estimated that the prevalence of pulmonary hypertension in patients with obstructive sleep apnea is 17% to 53%.
Increased cardiac workload in patients with morbid obesity is a direct result of increased blood flow requirements to adipose tissue. Because of the increased workload on the heart (and the potential for hypoxia), postoperative gastric bypass patients are at risk for acute myocardial ischemia, congestive heart failure, arrhythmias, and sudden cardiac death. These considerations may require monitoring of hemodynamic parameters, cardiac rhythm and rate, blood pressure (via an arterial catheter or a noninvasive cuff), central venous pressure, oxygen saturation, central venous oxygen saturation, and respiratory rate. When a blood pressure cuff is used, staff should ensure that it is appropriately sized.
Dehydration and third spacing of fluids may be manifested as decreased urine output, tachycardia, and relative hypotension. Assessment of intake and output and determination of blood chemistry profiles (blood urea nitrogen, creatinine, magnesium, and potassium) are important. Heart failure and pulmonary edema can be exacerbated in postoperative gastric bypass patients who require fluid loading. Accurate assessments and interventions are key to meeting the challenges of cardiovascular management.
Vascular Access
Obscured anatomical landmarks and variation of the depth needed for insertion of central venous catheters for vascular access are challenges in patients with morbid obesity. Standard-sized intravenous catheters may be too short, making the antecubital vein the vessel of choice for peripheral access. A central catheter can provide venous access and be used to monitor central venous pressure. A catheter 30 cm long may provide better access than shorter catheters do.4
Deep Vein Thrombosis
One of the major clinical risk factors for venous thromboembolism is obesity.32 A hypercoagulable, hypofibrinolytic state exists in obese patients following surgery and predisposes them to cardiovascular diseases as a result of hemostatic disturbances.33 Increases in the serum levels of fibrinogen, factor VII, and factor VIII lead to amplified coagulation and hypofibrinolysis with increased levels of plasminogen activator inhibitor-1. The decreased fibrinolysis often results in recurrent or lasting thrombosis.
Critically ill postoperative patients are at high risk for venous thromboembolism and subsequent pulmonary embolism associated with immobility, venous stasis, and the relatively hypercoagulable state. Use of sequential compression devices and early ambulation should be common prophylactic interventions to prevent deep vein thrombosis. Options for prophylactic anticoagulation therapy include subcutaneous administration of unfractionated or low-molecular-weight heparin and, rarely, intravenous administration of heparin. The choice of anticoagulation therapy must include a consideration of the associated risks and benefits of the therapy. Insertion of a filter in the inferior vena cava may be indicated in patients at high risk for pulmonary embolism, such as patients with venous stasis, a BMI greater than 60, truncal obesity, obstructive sleep apnea, obesity hypoventilation syndrome, a history of deep vein thrombosis or pulmonary embolism, or a hypercoagulable state.34
Pharmacotherapy
The pharmacokinetics of certain medications in patients with morbid obesity is difficult to predict because of the patients’ body size. Normal doses of medications may not be appropriate.32 Factors to consider include absorption, distribution, metabolism, and elimination of the drug to be used. In general, requirements for drug dosing are usually based on the proportion of adipose tissue and lean body mass.35 Appropriate drug dosages can be calculated on the basis of actual body weight, ideal body weight, or adjusted body weight,32 although the methods used to calculate drug dosages is highly controversial. Because of the complexity and the different points of view about the most appropriate method, a pharmacist should be consulted to determine appropriate medication regimens.
Low protein stores may decrease drug binding, resulting in an increased concentration of circulating drug and thereby increasing the risk of toxic effects. The increased fat-to-muscle ratio in bariatric patients is a further challenge in determining appropriate dosages. Muscle tissue carries more water than does adipose tissue. Drugs with lipophilic properties may be distributed into the adipose tissue. For drugs with hydrophilic properties, such as many antimicrobials (which can have strong toxic effects), Charlebois and Wilmoth32 recommend that dosages be based on the serum concentrations of the drug used rather than on the normal dosing guidelines. The preferred route of administration of pharmacological agents for patients with morbid obesity is the intravenous route. Drugs administered subcutaneously or via cutaneous patches have a delayed onset of action and an unpredictable duration because of the decreased blood supply in adipose tissue. Intramuscular injection should be avoided to prevent inadvertent subcutaneous administration.
Patient-controlled analgesia is a suitable strategy for postoperative pain management in gastric bypass patients.36 Postoperative epidural analgesia is not often used in gastric bypass patients because of the difficulty of locating exact spinal segments for proper insertion of a catheter.36
| Intramuscular injections should be avoided to prevent inadvertent subcutaneous administration.
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Skin and Wound Healing
Patients with morbid obesity are at high risk for skin breakdown and delayed wound healing because of the decreased vascularity in adipose tissue. Patients may have unavoidable intertrigo (dermatitis that occurs between folds where skin comes into contact with itself) because folds in the skin harbor moisture and bacteria. These areas are prone to infection and ulceration. Nursing attention includes meticulous skin care with daily inspection and frequent body repositioning as required. Vulnerable areas include folds under the breasts, back, abdomen, and perineum. The use of powders in skin folds is discouraged because the abrasive particles in powders combined with the weight of the folds leads to skin breakdown and ulceration.32 Cloth or gauze placed in skin folds can reduce the occurrence of irritation and fungal rashes.
Urine and fecal incontinence are common because of the large abdomen impinging on the bladder and bowel. Superobese patients may be unable to perform proper perineal cleansing, further contributing to skin breakdown. During the immediate postoperative phase, an indwelling urinary catheter may be required to aid in perineal toilet.
Patients with an open wound require dressing changes per a physician’s order. Detailed documentation includes assessment of wound edges and healing and type, color, and amount of drainage. Drainage tubes must be monitored to prevent skin erosion and ulcerations in skin folds. An abdominal binder may provide symptomatic support to the open incision.
Nutrition
Both restrictive and malabsorptive operations are associated with an increased risk for nutritional difficulties. Contrary to popular belief, many patients with morbid obesity have malnutrition. Fat stores for energy cannot be mobilized efficiently and certainly not rapidly, thereby leaving protein to be used as the primary energy source. Despite having what appears to be a large energy source, patients are at risk for malnutrition with loss of muscle and lean body mass. In gastric bypass patients, the additional stress of hypermetabolism and increased catabolism during the postoperative period increases the depletion of nutrients.
Increased morbidity and mortality rates are associated with malnutrition in critically ill patients after bariatric surgery.32 The enteral route of feeding is always preferred over intravenous parenteral nutrition; however, overfeeding must be avoided. Overfeeding can result in congestive heart failure, fluid overload, pulmonary edema, glucose intolerance, respiratory failure, and hepatic dysfunction.32
The typical postoperative diet is nothing by mouth until an upper gastrointestinal series (swallow test) is performed to exclude an anastomotic leak. This test is often done the day after surgery. Patients are then usually advanced to clear liquids, 30 mL 6 to 10 times per day, and then a full liquid diet that includes protein powder or shakes. Dietary steps to prevent dumping syndrome include avoiding foods with high levels of artificial and natural sugar, eating small frequent meals, eating and drinking slowly, chewing foods thoroughly, drinking liquids between meals and before eating but not with meals, and sitting in a reclining position for 30 minutes after meals.20
Generally, patients begin a pureed diet before discharge from the hospital, and 1 month after the operation they are able to advance to a mechanical soft diet. A multivitamin containing iron and vitamin B complex and calcium supplements, in addition to monthly injections of cyanocobalamin (vitamin B12), are used to prevent nutritional deficiencies, specifically in patients who have had Roux-en-Y gastric bypass and BPD-DS. When ingested, these nutrients bypass the duodenum, which is the primary site of absorption.
The greatest weight loss after gastric bypass occurs within the first 12 to 18 months. Habits that promote weight loss after surgery include eating 3 meals a day with 2 snacks, eliminating carbonated beverages, taking prescribed vitamins, obtaining adequate amounts of sleep, getting regular exercise, and achieving personal awareness. The primary reasons for poor outcomes include lack of exercise, poorly balanced meals with frequent "grazing" and snacking on energy-dense foods, and poor nutritional education.
Determining the most appropriate nutritional requirements for a patient who is morbidly obese may be a struggle because of the debate in the literature about the requirements. Consulting a dietician and collaborating with a bariatric physician will help determine nutritional needs.
| Many morbidly obese people have malnutrition because fat stores are not mobilized efficiently.
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Patients’ Mobility and Patients’ and Staff Members’ Safety
Early mobility within hours after surgery is a major goal for gastric bypass patients. However, healthcare providers must think of their personal safety as well as the safety of the patients when mobilization is started. Having proper equipment and resources is a top priority. Staff are more vulnerable to injury when attempting to mobilize obese patients. Patients should be encouraged to provide their own care when possible and to help with their mobility as much as possible. Use of specialized bariatric beds, air-assisted transfer devices, mechanical patient lifts, trapezes on beds, and other equipment to promote the safety of patients and healthcare staff is encouraged. Nursing safety and appropriate ergonomics should be incorporated into staff members’ orientation and ongoing education.
The importance of having appropriate equipment to care for morbidly obese patients in the hospital environment needs to be recognized. The multidisciplinary healthcare team should ensure the availability of safe operating room tables that accept weights of 135 to 360 kg (300–800 lb), surgical instruments, transport carts, wheelchairs, commodes, beds, scales, chairs, and diagnostic imaging equipment for procedures such as computed tomography, magnetic resonance imaging, and radiography that support weights of greater than 135 kg. Considerations of structural facility include widened door frames, floor-mounted rather than wall-mounted toilets, and ceiling lifts.
Psychosocial Support
Among the greatest challenges in caring for patients with morbid obesity who are undergoing bariatric surgery are the psychosocial needs that arise. Many of these patients have low self-esteem and decreased socialization, which can lead to manipulative behavior. Patients report feelings of shame, embarrassment, and fear. Psychological supportive care includes education, behavioral therapy, counseling, and support groups. This approach begins in the preoperative phase and continues through long-term postoperative care.
Members of the healthcare team will require a multidisciplinary educational approach related to the disease, type of operation performed, and accompanying postoperative care. Patients with morbid obesity need consistent emotional support and encouragement. Maintaining a professional attitude and building a therapeutic relationship with these patients will enhance development of collaborative goals and will ultimately improve the patients’ outcomes.
| Many patients have low self-esteem and decreased socialization, which can lead to manipulative behavior.
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Conclusions |
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TopAbstractCurrent Trends in Surgery...Postoperative ComplicationsUnique Nursing Considerations...ConclusionsReferences |
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ACKNOWLEDGMENTS |
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REFERENCES |
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TopAbstractCurrent Trends in Surgery...Postoperative ComplicationsUnique Nursing Considerations...ConclusionsReferences |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
