Discharge And Home Healthcare Guidelines

Teach the patient methods to reduce symptoms, prevent malnutrition and weight loss, and improve sleep and rest. Make sure the patient understands the dosage, route, action and purpose, side effects, and contraindications of the prescribed medications. Explain the potential for aspiration, respiratory impairment, weight loss or malnourishment, and sleep deprivation. Remind the patient to see the physician if symptoms of esophageal diverticula return or worsen.

Fat Embolism

DRG Category: 078

Mean LOS: 7.8 days

Description: MEDICAL: Pulmonary Embolism embolism is any undissolved mass that travels in the circulation and occludes a blood vessel. A fat embolism, which is an unusual complication from a traumatic injury, occurs when fat droplets enter the circulation and lodge in small vessels and capillaries, particularly in the lung and brain. Two theories exist that explain the pathophysiology of fat emboli: the mechanical theory and the biochemical theory. The mechanical theory states that trauma disrupts fat cells and tears veins in the bone marrow at the site of a fracture. Fat droplets enter the circulation because of increased pressure of the interstitium at the area of injury. The biochemical theory states that a stress-related release of catecholamines after trauma mobilizes fat molecules from a tissue. These molecules group into fat droplets and eventually obstruct the circulation. In addition, free fatty acids destroy pulmonary endothelium, increase capillary permeability in the lungs, and lead to pulmonary edema.

The result of either theory is the accumulation of fat droplets that are too large to pass easily through small capillaries, where they lodge and break apart into fatty acids, which are toxic to lung tissues, the capillary endothelium, and surfactant. Pulmonary hypertension, alveolar collapse, and even noncardiac pulmonary edema follow. Mortality rates are approximately 10% to 20%. Patients with increased age, underlying medical conditions, and poor physiological reserves have poorer health outcomes than do other patients.

Fat embolism is associated with severe traumatic injury with accompanying long-bone (tibial or femoral) or pelvic fractures and generally occurs within 3 days of the fracture. It has also been reported in patients with severe burns, head injury, or a severely compromised circulation. Non-traumatic disease states that have occasionally been associated with fat embolism include acute pancreatitis, alcoholism, diabetes mellitus, and osteomyelitis. Procedures such as liposuction, orthopedic surgery, joint replacement, abdominal surgery, and cardiac massage (closed chest) are also associated with fat embolism.

Most patients who develop the disorder are under age 30 and have severe associated injuries. Males are more likely than females to have a significant traumatic injury. No racial or ethnic considerations are known to be associated with fat embolism.

HISTORY. Elicit a history of recent traumatic injury. In most patients, the injury is obvious because of the presence of casts or traction. Some patients exhibit changes in mental status such as restlessness, delirium, or drowsiness progressing to coma and even seizures. Others complain of fever, anxiety, unexplained discomfort, or respiratory distress (shortness of breath, cough).

Fat embolization may be classified into three distinct forms based on the patient's progression of symptoms: subclinical, classic, and fulminant. Approximately half of patients with uncomplicated fractures have subclinical fat emboli, which resolve spontaneously within a few

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