Medsurg Nursing KEY POINTS Lecture Notes Ch1 69

Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 1: Nursing Practice Today
Nursing involves the (1) protection, promotion, and optimization of health and ailities!
(") prevention of illness and in#ury! ($) alleviation of suffering through the diagnosis and
treatment of human response! and (%) advocacy in the care of individuals, families,
communities, and populations&
Nurses offer s'illed care to those recuperating from illness or in#ury, advocate for
patients( rights, teach patients so that they can ma'e informed decisions, support patients
at critical times, and help them navigate the increasingly comple) health care system&
Certification in nursing specialties (e&g&, amulatory care, critical care, gerontologic,
pediatric, psychiatric and mental health, and community health nursing) is offered
through a variety of nursing organizations&
*ntry+level nurses ,ith an associate or accalaureate degree in nursing are prepared to
function as generalists& -ith additional preparation, nurses can assume roles such as
clinical nurse specialist and nurse practitioner&
The e)act roles (i&e&, independent, dependent, collaorative) of the nurse are often
determined y state and agency policies& .n most cases, the nurse(s role is one of
/interdependence and co+participation0 ,ith the patient and other health team memers&
Delegation of nursing interventions to licensed practical nurses1licensed vocational
nurses (2PNs123Ns) and unlicensed assistive personnel (45P) is an important function
of the professional nurse&
Healthy People 2010 is a road+ased program that involves government, private, pulic,
and nonprofit organizations in preventing disease and promoting health&
!idence-based "ractice (*6P) is the conscientious use of the est evidence (e&g&,
findings from research) in comination ,ith clinician e)pertise and patient preferences
and values in clinical decision+ma'ing&
Nursing informatics is a specialty that integrates nursing science, computer science, and
Copyright 7 "889 y :osy, .nc&, an affiliate of *lsevier .nc&
Key Points
information science in identifying, collecting, processing, and managing data and
information to support nursing practice, administration, education, and research&
The five elements of the nursing "rocess are assessment, diagnosis, planning,
implementation, and evaluation& ;nce egun, the nursing process is not only continuous
ut it is also cyclic in nature&
Standardi#ed nursing terminologies can promote continuity of patient care and provide
data that can support the crediility of the profession&
Nursing diagnoses descrie health states that nurses can legally diagnose and treat& 5
three+part nursing diagnosis statement includes the prolem, etiology, and signs and
symptoms&
Collaborati!e "roblems are potential or actual complications of disease or treatment that
nurses treat ,ith other health care providers, most fre<uently physicians&
The Nursing $utcomes Classification %N$C& is a research+ased, standardized
language for nursing outcomes& .t is used to evaluate the effects of nursing interventions&
N;C is a list of measures that descries patient outcomes influenced y nursing
interventions&
The Nursing 'nter!entions Classification %N'C& includes independent and collaorative
interventions that nurses carry out, or direct others to carry out, on ehalf of patients&
5 nursing inter!ention is any treatment ased on clinical #udgment and 'no,ledge that
a nurse performs to enhance "atient outcomes(
The setting of specific outcomes ,ith outcome indicators is necessary for systematic
measurement of the patient(s progress&
;utcomes may e developed y ,riting specific outcome statements or choosing
outcomes from the Nursing ;utcomes Classification (N;C)&
The Nursing .nterventions Classification (N.C) includes treatments (oth physiologic and
psychosocial) that nurses perform in all settings and specialties&
N.C and N;C provide a common language for communication among nurses and
facilitate computer collection of standardized nursing data&
1+"
Key Points
=uring the e!aluation phase, the nurse determines ,hether the patient outcomes and
nursing interventions ,ere realistic, measurale, and achievale&
5ssessment, diagnosis, outcomes, interventions, and evaluation of the patient(s response
to care are a critical part of the patient(s record&
-hen nursing terminologies are used in information systems for documentation of
nursing practice, nurses can trac' and report on the enefits of nursing care&
th
edition
Key Points
Chapter ": >ealth =isparities
Determinants of health are those factors that influence the health of individuals&
)ealth dis"arities refer to differences in measures in the health status among groups of
people in a community, a state, or the entire nation&
?acial, ethnic, and cultural differences e)ist in the health screening ehaviors, treatments
provided, and access to health care providers&
@actors such as stereotyping and pre#udice can affect health care see'ing ehavior in
minority populations&
=iscrimination and ias occur ,hen negative treatment occurs ased on race, ethnicity,
gender, aging, and se)ual orientation&
4se of standardized evidence+ased guidelines can reduce health disparities in diagnosis
and treatment&
.nterpersonal s'ills such as active listening, relationship uilding, and effective
communication are asic to the delivery of high <uality and e<uitale health care&
th
edition
Key Points
1+$
Key Points
Chapter %: >ealth >istory and Physical *)amination
The nurse and physician oth otain a patient history and perform a physical
e)amination, ut they use different formats and analyze the data differently&
The nursing assessment includes oth su#ective and o#ective data(
o Sub*ecti!e data are ,hat the patient tells the nurse aout himself or herself&
o $b*ecti!e data are otained using inspection, palpation, percussion, and
auscultation during the physical e)amination&
5 comprehensive database includes information aout the patient(s health status, health
maintenance ehaviors, individual coping patterns, support systems, current development
tas's, and any ris' factors or lifestyle changes&
-hen a patient is unale to provide data (e&g&, the person is aphasic or unconscious), the
person assuming responsiility for the patient(s ,elfare can e as'ed aout the patient&
Patients should e informed that federal legislation affects the e)change, privacy, and
security of an individual(s health information&
5ssessment data should e otained and organized systematically so that they can e
analyzed to ma'e #udgments aout the patient(s health status and health prolems&
;ne frame,or' for otaining data uses the functional health "atterns developed y
Aordon&
Bu#ective data include past health history, medications, surgery, or other treatments&
The t,o types of physical e)aminations are as follo,s:
o Screening
o +ocused (prolem+centered)
th
edition
Key Points
Chapter C: Patient and @amily Teaching
1+%
Key Points
Bpecific goals for patient education include health promotion, prevention of disease,
management of illness, and appropriate selection and use of treatment options&
5 teaching "lan includes assessment of the patient(s aility, need, and readiness to learn as
,ell as identification of prolems that can e resolved ,ith teaching&
Learning occurs ,hen there is an internal mental change characterized y rearrangement of
neural path,ays&
,eaching is a process of delierately arranging e)ternal conditions to promote the internal
transformation that results in a change in ehavior&
-hen teaching adults, it is important to identify ,hat is valued y the person to enhance
motivation&
-einforcement is a strong motivational factor for maintaining ehavior& Positive
reinforcement involves re,arding a desired ehavior ,ith a positive stimulus to increase its
occurrence&
?e<uired s'ills for the nurse as a teacher include 'no,ledge of the su#ect matter,
communication s'ills, and empathy&
6ecause of shortened hospital stays and clinic visits, the nurse and the patient need to set
priorities of the patient(s learning needs so that teaching can occur during any contact ,ith the
patient or family&
*ducation of family memers is important ecause family memers can promote the patient(s
self+care and prevent complications&
The teaching "rocess involves development of a plan that includes assessment, diagnosis,
setting patient outcomes or o#ectives, intervention, and evaluation&
The patient(s e)periences, rate of learning, and aility to retain information are affected y age&
Pain, fatigue, and certain medications influence the patient(s aility to learn&
5n)iety and depression can negatively affect the patient(s motivation and readiness to learn&
5n individual(s elief in his or her capaility to produce and regulate events in life affects
motivation, thought patterns, ehavior, and emotions&
)ealth literac. is defined as the degree to ,hich individuals have the capacity to otain,
process, and understand asic health information and services needed to ma'e appropriate
health decisions&
1+C
Key Points
*ach person has a distinct style of learning& The three learning styles are as follo,s:
(1) 3isual (reading)
(") 5uditory (listening)
($) Physical (doing things)
Learning ob*ecti!es are ,ritten statements that define e)actly ho, patients demonstrate their
mastery of the content&
2earning o#ectives contain the follo,ing four elements:
(1) -ho ,ill perform the activity or ac<uire the desired ehavior
(") The actual ehavior that the learner ,ill e)hiit to demonstrate mastery of the o#ective
($) The conditions under ,hich the ehavior is to e demonstrated
(%) The specific criteria that ,ill e used to measure the patient(s success
Belecting a particular strategy is determined y at least three factors:
(1) Patient characteristics (e&g&, age, educational ac'ground, nature of illness, culture)
(") Bu#ect matter
($) 5vailale resources
6ecause of e)tent of health illiteracy, it is no, recommended that all patient education
materials e ,ritten at the Cth+ to Dth+grade reading level&
*valuation strategies for teaching include oserving the patient directly, oservation of veral
and nonveral cues, discussion ,ith the patient or family memer, using a standardized
measurement tool, and the patient(s self+evaluation of progress&
th
edition
Key Points
Chapter D: ;lder 5dults
Ageism (negative attitude ased on another(s age) can lead to discrimination and
disparities in health care provided to older adults&
5ging affects every ody system& /iologic aging is a alance of positive (e&g&, healthy
diet, e)ercise, coping, resources) and negative factors (e&g&, smo'ing, oesity)&
6iologic theories can e divided into stochastic and non-stochastic theories&
1+D
Key Points
;lder ,omen are especially at ris' for chronic health prolems, including arthritis,
hypertension, stro'es, and diaetes&
The frail elderl. are individuals ,ho are more vulnerale ecause of declining physical
health and limited resources&
Acti!ities of dail. li!ing (5=2), including athing, dressing, eating, toileting, and
transferring, are important for the nurse to assess in the older patient living ,ith chronic
illness&
@or the hospitalized older adult, there are special concerns related to high surgical ris',
acute confusional state, nosocomial infection, and premature discharge ,ith an unstale
condition&
The intensity and comple)ity of caregiving place the caregi!er at ris' for high levels of
stress& This may lead to emotional prolems, including depression, anger, and resentment&
@amily memers are perpetrators in appro)imately E out of 18 cases of domestic elder
abuse and neglect(
Continuing care retirement communities, congregate housing, and assisted living
facilities are housing options for the older adult&
>ome health care services re<uire physician recommendation and s'illed nursing care for
:edicare reimursement&
*thical issues surrounding care of the older adult include using restraints, evaluating the
patient(s aility to ma'e decisions, initiating resuscitation, treating infections, providing
nutrition and hydration, and advocating for an institutional ethics committee&
?educing disaility through geriatric rehabilitation is important to the <uality of life of
the older adult&
5ge+related changes in pharmacodynamics and pharmaco'inetics of drugs, as ,ell as
"ol."harmac., put the older adult at ris' for adverse drug reactions&
=epression is the most common mood disorder in older adults&
The comprehensive nursing geriatric assessment includes a thorough history using a
functional health pattern format, physical assessment, mood assessment, mental status
evaluation, 5=2 and instrumental 5=2 (.5=2) evaluation, and social+environmental
assessment&
1+9
Key Points
th
edition
Key Points
Chapter 9: Community+6ased Nursing and >ome Care
The focus of communit.-based nursing is the illness+oriented care of individuals and
families throughout the lifespan&
:any factors are changing the health care system, including socioeconomic status,
demographics, prevalence and type of illness, technology, and increased consumerism&
The goals of case management are to provide <uality care along a continuum, decrease
fragmentation of care across many settings, enhance the patient(s <ualify of life, and
contain cost&
The use of =iagnosis ?elated Aroups (=?As) has had a dramatic impact on health care&
>ealth care is constrained y third+party payer cost containment&
Community+ased settings ,here nursing care is delivered include ambulator. care,
transitional care, and long-term care (s'illed nursing, intermediate care, and residential
care facilities)&
Communit.-oriented nursing involves the engagement of nursing in promoting and
protecting the health of populations&
)ome health care may include health maintenance, education, illness prevention,
diagnosis and treatment of disease, palliative care, and rehailitation&
S0illed nursing care may include oservation, assessment, management evaluation,
teaching, training, administration of medications, ,ound care, tue feeding, catheter care,
and ehavioral health interventions&
.n home care situations, it is common for caregivers to ecome physically, emotionally,
and economically over,helmed ,ith responsiilities and demands of caregiving&
The home health care team may include the patient, family, nurses, physician, social
,or'er, physical therapist, occupational therapist, speech therapist, home health aide,
pharmacist, respiratory therapist, and dietitian&
1+F
Key Points
th
edition
Key Points
Chapter F: Complementary and 5lternative Therapies
Com"lementar. and alternati!e thera"ies include a road domain of resources,
including health systems, modalities, and practices other than those intrinsic to the
dominant health system of a particular society or culture&
This definition highlights that ,hat might e considered /complementary and alternative0
in one country or at one period of history might e considered /conventional0 in another
place or time&
.ndividuals often /self+select0 these therapies, using them ,ithout professional
supervision&
Nearly half of the users of these therapies do not consult an alternative and
complementary practitioner or disclose such use to their traditional health care provider&
Patients should e advised that complementary therapies do not replace conventional
therapies, ut can often e used in comination ,ith conventional therapies&
,raditional Chinese Medicine (TC:) is a complete system of medicine ,ith an
individualized form of diagnosis and treatment, as ,ell as having its focus on prevention&
TC: includes acupuncture, Chinese heral medicine, and other modalities&
Mind-bod. inter!entions are a variety of techni<ues designed to facilitate the mind(s
capacity to affect ody function, including ehavioral, psychologic, social, and spiritual
approaches to health such as imagery, iofeedac', prayer, and meditation&
;ver the past $8 years, a resurgence of interest in herbal thera". has occurred in
countries ,hose health care is dominated y the iomedical model&
:edicinal plants ,or' in much the same ,ay as drugs! oth are asored and trigger
iologic effects that can e therapeutic& :any have more than one physiologic effect and
thus have more than one condition for ,hich they can e used&
Patients should e advised that if they ta'e heral therapies, they should adhere to the
suggested dosage& >eral preparations ta'en in large doses can e to)ic&
1+E
Key Points
Mani"ulati!e and bod.-based methods include interventions and approaches to health
care ased on manipulation or movement of the ody& *)amples include chiropractic
therapy, yoga, massage, and acupressure&
Massage is a form of touch and also a form of caring, communication, and comfort&
Nurses can use specific massage techni<ues as part of nursing care, ,hen indicated y the
nursing diagnosis or patient assessment&
nerg. thera"ies are those that involve the manipulation of energy fields such as
Therapeutic Touch, >ealing Touch, and ?ei'i&
,hera"eutic ,ouch (TT) is a method of detecting and alancing human energy that ,as
developed #ointly y a nurse and a traditional healer&
.t is important for the nurse to collect data on the patient(s use of complementary and
alternative therapies&
th
edition
Key Points
Chapter E: Btress and Btress :anagement
Stress occurs ,hen individuals perceive that they cannot ade<uately cope ,ith the
demands eing made on them or ,ith the threats to their ,ell+eing&
Key personal characteristicsGsuch as hardiness, sense of coherence, resilience, and
attitudeGuffer the impact of stress&
The physiologic response of the person to stress is reflected in the interrelationship of the
nervous, endocrine, and immune systems& Btress activation of these systems affects other
systems, such as the cardiovascular, respiratory, gastrointestinal, renal, and reproductive
systems&
Btress can have effects on cognitive function, including poor concentration, memory
prolems, distressing dreams, sleep disturances, and impaired decision+ma'ing&
2ong+term stress may increase the ris' of cardiovascular diseases such as atherosclerosis
and hypertension& ;ther conditions either precipitated or aggravated y stress include
migraine headaches, irritale o,el syndrome, and peptic ulcers&
1+18
Key Points
Co"ing is defined as a person(s cognitive and ehavioral efforts to manage specific
e)ternal or internal stressors that seem to e)ceed availale resources&
Coping can e either positive or negative& Positive coping includes activities such as
e)ercise and use of social support& Negative coping may include sustance ause and
denial&
Coping strategies can also e divided into t,o road categories: emotion+focused coping
and prolem+focused coping&
motion-focused co"ing involves managing the emotions that an individual feels ,hen
a stressful event occurs& Problem-focused co"ing attempts to find solutions to resolve
the prolems causing the stress&
-ela1ation strategies can e used to cope ,ith stressful circumstances and elicit the
rela)ation response&
The rela1ation res"onse is the state of physiologic and psychologic deep rest& .t is the
opposite of the stress response and is characterized y decreased sympathetic nervous
system activity, ,hich leads to decreased heart rate and respiratory rate, decreased lood
pressure, decreased muscle tension, decreased rain activity, and increased s'in
temperature&
?egular elicitation of the rela)ation response can e achieved through rela)ation
reathing, meditation, imagery, music, muscle rela)ation, and massage&
th
edition
Key Points
Chapter 18: Pain
Pain is defined as ,hatever the person e)periencing the pain says it is, e)isting ,henever
the person says it does&
4ntreated pain can result in unnecessary suffering, physical and psychosocial
dysfunction, impaired recovery from acute illness and surgery, immunosuppression, and
sleep disturances&
1+11
Key Points
.nade<uate pain management may e due to (1) insufficient 'no,ledge and s'ills to
assess and treat pain! (") un,illingness of providers to elieve patients( report of pain! ($)
lac' of time, e)pertise, and perceived importance of conducting regular pain assessments!
(%) inaccurate and inade<uate information regarding addiction, tolerance, respiratory
depression, and other side effects of opioids! and (C) fear that aggressive pain
management may hasten or cause death&
Components of the nursing role include (1) assessing pain and communicating this
information to other health care providers, (") ensuring the initiation and coordination of
ade<uate pain relief measures, ($) evaluating the effectiveness of these interventions, and
(%) advocating for people ,ith pain&
Pain has many dimensions and components, including the follo,ing:
o The physiologic dimension of pain includes the genetic, anatomic, and physical
determinants of pain&
o The affective component of pain is the emotional response to the pain e)perience&
o The behavioral component of pain refers to the oservale actions used to e)press
or control the pain&
o The cognitive component of pain refers to eliefs, attitudes, memories, and
meaning attriuted to the pain&
o The sociocultural dimension of pain encompasses factors such as demographics,
support systems, social roles, and culture&
The emotional distress of pain can cause suffering, ,hich is defined as the state of severe
distress associated ,ith events that threaten the intactness of the person&
Culture also affects the e)perience of pain, specifically the pain e)pression, medication
use, and pain+related eliefs and coping&
Pain is most commonly categorized as nociceptive or neuropathic ased on underlying
pathology or as acute or chronic&
Nocice"tion is the physiologic process y ,hich information aout tissue damage is
communicated to the central nervous system& Nociception involves transduction,
transmission, perception, and modulation&
o ,ransduction is the conversion of a mechanical, thermal, or chemical stimulus
into a neuronal action potential&
No)ious (tissue+damaging) stimuli cause the release of numerous
chemicals into the area surrounding the peripheral nociceptors&
.nflammation and the suse<uent release of chemical mediators increase
the li'elihood of transduction&
The pain produced from activation of peripheral nociceptors is called
nociceptive pain&
Pain arising from anormal processing of stimuli y the nervous system is
called neuropathic pain&
1+1"
Key Points
=ecreasing the effects of chemicals released at the periphery is the asis of
several drugs (e&g&, nonsteroidal antiinflammatory drugs HNB5.=sI)&
o ,ransmission is the movement of pain impulses from the site of transduction to
the rain&
Dermatomes are areas on the s'in that are innervated primarily y a
single spinal cord segment&
-eferred "ain must e considered ,hen interpreting the location of pain
reported y the person ,ith in#ury to or disease involving visceral organs&
o Perce"tion occurs ,hen pain is recognized, defined, and responded to y the
individual e)periencing the pain& The rain is necessary for pain perception&
o Modulation involves the activation of descending path,ays that e)ert inhiitory
or facilitatory effects on the transmission of pain&
Neuropathic pain is further classified as somatic and visceral&
o Somatic "ain is characterized y deep aching or throing that is ,ell localized
and arises from one, #oint, muscle, s'in, or connective tissue&
o 2isceral "ain, ,hich may result from stimuli such as tumor involvement or
ostruction, arises from internal organs&
Neuro"athic "ain is caused y damage to peripheral nerves or CNB& Common causes of
neuropathic pain include trauma, inflammation, metaolic disease, infections of the
nervous system, tumors, to)ins, and neurologic disease&
5cute pain and chronic pain are different as reflected in their cause, course,
manifestations, and treatment&
o Acute "ain typically diminishes over time as healing occurs&
o Chronic "ain, or persistent pain, lasts for longer periods, often defined as longer
than $ months or past the time ,hen an e)pected acute pain or acute in#ury should
suside&
The goals of a nursing pain assessment are (1) to descrie the patient(s multidimensional
pain e)perience for the purpose of identifying and implementing appropriate pain
management techni<ues and (") to identify the patient(s goal for therapy and resources
for self+management&
5 comprehensive assessment of pain includes descriing the onset, duration,
characteristics, pattern, location, intensity, <uality, and associated symptoms such as
an)iety and depression&
/rea0through "ain is a transient, moderate to severe pain that occurs eyond the pain
treated y current analgesics&
Pain scales are useful tools to help the patient communicate pain intensity& Bcales must e
ad#usted for age and cognitive development&
1+1$
Key Points
Patients typically descrie neuropathic pain as a urning, numing, shooting, staing, or
itchy sensation&
Nociceptive pain may e descried as sharp, aching, throing, and cramping& 5ssociated
symptoms such as an)iety, fatigue, and depression may e)acerate or e e)acerated y
pain&
Btrategies for pain management include prescription and nonprescription drugs and
nondrug therapies such as hot and cold applications, complementary and alternative
therapies (e&g&, heral products, acupuncture), and rela)ation strategies (e&g&, imagery)&
o 5ll strategies must e documented, oth those that ,or' and those that are
ineffective&
o Patient and family eliefs, attitudes, and e)pectations influence responses to pain
and pain treatment&
Pain medications generally are divided into three categories: nonopioids, opioids, and co+
analgesic or ad#uvant drugs&
o :ild pain often can e relieved using nonopioids alone&
o :oderate to severe pain usually re<uires an opioid&
o Neuropathic pain often re<uires a co+analgesic and ad#uvant drug&
o Nonopioid pain medications include acetaminophen, aspirin, and nonsteroidal
antiinflammatory agents (NB5.=s)&
NB5.=s are associated ,ith a numer of side effects, including leeding tendencies,
gastrointestinal ulcers and leeding, and renal and CNB dysfunction&
$"ioids are the strongest analgesics availale&
o ;pioids produce their effects y inding to receptors in the CNB&
o Common side effects of opioids include constipation, nausea, vomiting, sedation,
respiratory depression, and pruritus&
o 5 o,el regimen should e instituted at the eginning of opioid therapy and
should continue for as long as the person ta'es opioids&
o Concerns aout sedation and respiratory depression are t,o of the most common
fears associated ,ith opioids&
o .f severe respiratory depression occurs and stimulation of the patient (calling and
sha'ing patient) does not reverse the somnolence or increase the respiratory rate
and depth, nalo)one (Narcan), an opioid antagonist, can e administered
intravenously or sucutaneously&

Ad*u!ant analgesic thera"ies include antidepressants, antiseizure drugs,
"
+adrenergic
agonists, and corticosteroids&
o Tricyclic antidepressants enhance the descending inhiitory system and are
effective for a variety of pain syndromes, particularly neuropathic pain
syndromes&
1+1%
Key Points
o 5ntiseizure or antiepileptic drugs (5*=s) affect oth peripheral nerves and the
CNB and are effective for neuropathic pain and prophylactic treatment of
migraine headaches&
o Clonidine (Catapres) and tizanidine (Janafle)) are the most ,idely used
"
+
adrenergic agonists and may e used for chronic headache and neuropathic pain&
o CorticosteroidsGincluding de)amethasone H=ecadronI, prednisone, and
methylprednisolone H:edrolIGare used for management of acute and chronic
cancer pain, pain secondary to spinal cord compression, and inflammatory #oint
pain syndromes&
5ppropriate analgesic scheduling focuses on prevention or control of pain rather than the
provision of analgesics only after the patient(s pain has ecome severe&
3uianalgesic dose refers to a dose of one analgesic that is e<uivalent in pain+relieving
effects compared ,ith another analgesic&
;pioids and other analgesic agents can e delivered via many routes&
o :ost pain medications are availale in oral preparations, such as li<uid and talet
formulations& ;pioids can e administered under the tongue or held in the mouth
and asored into systemic circulation, ,hich ,ould e)empt them from the first+
pass effect&
o @entanyl citrate (5cti<) is administered transmucosally&
o .ntranasal administration allo,s delivery of a medication (e&g&, utorphanol
HBtadolI) to highly vascular mucosa and avoids the first+pass effect&
o 5nalgesics availale as rectal suppositories include hydromorphone,
o)ymorphone, morphine, and acetaminophen&
o .ntravenous administration is the est route ,hen immediate analgesia and rapid
titration are necessary&
o .ntraspinal (epidural or intrathecal) opioid therapy involves inserting a catheter
into the suarachnoid space (intrathecal delivery) or the epidural space (epidural
delivery)&
o .ntraspinally administered analgesics are highly potent ecause they are delivered
close to the receptors in the spinal cord dorsal horn&
2ong+term epidural catheters may e placed for patients ,ith terminal
cancer or those ,ith certain pain syndromes that are unresponsive to other
treatments&
.ntraspinal catheters can e surgically implanted for long+term pain relief&
5 specific type of .3 delivery system is "atient-controlled analgesia
(PC5) or demand analgesia& .t can also e connected to an epidural
catheter (patient+controlled epidural analgesia HPC*5I)& -ith PC5, a dose
of opioid is delivered ,hen the patient decides that a dose is needed&
Neuroablati!e inter!entions are performed for severe pain that is unresponsive to all
other therapies&
1+1C
Key Points
Neuroaugmentation involves electrical stimulation of the rain and the spinal cord&
:assage (superficial or deep) is a common therapy for pain& 5 trigger "oint is a
circumscried hypersensitive area ,ithin a tight and of muscle and is caused y acute or
chronic muscle strain&
*)ercise is a critical part of the treatment plan for patients ,ith chronic pain, particularly
those e)periencing musculos'eletal pain&
,ranscutaneous electrical ner!e stimulation (T*NB) involves the delivery of an
electric current through electrodes applied to the s'in surface over the painful region, at
trigger points, or over a peripheral nerve&
Percutaneous electrical ner!e stimulation (P*NB) stimulates deeper peripheral tissues
through a needle ,ith an attached stimulator& The needle is inserted near a large
peripheral or spinal nerve&
5cupuncture is a techni<ue of Traditional Chinese :edicine in ,hich very thin needles
are inserted into the ody at designated points to reduce musculos'eletal pain, repetitive
strain disorders, myofascial pain syndrome, postsurgical pain, postherpetic neuralgia,
peripheral neuropathic pain, and headaches&
>eat therapy can e either superficial or deep&
Cold therapy involves the application of either moist or dry cold to the s'in&
Techni<ues to alter the affective, cognitive, and ehavioral components of pain include
distraction, hypnosis, and rela)ation strategies&
The nurse acts as planner, educator, patient advocate, interpreter, and supporter of the
patient in pain and the patient(s family& .t is important to realize that a nurse(s eliefs and
attitudes may hinder appropriate pain management&
Aerontologic considerations:
o Treatment of pain in the elderly patient is complicated&
o ;lder adults metaolize drugs more slo,ly than younger persons and thus are at
greater ris' for higher lood levels and adverse effects&
o The use of NB5.=s in elderly patients is associated ,ith a high fre<uency of
serious A. leeding&
o ;lder people often ta'e many drugs for one or more chronic conditions&
o Cognitive impairment and ata)ia can e e)acerated ,hen analgesics such as
opioids, antidepressants, and antiseizure drugs are used&
o >ealth care providers for older patients should titrate drugs slo,ly and monitor
carefully for side effects&
1+1D
Key Points
th
edition
Key Points
Chapter 11: *nd+of+2ife and Palliative Care
nd-of-life care (*;2 care) is the term currently used to descrie issues related to dying
and death care&
*;2 care focuses on the physical and psychosocial needs of the patients and their
families at the end of life&
Death is the irreversile cessation of circulatory and respiratory function or the
irreversile cessation of all functions of the entire rain, including the rainstem&
/erea!ement is an individual(s emotional response to the loss of a significant person&
4rief develops from ereavement and is a dynamic psychologic and physiologic
response follo,ing the loss&
5ssessment of spiritual needs in *;2 care is a 'ey consideration&
@amily involvement is integral to providing culturally competent *;2 care&
Persons ,ho are legally competent may choose organ donation&
Ad!ance care "lanning is focused on anticipated challenges that the patient and family
,ill face ecause of illness, medical treatment, and other concerns&
The nurse needs to e a,are of legal issues and the ,ishes of the patient&
Ad!ance directi!es and organ donor information should e located in the medical record
and identified on the patient(s record and1or the nursing care plan&
Palliati!e care is the active total care of patients ,hose disease is not responsive to
curative treatment& Palliative care focuses on controlling pain and other symptoms, as
,ell as reducing psychologic, social, and spiritual distress for the patient and the family&
1+19
Key Points
Palliative care is the frame,or' for hos"ice care& Palliative care can start much earlier in
a disease process, ,hereas hospice traditionally is limited to the pro#ected last D months
of life&
5dmission to a hospice program has t,o criteria: (1) the patient must desire the services!
and (") a physician must certify that the patient has D months or less to live&
The o#ective of a ereavement program is to provide support and to assist survivors in
the transition to a life ,ithout the deceased person&
The physical assessment is areviated in *;2 care and focuses on changes that
accompany terminal illness and the specific disease process&
@amilies need ongoing information on the disease, the dying process, and any care that
,ill e provided&
?espiratory distress and shortness of reath (dyspnea) are common near the end of life&
The sensation of air hunger results in an)iety for the patient and family memers&
:ost terminally ill and dying people do not ,ant to e alone and fear loneliness&

Priority interventions for grief must focus on providing an environment that allo,s the
patient to e)press feelings&
People ,ho are dying deserve and re<uire the same physical care as people ,ho are
e)pected to recover&
To meet the holistic needs of the patient, the nurse collaorates ,ith the social ,or'er,
chaplain, physical therapist, occupational therapists, certified nursing assistants, and
physician&
The patient near death may seem to e ,ithdra,n from the physical environment,
maintaining the aility to hear ,hile not eing ale to respond&
.t is important not to delay or deny pain relief measures to a terminally ill patient&
B'in integrity is difficult to maintain at the end of life due to immoility, urinary and
o,el incontinence, dry s'in, nutritional deficits, anemia, friction, and shearing forces&
5fter the patient is pronounced dead, the nurse prepares or delegates preparation of the
ody for immediate vie,ing y the family ,ith consideration for cultural customs and in
accordance ,ith state la, and agency policies and procedures&
1+1F
Key Points
The role of caregiver includes ,or'ing and communicating ,ith the patient, supporting
the patient(s concerns, helping the patient resolve any unfinished usiness, ,or'ing ,ith
other family memers and friends, and dealing ,ith the caregiver(s o,n needs and
feelings&
5n understanding of the grieving process as it affects oth the patient and the family
caregivers is of great importance&
?ecognizing signs and ehaviors among family memers ,ho may e at ris' for
anormal grief reactions is an important nursing intervention&
Caring for dying patients is intense and emotionally charged& .t is important to consider
interventions that help ease physical and emotional stress for the nurse&
Terminal illness and dying are e)tremely personal events that affect the patient, the
family, and health care providers&
th
edition
Key Points
Chapter 1": 5ddictive 6ehaviors
The illicit sustances most commonly used in the 4nited Btates include
mari#uana1hashish, cocaine, hallucinogens, and heroin&
Compulsive ehaviors, including eating disorders, gamling, computer gaming and
interacting, and e)cessive e)ercise, are considered addicti!e beha!iors(
Addiction is a comple) disorder that is a treatale, chronic, relapsing disease& .t is
considered a ioehavioral disorder&
5ddiction results from the prolonged effects of addictive drugs or ehaviors on the rain&
The brain reward s.stem is a system that creates the sensation of pleasure& The
neurotransmitter dopamine plays a role in addiction&
Aenetics, environment, and sociocultural factors contriute to addiction&
Toacco:
1+1E
Key Points
o The most common addictive ehavior is toacco use& The complications
associated ,ith the use of toacco (nicotine) are related to dose and method of
ingestion&
o Toacco use is the leading cause of preventale illness and death in the 4nited
Btates&
Cocaine:
o .s the most potent of the aused stimulants& 6esides its effects on the rain re,ard
system, cocaine produces adrenalin+li'e effects&
o Persons ,ho ause cocaine have prolems related to sleep, appetite, depression,
respiratory infections, chest pain, and1or headaches&
5mphetamines stimulate the central and peripheral nervous systems& They cause
increased alertness, improved performance, relief of fatigue, and anore)ia&
Caffeine promotes alertness and alleviates fatigue& .t is a ,ea' CNB stimulant&
5lcohol:
o .s consumed y almost C8K of 5mericans over the age of 1"& 5lcohol ause
affects 18K of the population&
o 5lcoholism is a chronic and potentially fatal disease if not treated&
o .n alcoholics, arupt ,ithdra,al may have life+threatening effects& Persons ,ho
ause alcohol often have a numer of health prolems&
o 5cute alcohol to)icity can occur ,ith inge drin'ing or the use of alcohol ,ith
other CNB depressants&
Bedative+hypnotic agents:
o Commonly used ones include ariturates, enzodiazepines, and ariturate+li'e
drugs&
o Bedative+hypnotics act on the CNB to cause sedation at lo, doses and sleep at
high doses& Tolerance develops rapidly&
Bigns and symptoms of opioid overdose include pinpoint pupils, clammy s'in, depressed
respiration, coma, and death (if not treated)&
;pioid overdose can precipitate a medical emergency&
Cannais (or mari#uana) is the most ,idely used illicit drug in North 5merica& :ari#uana
produces euphoria, sedation, and hallucinations&
The nurse must e alert to signs and symptoms of the many health prolems associated
,ith addictive ehaviors&
1+"8
Key Points
.t is important for the nurse to promote an open and non#udgmental communication style
,ith the patient&
5 drug o!erdose is an emergency situation, and management is ased on the type of
sustance involved&
.n general, withdrawal signs and symptoms are opposite in nature from the direct effects
of the drug&
The patient ,ho is dependent on sustances is at ris' for postoperative complications&
Bevere pain should e treated ,ith opioids and at a much higher dosage than that used
,ith drug+naLve persons&
.t is the nurse(s responsiilityGin collaoration ,ith a multidisciplinary team composed
of physicians, social ,or'ers, and addiction specialistsGto address the patient(s
sustance ause prolem and motivate the patient to change ehaviors and see' treatment
for the addiction&
th
edition
Key Points
Chapter 1$: .nflammation and -ound >ealing
The inflammator. res"onse is a se<uential reaction to cell in#ury& .t neutralizes and
dilutes the inflammatory agent, removes necrotic materials, and estalishes an
environment suitale for healing and repair&
The asic types of inflammation are acute, suacute, and chronic&
o .n acute inflammation, the healing occurs in " to $ ,ee's and usually leaves no
residual damage&
o Subacute inflammation has the features of the acute process ut lasts longer&
o Chronic inflammation lasts for ,ee's, months, or even years&
The inflammatory response can e divided into a vascular response, a cellular response,
formation of e)udate, and healing&
The !ascular res"onse results in vasodilation causing hyperemia (increased lood flo,
in the area), ,hich raises filtration pressure&
1+"1
Key Points
=uring the cellular res"onse, neutrophils and monocytes move to the inner surface of the
capillaries (margination) and then through the capillary ,all (diapedesis) to the site of
in#ury&
1udate consists of fluid and leu'ocytes that move from the circulation to the site of
in#ury& The nature and <uantity of e)udate depend on the type and severity of the in#ury
and the tissues involved&
)ealing includes the t,o ma#or components of regeneration and repair& -egeneration is
the replacement of lost cells and tissues ,ith cells of the same type& -e"air is the more
common type of healing and usually results in scar formation&
The est management of inflammation is the prevention of infection, trauma, surgery, and
contact ,ith potentially harmful agents&
The purposes of wound management include (1) cleaning a ,ound to remove any dirt
and deris from the ,ound ed, (") treating infection to prepare the ,ound for healing,
and ($) protecting a clean ,ound from trauma so that it can heal normally&
5 "ressure ulcer is a localized area (usually over a ony prominence) of tissue necrosis
caused y unrelieved pressure that occludes lood flo, to the tissues& Pressure ulcers
generally fall under the category of healing y secondary intention&
Care of a patient ,ith a pressure ulcer re<uires local care of the ,ound and support
measures of the whole person, including ade<uate nutrition, pain management, control of
other medical conditions, and pressure relief&
th
edition
Key Points
Chapter 1%: Aenetics, 5ltered .mmune ?esponses, and Transplantation
4N,'CS
Aenetic disorders can e categorized into autosomal dominant, autosomal recessive, or
se)+lin'ed (M+lin'ed) recessive disorders&
o Autosomal dominant disorders are caused y a mutation of a single gene pair
(heterozygous) on a chromosome&
o Autosomal recessi!e disorders are caused y a mutation in t,o gene pairs
(homozygous) on a chromosome&
1+""
Key Points
o M+lin'ed recessive disorders are caused y a mutation on the M chromosome&
The different types of genetic testing include direct testing, lin'age testing, iochemical
testing, and 'aryotyping&
4ene thera". is an e)perimental techni<ue used to replace or repair defective or missing
genes ,ith normal genes&
Stem cells are cells in the ody that have the aility to differentiate into other cells& Btem
cells can e divided into t,o types: emryonic and adult&
AL,-D 'MM5N -SP$NSS
'mmunit. is a state of responsiveness to foreign sustances such as microorganisms and
tumor proteins& .mmune responses serve three functions: defense, homeostasis, and
surveillance&
.mmunity is classified as innate (natural) or ac<uired& 5c<uired immunity is the
development of immunity, either active or passive&
The immune response involves comple) interactions of T cells, 6 cells, monocytes, and
neutrophils& These interactions depend on c.to0ines (solule factors secreted y -6Cs
and a variety of other cells in the ody) that act as messengers et,een the cell types&
)umoral immunit. consists of antiody+mediated immunity& .n contrast, immune
responses initiated through specific antigen recognition y T cells are termed cell-
mediated immunit.( 6oth humoral and cell+mediated immunity are needed to remain
healthy&
'mmunocom"etence e)ists ,hen the ody(s immune system can identify and inactivate
or destroy foreign sustances&
5 h."ersensiti!it. reaction occurs ,hen the immune response is overreactive against
foreign antigens or fails to maintain self+tolerance& This results in tissue damage&
5lthough an alteration of the immune system may e manifested in many ,ays, allergies
or type . hypersensitivity reactions are seen most fre<uently&
o Common allergic reactions include anaphyla)is and atopic reactions&
o 5llergic rhinitis, atopic dermatitis, urticaria, and angioedema are common type .
hypersensitivity reactions&
5fter an allergic disorder is diagnosed, the therapeutic treatment is aimed at reducing
e)posure to the offending allergen, treating the symptoms, and if necessary, desensitizing
the person through immunotherapy&
1+"$
Key Points
Ana"h.lactic reactions occur suddenly in hypersensitive patients after e)posure to the
offending allergen& They may occur follo,ing parenteral in#ection of drugs (especially
antiiotics), lood products, and insect stings&
:ost allergic reactions are chronic and are characterized y remissions and e)acerations
of symptoms&
The ma#or categories of drugs used for symptomatic relief of chronic allergic disorders
include antihistamines, sympathomimetic1decongestant drugs, corticosteroids, antipruritic
drugs, and mast cellNstailizing drugs&
.mmunotherapy is the recommended treatment for control of allergic symptoms ,hen the
allergen cannot e avoided and drug therapy is not effective&
T,o types of late) allergies can occur: type .3 allergic contact dermatitis and type .
allergic reactions&
Multi"le chemical sensiti!ities (:CB) is an ac<uired disorder in ,hich certain people
e)posed to various foods and chemicals in the environment have many symptoms related
to multiple ody systems&
The human leu0oc.te antigen (>25) system consists of a series of lin'ed genes that
occur together on the si)th chromosome in humans& 6ecause of its importance in the
study of tissue matching, the chromosomal region incorporating the >25 genes is termed
the ma#or histocompatiility comple)&
Autoimmunit. is an immune response against self& The immune system no longer
differentiates self from nonself&
.mmunodeficiency disorders involve an impairment of one or more immune mechanisms,
,hich include the follo,ing:
(1) Phagocytosis
(") >umoral response
($) Cell+mediated response
(%) Complement
(C) 5 comined humoral and cell+mediated deficiency
.mmunodeficiency disorders are primary if the immune cells are improperly developed or
asent and secondary if the deficiency is caused y illnesses or treatment&
,-ANSPLAN,A,'$N
Commonly transplanted organs and tissues include corneas, 'idneys, s'in, one marro,,
heart valves, one, and connective tissues&
1+"%
Key Points
The degree of >25 matching re<uired or deemed suitale for successful solid organ
transplantation depends on the type of organ and the transplant center at ,hich the
transplant is eing performed&
?e#ection of organs occurs if the donor organ does not perfectly match the recipient(s
>25s& The re#ection can e prevented y closely matching 56;, ?h, and >25s et,een
donor and recipient&
The three types of organ re#ection can e classified as hyperacute, acute, and chronic&
The goal of immunosu""ressi!e thera". is to ade<uately suppress the immune response
to prevent re#ection of the transplanted organ ,hile maintaining sufficient immunity to
prevent over,helming infection&
Commonly used immunosuppressive drugs include corticosteroids, cyclosporine,
tacrolimus (Prograf), and mycophenolate mofetil (CellCept)&
th
edition
Key Points
Chapter 1C: .nfection and >uman .mmunodeficiency 3irus .nfection
'N+C,'$N
5n infection is an invasion of the ody y a pathogen (any microorganism that causes
disease) and the resulting signs and symptoms that develop in response to the invasion&
The most common causes of infection are acteria, viruses, fungi, and protozoa&
5n emerging infection is an infectious disease ,hose incidence has increased in the past
"8 years or threatens to increase in the immediate future&
*merging infectious diseases can originate from un'no,n sources, contact ,ith animals,
changes in 'no,n diseases, or iologic ,arfare&
-esistance occurs ,hen pathologic organisms change in ,ays that decrease the aility of
a drug (or a family of drugs) to treat disease&
:ethicillin+resistant Staphylococcus aureus (:?B5), vancomycin+resistant enterococci
(3?*), and penicillin+resistant Streptococcus pneumoniae are three of the most
troulesome antiiotic+resistant acteria currently causing prolems in North 5merica&
1+"C
Key Points
Nosocomial infections are infections that are ac<uired as a result of e)posure to a
microorganism in a hospital setting and typically occur ,ithin 9" hours of
hospitalization&
@or older adult patients, the rate of nosocomial infection is t,o to three times higher than
for younger patients&
)5MAN 'MM5N$D+'C'NC6 2'-5S 'N+C,'$N
The human immunodeficienc. !irus (>.3) is a rionucleic acid (?N5) virus, ,hich
means it replicates going from ?N5 to deo)yrionucleic acid (=N5)&
>.3 can only e transmitted under specific conditions that allo, contact ,ith infected
ody fluids, including lood, semen, vaginal secretions, and reast mil'&
Be)ual contact ,ith an >.3+infected partner is the most common mode of transmission&
.mmune dysfunction in >.3 disease is caused predominantly y damage to and
destruction of C=%
O
T cells (also 'no,n as T helper cells or C=%
O
T lymphocytes)&
The ma#or concern related to immune suppression is the development of o""ortunistic
diseases (infections and cancers that occur in immunosuppressed patients that can lead to
disaility, disease, and death)&
>.3 infections are divided into acute, early chronic, intermediate chronic, and late
chronic infection&
2ate chronic infection is also 'no,n as ac3uired immunodeficienc. s.ndrome (5.=B)&
The most useful screening tests for >.3 are those that detect >.3+specific antiodies& The
ma#or prolem ,ith these tests is that there is a median delay of " months after infection
efore antiodies can e detected& This creates a window "eriod during ,hich an
infected individual may not test positive for >.3+antiody&
The goals of drug therapy in >.3 infection are to (1) decrease the !iral load, (") maintain
or raise C=%
O
T cell counts, and ($) delay the development of >.3+related symptoms and
opportunistic diseases&
The ma#or drug classifications for >.3 include nonnucleoside reverse transcriptase
inhiitors (NN?T.s), nucleoside reverse transcriptase inhiitors (N?T.s), nucleotide
reverse transcriptase inhiitors (Nt?T.s), protease inhiitors (P.s), and entry inhiitors&
:anagement of >.3 is complicated y the many opportunistic diseases that can develop
as the immune system deteriorates&
1+"D
Key Points
*)amples of opportunistic infections include Pneumocystis jiroveci pneumonia (PCP),
Mycobacterium avium comple) (:5C), and Kaposi sarcoma&
Nursing care for individuals not 'no,n to e infected ,ith >.3 should focus on
ehaviors that could put the person at ris' for >.3 infection and other se)ually
transmitted and lood+orne diseases&
The overriding goals of therapy for infected individuals are to 'eep the viral load as lo,
as possile for as long as possile, maintain or restore a functioning immune system,
improve the patient(s <uality of life, prevent opportunistic disease, reduce >.3+related
disaility and death, and prevent ne, infections&
>.3+infected patients share prolems e)perienced y all individuals ,ith chronic
diseases, ut these prolems are e)acerated y negative social constructs surrounding
>.3&
th
edition
Key Points
Chapter 1D: Cancer
Cancer encompasses a road range of diseases of multiple causes that can arise in any
cell of the ody capale of evading regulatory controls over proliferation and
differentiation&
T,o ma#or dysfunctions present in the process of cancer are (1) defective cellular
proliferation (gro,th) and (") defective cellular differentiation&
Cancer cells usually proliferate at the same rate of the normal cells of the tissue from
,hich they arise& >o,ever, cancer cells divide indiscriminately and haphazardly and
sometimes produce more than t,o cells at the time of mitosis&
Protooncogenes are normal cellular genes that are important regulators of normal
cellular processes& -hen these genes ecome mutated, they can egin to function as
oncogenes (tumor+inducing genes)&
Tumors can e classified as enign or malignant&
o /enign neo"lasms are ,ell+differentiated&
o Malignant neo"lasms range from ,ell+differentiated to undifferentiated&
1+"9
Key Points
The stages of cancer include initiation, promotion, and progression&
o The first stage, initiation, is the occurrence of a mutation in the cell(s genetic
structure, resulting from an inherited mutation, an error that occurs during =N5
replication, or follo,ing e)posure to a chemical, radiation, or viral agent&
o Promotion, the second stage in the development of cancer, is characterized y the
reversile proliferation of the altered cells&
o Progression, the final stage, is characterized y increased gro,th rate of the
tumor, increased invasiveness, and spread of the cancer to a distant site
(metastasis)&
Bince cancer cells arise from normal human cells, the immune response mounted against
cancer cells may e inade<uate to effectively eradicate them&
The process y ,hich cancer cells evade the immune system is termed immunologic
escape&
Tumors can e classified according to anatomic site, histologic %grading&, and e)tent of
disease (staging)&
o .n the anatomic classification of tumors, the tumor is identified y the tissue of
origin, the anatomic site, and the ehavior of the tumor (i&e&, enign or malignant)&
o .n histologic grading of tumors, the appearance of cells and the degree of
differentiation are evaluated pathologically& @or many tumor types, four grades
are used to evaluate anormal cells ased on the degree to ,hich the cells
resemle the tissue of origin&
o The staging classification system is ased on a description of the e)tent of the
disease rather than on cell appearance&
The iopsy procedure is the only definitive means of diagnosing cancer&
The goal of cancer treatment is cure, control, or palliation&
o -hen cure is the goal, the treatment offered is e)pected to have the greatest
chance of disease eradication and may involve local therapy (i&e&, surgery or
radiation) alone or in comination ,ith or ,ithout periods of ad#unctive systemic
therapy (i&e&, chemotherapy)&
o Control is the goal of the treatment plan for many cancers that cannot e
completely eradicated ut are responsive to anticancer therapies and, as ,ith other
chronic illnesses such as diaetes mellitus and heart failure, can e managed for
long periods of time ,ith therapy&
o -ith palliation, relief or control of symptoms and the maintenance of a
satisfactory <uality of life are the primary goals rather than cure or control of the
disease process&
:odalities for cancer treatment ,ith all three goals include surgery, chemotherapy,
radiation therapy, and iologic and targeted therapy&
1+"F
Key Points
The goal of chemothera". is to eliminate or reduce the numer of malignant cells
present in the primary tumor and metastatic tumor site(s)&
Chemotherapeutic drugs are classified in general groups according to their molecular
structure and mechanisms of action&
Chemotherapy can e administered y multiple routes, such as central vascular access
devices, peripherally inserted central venous catheters, or implanted infusion ports&
?egional treatment ,ith chemotherapy involves the delivery of the drug directly to the
tumor site&
Chemotherapy+induced side effects are the result of the destruction of normal cells,
especially those that are rapidly proliferating such as those in the one marro,, lining of
the gastrointestinal system, and the integumentary system (s'in, hair, and nails)&
-adiation is the emission and distriution of energy through space or a material medium&
?adiation is used to treat a carefully defined area of the ody to achieve local control of
disease&
Bimulation is a part of radiation treatment planning used to determine the optimal
treatment method y focusing on the geometric aspects of treatment&
Nurses play a 'ey role in assisting patients to cope ,ith the psychoemotional issues
associated ,ith receiving cancer treatment&
*ducating patients aout their treatment regimen, supportive care options (e&g&,
antiemetics, antidiarrheals), and ,hat to e)pect during the course of treatment is
important to help decrease fear and an)iety, encourage adherence, and guide at+home
self+management&
:yelosuppression is one of the most common effects of chemotherapy, and, to a lesser
e)tent, it can also occur ,ith radiation&
@atigue is a nearly universal symptom affecting 98K to 188K of patients ,ith cancer&
The intestinal mucosa is one of the most sensitive tissues to radiation and chemotherapy&
Nausea and vomiting are common se<uelae of chemotherapy and, in some instances,
radiation therapy&
6iologic and targeted therapy can e effective alone or in comination ,ith surgery,
radiation therapy, and chemotherapy&
1+"E
Key Points
/iologic thera". consists of agents that modify the relationship et,een the host and the
tumor y altering the iologic response of the host to the tumor cells&
,argeted thera". interferes ,ith cancer gro,th y targeting specific cellular receptors
and path,ays that are important in tumor gro,th&
Capillary lea' syndrome, pulmonary edema, one marro, depression, and fatigue are
associated ,ith iologic therapy&
)emato"oietic stem cell trans"lantation is an effective, lifesaving procedure for a
numer of malignant and nonmalignant diseases&
o >ematopoietic stem cell transplants are categorized as allogeneic, syngeneic, or
autologous&
o .n allogeneic transplantation, stem cells are ac<uired from a donor ,ho has een
determined to e human leu'ocyte antigen (>25)Nmatched to the recipient&
o Byngeneic transplantation is a type of allogeneic transplant that involves otaining
stem cells from one identical t,in and infusing them into the other&
o .n autologous transplantation patients receive their o,n stem cells ac' follo,ing
myeloalative (destroying one marro,) chemotherapy&
4ene thera". is an e)perimental therapy that involves introducing genetic material into
a person(s cell to fight a disease, such as cancer&
Cancer patients may develop complications related to the continual gro,th of the
malignancy into normal tissue or to the side effects of treatment&
:oderate to severe pain occurs in appro)imately C8K of patients ,ho are receiving
active treatment for their cancer and in F8K to E8K of patients ,ith advanced cancer&
th
edition
Key Points
Chapter 19: @luid, *lectrolyte, and 5cid+6ase .malances
6ody fluids and electrolytes play an important role in homeostasis(
:any diseases and their treatments have the aility to affect fluid and electrolyte
alance&
1+$8
Key Points
-ater is the primary component of the ody, accounting for appro)imately D8K of the
ody ,eight in the adult&
The t,o ma#or fluid compartments in the ody are intracellular and e)tracellular&
The measurement of electrol.tes is important to the nurse in evaluating electrolyte
alance, as ,ell as in determining the composition of electrolyte preparations&
$smolalit. is important ecause it indicates the ,ater alance of the ody&
.n the metaolically active cell, there is a constant e)change of sustances et,een the
cell and the interstitium, ut no net gain or loss of ,ater occurs&
The ma#or colloid in the vascular system contriuting to the total osmotic "ressure is
protein&
The amount and direction of movement et,een the interstitium and the capillary are
determined y the interaction of (1) capillary h.drostatic "ressure, (") plasma oncotic
pressure, ($) interstitial hydrostatic pressure, and (%) interstitial oncotic pressure&
.f capillary or interstitial pressures are altered, fluid may anormally shift from one
compartment to another, resulting in edema or deh.dration&
@luid is dra,n into the plasma space ,henever there is an increase in the plasma osmotic
or oncotic pressure& This could happen ,ith administration of colloids, de)tran,
mannitol, or hypertonic solutions&
+irst s"acing descries the normal distriution of fluid in the intracellular fluid (.C@)
and e)tracellular fluid (*C@) compartments& Second s"acing refers to an anormal
accumulation of interstitial fluid (i&e&, edema)& ,hird s"acing occurs ,hen fluid
accumulates in a portion of the ody from ,hich it is not easily e)changed ,ith the rest
of the *C@&
-ater alance is maintained via the finely tuned alance of ,ater inta'e and e)cretion&
5n intact thirst mechanism is important for fluid alance& The patient ,ho cannot
recognize or act on the sensation of thirst is at ris' for fluid deficit and hyperosmolality&
5n increase in plasma osmolality or a decrease in circulating lood volume ,ill
stimulate antidiuretic hormone (5=>) secretion& ?eduction in the release or action of
5=> produces diaetes insipidus&
5ldosterone is a mineralocorticoid ,ith potent sodium+retaining and potassium+e)creting
capaility&
1+$1
Key Points
The primary organs for regulating fluid and electrolyte alance are the 'idneys, lungs,
and gastrointestinal tract&
'nsensible water loss, ,hich is invisile vaporization from the lungs and s'in, assists in
regulating ody temperature&
-ith severely impaired renal function, the 'idneys cannot maintain fluid and electrolyte
alance& This condition results in edema, potassium, and phosphorus retention, acidosis,
and other electrolyte imalances&
Btructural changes to the 'idney and a decrease in the renal lood flo, lead to a decrease
in the glomerular filtration rate, decreased creatinine clearance, the loss of the aility to
concentrate urine and conserve ,ater, and narro,ed limits for the e)cretion of ,ater,
sodium, potassium, and hydrogen ions&
@luid and electrolyte imalances are commonly classified as deficits or e)cesses&
@luid volume deficit can occur ,ith anormal loss of ody fluids (e&g&, diarrhea, fistula
drainage, hemorrhage, polyuria), inade<uate inta'e, or a plasma+to+interstitial fluid shift&
The use of "%hour inta'e and output records gives valuale information regarding fluid
and electrolyte prolems&
:onitoring the patient for cardiovascular and neurologic changes is necessary to prevent
or detect complications from fluid and electrolyte imalances&
5ccurate daily ,eights provide the easiest measurement of volume status& -eight
changes must e otained under standardized conditions&
*dema is assessed y pressing ,ith a thum or forefinger over the edematous area&
The rates of infusion of .3 fluid solutions should e carefully monitored&
The goal of treatment in fluid and electrolyte imalances is to treat the underlying cause&
S$D'5M
.s the ma#or *C@ cation&
5n elevated serum sodium may occur ,ith ,ater loss or sodium gain&
Hyponatremia:
o Common causes include ,ater e)cess from inappropriate use of sodium+free or
hypotonic .3 fluids&
o Bymptoms of hyponatremia are related to cellular s,elling and are first
1+$"
Key Points
manifested in the central nervous system (CNB)&
P$,ASS'5M
.s the ma#or .C@ cation&
@actors that cause potassium to move from the .C@ to the *C@ include acidosis, trauma
to cells (as in massive soft tissue damage or in tumor lysis), and e)ercise&
Hyperkalemia
o The most common cause is renal failure& >yper'alemia is also common ,ith
massive cell destruction (e&g&, urn or crush in#ury, tumor lysis)! rapid transfusion
of stored, hemolyzed lood! and cataolic states (e&g&, severe infections)&
o :anifestations of hyper'alemia include cramping leg pain, follo,ed y ,ea'ness
or paralysis of s'eletal muscles&
o 5ll patients ,ith clinically significant hyper'alemia should e monitored
electrocardiographically to detect dysrhythmias and to monitor the effects of
therapy& Cardiac depolarization is decreased, leading to flattening of the P ,ave
and ,idening of the P?B ,ave& ?epolarization occurs more rapidly, resulting in
shortening of the PT interval and causing the T ,ave to e narro,er and more
pea'ed& 3entricular firillation or cardiac standstill may occur&
o The patient e)periencing dangerous cardiac dysrhythmias should receive .3
calcium gluconate immediately ,hile the potassium is eing eliminated and
forced into cells&
Hypokalemia
o The most common causes are from anormal losses via either the 'idneys or the
gastrointestinal tract& 5normal losses occur ,hen the patient is diuresing,
particularly in the patient ,ith an elevated aldosterone level&
o .n the patient ,ith hypo'alemia, cardiac changes include impaired repolarization,
resulting in a flattening of the T ,ave and eventually in emergence of a 4 ,ave&
The incidence of potentially lethal ventricular dysrhythmias is increased in
hypo'alemia&
o Patients ta'ing digo)in e)perience increased digo)in to)icity if their serum
potassium level is lo,& B'eletal muscle ,ea'ness and paralysis may occur ,ith
hypo'alemia& Bevere hypo'alemia can cause ,ea'ness or paralysis of respiratory
muscles, leading to shallo, respirations and respiratory arrest&
o >ypo'alemia is treated y giving potassium chloride supplements and increasing
dietary inta'e of potassium&
CALC'5M
Hypercalcemia
o 5out t,o thirds of cases are caused y hyperparathyroidism and one third are
caused y malignancy, especially from reast cancer, lung cancer, and multiple
myeloma&
o :anifestations of hypercalcemia include decreased memory, confusion,
1+$$
Key Points
disorientation, fatigue, muscle ,ea'ness, constipation, cardiac dysrhythmias, and
renal calculi&
o Treatment of hypercalcemia is promotion of e)cretion of calcium in urine y
administration of a loop diuretic and hydration of the patient ,ith isotonic saline
infusions&
Hypocalcemia
o .s caused y a decrease in the production of parathyroid hormone&
o >ypocalcemia is characterized y increased muscle e)citaility resulting in
tetany&
o 5 patient ,ho has had nec' surgery including thyroidectomy is oserved
carefully for signs of hypocalcemia&
Phos"hate
The ma#or condition that can lead to hyperphosphatemia is acute or chronic renal failure&
>ypophosphatemia (lo, serum phosphate) is seen in the patient ,ho is malnourished or
has a malasorption syndrome&
MA4NS'5M
>ypomagnesemia (lo, serum magnesium level) produces neuromuscular and CNB
hyperirritaility&
>ypermagnesemia usually occurs only ,ith an increase in magnesium inta'e
accompanied y renal insufficiency or failure&
AC'D-/AS 'M/ALANCS
Patients ,ith diaetes mellitus, chronic ostructive pulmonary disease, and 'idney
disease fre<uently develop acid+ase imalances& 3omiting and diarrhea may cause loss
of acids and ases&
The nurse must al,ays consider the possiility of acid+ase imalance in patients ,ith
serious illnesses&
The buffer s.stem is the fastest acting system and the primary regulator of acid+ase
alance&
The lungs help maintain a normal p> y e)creting C;
"
and ,ater, ,hich are y+products
of cellular metaolism&
The three renal mechanisms of acid elimination are secretion of small amounts of free
hydrogen into the renal tuule, comination of >
O
,ith ammonia (N>
$
) to form
ammonium (N>
%
O
), and e)cretion of ,ea' acids&
1+$%
Key Points
5cid+ase imalances are classified as respiratory or metaolic&
o -es"irator. acidosis (caronic acid e)cess) occurs ,henever there is
hypoventilation&
o -es"irator. al0alosis (caronic acid deficit) occurs ,henever there is
hyperventilation&
o Metabolic acidosis (ase icaronate deficit) occurs ,hen an acid other than
caronic acid accumulates in the ody or ,hen icaronate is lost from ody
fluids&
o Metabolic al0alosis (ase icaronate e)cess) occurs ,hen a loss of acid
(prolonged vomiting or gastric suction) or a gain in icaronate occurs&
5rterial lood gas (56A) values provide valuale information aout a patient(s acid+ase
status, the underlying cause of the imalance, the ody(s aility to regulate p>, and the
patient(s overall o)ygen status&
.n cases of acid+ase imalances, the treatment is directed to,ard correction of the
underlying cause&
@luid replacement therapy is used to correct fluid and electrolyte imalances&
o 5 h."otonic solution provides more ,ater than electrolytes, diluting the *C@&
o Plasma e)panders stay in the vascular space and increase the osmotic pressure&
o 5 h."ertonic solution initially raises the osmolality y the *C@ and e)pands it&
th
edition
Key Points
Chapter 1F: Nursing :anagement: Preoperative Care
Surger. is performed to diagnose, cure, palliate, prevent, e)plore, and1or provide
cosmetic improvement&
Ambulator. surger. is generally preferred y patients, physicians, and third+party
payers&
The preoperative nursing assessment is performed to:
o =etermine the patient(s psychologic and physiologic factors that may contriute
to operative ris' factors
o *stalish aseline data
o .dentify and document the surgical site
o .dentify prescription and over+the+counter (;TC) drugs and heral products
1+$C
Key Points
o Confirm laoratory results
o Note cultural and ethnic factors that may affect the surgical e)perience
o 3alidate that the consent form has een signed and ,itnessed
Common fears associated ,ith surgery include the potential for death, permanent
disaility resulting from surgery, pain, change in ody image, or results of a diagnostic
procedure&
.n the nursing assessment, information should also e otained aout the patient(s family
concerning any history of adverse reactions to or prolems ,ith anesthesia&
5ll findings on the medication history should e documented and communicated to the
intraoperative and postoperative personnel&
Patients should also e screened for possile late) allergies&
The preoperative assessment of the older person(s aseline cognitive function is
especially crucial for intraoperative and postoperative evaluation&
The patient ,ith diaetes mellitus is especially at ris' for adverse effects of anesthesia
and surgery&
;esity stresses oth the cardiac and pulmonary system and ma'es access to the surgical
site and anesthesia administration more difficult&
Preoperative teaching involves the follo,ing:
o Three types of information: sensory, process, and procedural&
o =ifferent patients, ,ith varying cultures, ac'grounds, and e)periences, may ,ant
different types of information&
o 5ll teaching should e documented in the patient(s medical record&
o 5ll patients should receive instruction aout deep reathing, coughing, and
moving postoperatively&
'nformed consent:
o .s an active, shared decision+ma'ing process et,een the provider and the
recipient of care&
o 5 true medical emergency may override the need to otain consent&
;n the day of surgery, the nurse is responsile for the follo,ing:
o @inal preoperative teaching
o 5ssessment and communication of pertinent findings
o *nsuring that all preoperative preparation orders have een completed
o *nsuring that records and reports are present and complete to accompany the
patient to the ;?
1+$D
Key Points
o 3erifying the presence of a signed operative consent
o 2aoratory data
o 5 history and physical e)amination report
o 5 record of any consultations
o 6aseline vital signs
o Nurses( notes complete to that point&
Preoperative medications may include the follo,ing:
o 6enzodiazepines and ariturates for sedation and amnesia
o 5nticholinergics to reduce secretions
o ;pioids to decrease intraoperative anesthetic re<uirements and pain
o 5dditional drugs include antiemetics, antiiotics, eye drops, and regular
prescription drugs
@re<uently performed procedures in the older adult are cataract e)traction, coronary and
vascular procedures, prostate surgery, herniorrhaphy, cholecystectomy, and hip repair&
;lder adults may have sensory, motor, and cognitive deficits necessitating that more time
may e needed to complete preoperative testing and understand preoperative instructions&
These changes also re<uire attention to promote patient safety and prevent in#ury&
th
edition
Key Points
Chapter 1E: Nursing :anagement: .ntraoperative Care
The surgical suite is divided into three distinct areas: unrestricted, semirestricted, and
restricted&
o The unrestricted area is ,here personnel in street clothes can interact ,ith those
in scru clothing&
o .n the semirestricted area, personnel must ,ear surgical attire and cover all head
and facial hair&
o .n the restricted area,hich includes the o"erating room (;?), the sin' area,
and clean coreGmas's are re<uired to supplement surgical attire&
.n the holding area, the perioperative nurse ma'es the final identification and assessment
efore the patient is transferred into the ;? for surgery& Procedures such as inserting
intravenous (.3) catheters and arterial lines, removing casts, and drug administration may
occur here&
1+$9
Key Points
The ;? is a uni<ue acute care setting removed from other hospital clinical units& .t is
controlled geographically, environmentally, and acteriologically, and it is restricted in
terms of the inflo, and outflo, of personnel&
The "erio"erati!e nurse is a registered nurse ,ho implements patient care during the
perioperative period& This includes the follo,ing:
o Preparing the ;? for the patient
o Berving as the patient(s advocate during surgery
o 5ssessing the patient for additional needs or tas's efore surgery
o *ducating the patient and family memers
The function of circulating is implemented y the perioperative nurse ,ho is not
scrued, go,ned, and gloved and remains in the unsterile field&
The function of scrubbing is implemented y the nurse ,ho follo,s the designated
scru procedure, is go,ned and gloved in sterile attire, and remains in the sterile field&
The registered nurse first assistant %-N+A& ,or's in collaoration ,ith the surgeon to
produce an optimal surgical outcome for the patient&
5ssessment data important to intraoperative nursing care include the patient(s vital signs,
height, ,eight, and age! allergic reactions to food, drugs, and late)! condition and
cleanliness of s'in! s'eletal and muscle impairments! perceptual difficulties! level of
consciousness! nothing+y+mouth (NP;) status! and any sources of pain or discomfort&
Burgical hand antisepsis is re<uired of all sterile memers of the surgical team (scru
assistant, surgeon, and assistant)&
The center of the sterile field is the site of the surgical incision&
The nurse must understand the mechanism of anesthetic administration and the
pharmacologic effects of the agents as ,ell as the location of all emergency drugs and
e<uipment in the ;? area&
.t is a nursing responsiility to secure the patient(s e)tremities, provide ade<uate padding
and support, and otain sufficient physical or mechanical help to avoid unnecessary
straining of self or patient&
The tas' of prepping the patient for surgery is usually the responsiility of the circulating
nurse&
The patient(s response to nursing care is evaluated y the ;? nurse, ased on outcome
criteria estalished during the development of the patient(s plan of care&
1+$F
Key Points
ANS,)S'A
5n asolute contraindication of any anesthetic techni<ue is patient refusal&
:oderate sedation1analgesia (conscious sedation):
o .s a drug+induced depression of consciousness that retains the patient(s aility to
maintain her or his o,n air,ay and respond appropriately to veral commands
o .n this type of anesthesia, the patient achieves a level of emotional and physical
acceptance of a painful procedure (e&g&, colonoscopy)&
4eneral anesthesia:
o :ay e administered y intravenous, inhalation, or rectal routes, or as a
comination of these&
o Nearly all routine general anesthetics egin ,ith an .3 induction agent&
.nhalation agents:
o 5dministered y an endotracheal tue, a laryngeal mas' air,ay, or a
tracheostomy and enter the ody via the lung alveoli&
o Complications of inhalation anesthesia include coughing, laryngospasm,
ronchospasm, increased secretions, and respiratory depression&
=rugs to achieve unconsciousness, analgesia, amnesia, muscle rela)ation, or autonomic
nervous system control are added to an inhalation anesthetic and are termed ad#uncts&
Local anesthesia administered either topically or y in#ection allo,s for an operative
procedure to e performed on a particular part of the ody ,ithout loss of consciousness
or sedation&
The initial clinical manifestations of anaphyla)is may e mas'ed y anesthesia&
To prevent malignant h."erthermia, it is important for the nurse to otain a careful
family history and e alert to its development perioperatively&
th
edition
Key Points
Chapter "8: Nursing :anagement: Postoperative Care
The postoperative period egins immediately after surgery and continues until the patient is
discharged from medical care&
P$S,ANS,)S'A CA- 5N',
1+$E
Key Points
Priority care in the "ostanesthesia care unit (P5C4) includes monitoring and
management of respiratory and circulatory function, pain, temperature, and the surgical
site&
5ssessment egins ,ith an evaluation of the air,ay, reathing, and circulation (56C)&
5ny evidence of respiratory compromise re<uires prompt intervention&
Pulse o)imetry monitoring is initiated ecause it provides a noninvasive means of
assessing the ade<uacy of o)ygenation&
*lectrocardiographic (*CA) monitoring is initiated to determine cardiac rate and rhythm&
The initial neurologic assessment focuses on level of consciousness, orientation, sensory
and motor status, and size, e<uality, and reactivity of the pupils&
6ecause hearing is the first sense to return, the nurse e)plains all activities to the patient
from the moment of admission to the P5C4&
P$,N,'AL C$MPL'CA,'$NS 'N ,) PAC5
-es"irator.
.n the immediate postanesthesia period, the most common causes of air,ay compromise
include airwa. obstruction, hypo)emia, and hypoventilation&
Patients at ris' include those ,ho have had general anesthesia, are older, smo'e heavily,
have lung disease, are oese, or have undergone air,ay, thoracic, or adominal surgery&
)."o1emia, specifically an arterial o)ygen tension (Pa;
"
) of less than D8 mm >g, is
characterized y a variety of nonspecific clinical signs and symptoms, ranging from
agitation to somnolence, hypertension to hypotension, and tachycardia to radycardia&
o The most common cause of postoperative hypo)emia is atelectasis, ,hich
occurs as a result of retained secretions or decreased respiratory e)cursion&
o ;ther causes include pulmonary edema, aspiration, and bronchos"asm(
)."o!entilation is characterized y a decreased respiratory rate or effort, hypo)emia,
and an increasing arterial caron dio)ide tension (PaC;
"
), ,hich also 'no,n as
hypercapnia&
The nurse evaluates air,ay patency! chest symmetry! and the depth, rate, and character of
respirations& The chest ,all is oserved for symmetry of movement ,ith a hand placed
lightly over the )iphoid process& 6reath sounds are auscultated anteriorly, laterally, and
posteriorly&
?egular monitoring of vital signs and use of pulse o)imetry are necessary for early
recognition of respiratory prolems&
1+%8
Key Points
The presence of hypo)emia from any cause may e reflected y rapid reathing, gasping,
apprehension, restlessness, and a rapid or thready pulse&
Proper positioning facilitates respiration and protects the air,ay& 4nless contraindicated
y the surgical procedure, the unconscious patient is positioned in a lateral /recovery0
position& ;)ygen therapy ,ill e used if the patient has had general anesthesia and1or the
anesthesia care provider (5CP) orders it&
Cardio!ascular
The most common cardiovascular prolems include hypotension, hypertension, and
dysrhythmias& Patients at greatest ris' include those ,ith alterations in respiratory
function, a history of cardiovascular disease, the elderly, the deilitated, and the critically
ill&
Hypotension is most commonly caused y unreplaced fluid and lood loss, ,hich may
lead to hypovolemic shoc'& Treatment of hypotension egins ,ith o)ygen therapy to
promote o)ygenation of hypoperfused organs&
Hypertension is most fre<uently the result of pain, an)iety, ladder distention, or
respiratory compromise& Treatment of hypertension ,ill center on eliminating the
precipitating cause&
Dysrhythmias are often the result of hypo'alemia, hypo)emia, hypercaria, alterations in
acid+ase status, circulatory instaility, hypothermia, pain, surgical stress, and pree)isting
heart disease& Treatment is directed to,ard eliminating the cause&
3ital signs are monitored fre<uently (i&e&, every 1C minutes, or more often until stailized,
and then at less+fre<uent intervals)&
The anesthesia care provider (5CP) or surgeon should e notified if the follo,ing occur:
o Bystolic 6P is less than E8 mm >g or greater than 1D8 mm >g&
o Pulse rate is less than D8 eats per minute or more than 1"8 eats per minute&
o Pulse pressure (difference et,een systolic and diastolic pressures) narro,s&
o 6P gradually decreases during several consecutive readings&
o There is a change in cardiac rhythm&
o There is a significant variation from preoperative readings&
Neurologic
mergence delirium, or /,a'ing up ,ild,0 can include restlessness, agitation,
disorientation, thrashing, and shouting& .t may e caused y anesthetic agents, hypo)ia,
ladder distention, pain, electrolyte anormalities, or the patient(s state of an)iety
preoperatively&
Dela.ed emergence is most commonly caused y prolonged drug action, particularly of
opioids, sedatives, and inhalational anesthetics, as opposed to neurologic in#ury&
1+%1
Key Points
The most common cause of postoperative agitation is hypo)emia&
4ntil the patient is a,a'e and ale to communicate effectively, it is the responsiility of
the P5C4 nurse to act as a patient advocate and to maintain the patient(s safety&
The patient(s level of consciousness, orientation, and memory and aility to follo,
commands are assessed& The size, reactivity, and e<uality of the pupils are determined&
Pain is a common prolem and a significant fear for the patient in the P5C4&
/od. ,em"erature
)."othermia, a core temperature less than ED&FQ @ ($DQ C), occurs ,hen heat loss is
greater than heat production& >eat loss during the perioperative period can e due to
radiation, convection, conduction, and evaporation, infusion of cool .3 fluids, and
ventilation ,ith dry gases&
@re<uent assessment of the patient(s temperature is important to detect patterns of
hypothermia and1or fever&
P$,N,'AL P-$/LMS 'N ,) CL'N'CAL 5N',
-es"irator.
Common causes of respiratory prolems are atelectasis and pneumonia, especially
after adominal and thoracic surgery&
=eep reathing is encouraged to facilitate gas e)change& The patient should e
encouraged to reathe deeply 18 times every hour ,hile a,a'e&
The patient(s position should e changed every 1 to " hours to allo, full chest
e)pansion and to increase perfusion of oth lungs& 5mulation, not #ust sitting in a
chair, should e aggressively carried out as soon as physician approval is given&
Cardio!ascular
Postoperative fluid and electrolyte imalances are contriuting factors to cardiovascular
prolems& @luid overload may occur ,hen .3 fluids are administered too rapidly, ,hen
chronic (e&g&, cardiac, renal) disease e)ists, or ,hen the patient is an older adult&
S.nco"e (fainting) may occur as a result of decreased cardiac output, fluid deficits, or
defects in cereral perfusion&
5n accurate inta'e and output record should e 'ept, and laoratory findings (e&g&,
electrolytes, hematocrit) should e monitored&
The nurse should e alert for symptoms of too slo, or too rapid a rate of fluid
replacement&
1+%"
Key Points
>ypo'alemia causing dysrhythmias can e a conse<uence of urinary and gastrointestinal
(A.) tract losses, and inade<uate potassium replacement&

=eep vein thromosis (=3T) may form in leg veins as a result of inactivity, ody
position, and pressure, all of ,hich lead to venous stasis and decreased perfusion&
o 2eg e)ercises should e encouraged 18 to 1" times every 1 to " hours ,hile
a,a'e& *arly amulation is the most significant general nursing measure to
prevent postoperative complications&
o Bucutaneous heparin (or lo,+molecular+,eight heparin H2:->I) in
comination ,ith antiemolism stoc'ings are used to prevent =3T&
Neurologic
T,o types of postoperative cognitive impairment are seen in surgical patients: delirium
and postoperative cognitive dysfunction&
Confusion or delirium may arise from a variety of psychologic and physiologic sources,
including fluid and electrolyte imalances, hypo)emia, drug effects, sleep deprivation,
and sensory deprivation or overload&
5lcohol ,ithdra,al delirium is a reaction characterized y restlessness, insomnia and
nightmares, irritaility, and auditory or visual hallucinations&
To prevent or manage postoperative delirium, the nurse should address factors 'no,n to
contriute to the condition&
The nurse should attempt to prevent psychologic prolems in the postoperative period y
providing ade<uate support for the patient&
Pain is a common prolem during the postoperative period& Pain can contriute to
dysfunction of the immune system and lood clotting, delayed return of normal gastric
and o,el function, and increased ris' of atelectasis and impaired respiratory function&
The patient(s self+report is the single most reliale indicator of pain&
.dentifying the location of the pain is important& .ncisional pain is to e e)pected, ut
other causes of pain, such as a full ladder, may e present&
The most effective interventions for postoperative pain management include using a
variety of analgesics&
Postoperative pain relief is a nursing responsiility& The nurse should notify the physician
and re<uest a change in the order if the analgesic either fails to relieve the pain or ma'es
the patient e)cessively lethargic or somnolent&
Patient+controlled analgesia (PC5) and e"idural analgesia are t,o alternative
1+%$
Key Points
approaches for pain control&
/od. ,em"erature and 'nfection
Temperature variation provides valuale information aout the patient(s status& @ever
may occur at any time& 5 mild elevation (up to 188&%Q @ H$FQ CI) during the first %F hours
usually reflects the surgical stress response&
-ound infection, particularly from aeroic organisms, is often accompanied y a fever
that spi'es in the afternoon or evening and returns to near+normal levels in the morning&
.ntermittent high fever accompanied y sha'ing chills and diaphoresis suggests
septicemia&
4astrointestinal
Numerous factors have een identified as contriuting to the development of nausea and
vomiting, including gender (female), history of motion sic'ness or previous postoperative
nausea and vomiting, anesthetics or opioids, and duration and type of surgery&
o .f vomiting occurs, it is important to determine the <uantity, characteristics,
and color of the vomitus&
o The adomen is assessed for distention and the presence of o,el sounds& 5ll
four <uadrants are auscultated to determine the presence, fre<uency, and
characteristics of the sounds&
o Postoperative nausea and vomiting are treated ,ith the use of antiemetic or
pro'inetic drugs&
o 5dominal distention is caused y decreased peristalsis as a result of handling
of the intestine during surgery and limited dietary inta'e efore and after
surgery&
o 5dominal distention may e prevented or minimized y early and fre<uent
amulation&
5 nasogastric tue may e used to decompress the stomach to prevent nausea,
vomiting, and adominal distention&
5rinar.
2o, urine output (F88 to 1C88 ml) in the first "% hours after surgery may e e)pected,
regardless of fluid inta'e&
5cute urinary retention can occur in the postoperative period due to anesthesia, location of
the surgery (e&g&, lo,er adominal, pelvic), pain, immoility, and the recument position
in ed&
o The urine of the postoperative patient should e e)amined for oth <uantity and
<uality&
o :ost patients urinate ,ithin D to F hours after surgery& .f no voiding occurs, the
adominal contour should e inspected and the ladder assessed for distention&
1+%%
Key Points
7ound 'nfection
-ound infection may result from contamination of the ,ound from three ma#or sources:
e)ogenous flora present in the environment and on the s'in, oral flora, and intestinal
flora&
The incidence of ,ound sepsis is higher in patients ,ho are malnourished,
immunosuppressed, or older, or ,ho have had a prolonged hospital stay or a lengthy
surgical procedure (lasting more than $ hours)&
*vidence of ,ound infection usually does not ecome apparent efore the third to the
fifth postoperative day&
o 2ocal manifestations include redness, s,elling, and increasing pain and tenderness at
the site&
o Bystemic manifestations are fever and leu'ocytosis&
Nursing assessment of the ,ound and dressing re<uires 'no,ledge of the type of ,ound, the
drains inserted, and e)pected drainage related to the specific type of surgery&
o 5 small amount of serous drainage is common from any type of ,ound&
o .f a drain is in place, a moderate to large amount of drainage may e e)pected&
o =rainage is e)pected to change from sanguineous (red) to serosanguineous (pin') to
serous (clear yello,)& The drainage output should decrease over hours or days,
depending on the type of surgery&
o -ound infection may e accompanied y purulent drainage& 7ound dehiscence
(separation and disruption of previously #oined ,ound edges) may e preceded y a
sudden discharge of ro,n, pin', or clear drainage&
o -hen drainage occurs on the dressing, the type, amount, color, consistency, and odor
of drainage are noted&
D'SC)A-4
The choice of discharge site is ased on patient acuity, access to follo,+up care, and the
potential for postoperative complications&
The decision to discharge the patient from the P5C4 is ased on ,ritten discharge
criteria&
=ischarge to the clinical unit:
o 3ital signs should e otained, and patient status should e compared ,ith the
report provided y the P5C4& =ocumentation of the transfer is then completed,
follo,ed y a more in+depth assessment& Postoperative orders and appropriate
nursing care are then initiated&
5mulatory surgery discharge:
o The patient leaving an amulatory surgery setting must e moile and alert to
provide a degree of self+care ,hen discharged to home&
o The nurse specifically documents the discharge instructions provided to the
1+%C
Key Points
patient and family&
4-$N,$L$4'C C$NS'D-A,'$NS
;lder adults have decreased respiratory function, including decreased aility to cough,
decreased thoracic compliance, and decreased lung tissue, placing them at greater ris'
during the perioperative period&
=rug to)icity is a potential prolem& ?enal and liver function must e carefully assessed
in the postoperative phase to prevent drug overdosage and to)icity&
th
edition
Key Points
Chapter "1: Nursing 5ssessment: 3isual and 5uditory Bystems
S,-5C,5-S AND +5NC,'$NS
The visual system includes e)ternal tissues and structures surrounding the eye&
o *)ternal structures include the eyero,s, eyelids, eyelashes, lacrimal system,
con*uncti!a, cornea, sclera, and e)traocular muscles&
o .nternal structures include the iris, lens, ciliary ody, choroid, and retina(
The cornea, a3ueous humor, lens, and vitreous must all remain clear for light to reach
the retina and stimulate the photoreceptor cells&
?efraction is the aility of the eye to end light rays so that they fall on the retina& -hen
light does not focus properly, it is called refractive error&
Types of refractive errors are m.o"ia (nearsightedness) and h."ero"ia (farsightedness)&
Astigmatism is caused y corneal unevenness resulting in visual distortion& Presyopia is
a type of hyperopia due to aging&
The auditory system consists of peripheral and central systems&
o Peripheral system includes the e)ternal, middle, and inner ear and is involved
,ith sound reception and perception&
o The central system (rain and its path,ays) integrates and assigns meaning to
,hat is heard&
1+%D
Key Points
Presb.cusis can result from aging or insults from a variety of sources& ,innitus, or
ringing in the ears, may accompany the hearing loss that results from the aging process&
*)ternal and middle ear portions conduct and amplify sound ,aves from the
environment& Prolems located in these areas cause conductive hearing loss ,ith changes
in sound perception1sensitivity&
The inner ear functions in hearing and alance& Prolems located in this area or along the
nerve path,ay from the rain cause sensorineural hearing loss ,ith changes in tone
perception1sensitivity&
Central auditory system prolems cause central hearing loss ,ith difficulty in
understanding the meaning of ,ords&
ASSSSMN, AND D'A4N$S,'C S,5D'S
Patient information otained should include past eye1ear health and family history&
>istory also should include specific diseases and medications 'no,n to cause vision and
hearing prolems& Past history of visual and auditory tests and eye1ear trauma is also
noted&
3isual assessment determines visual acuity, aility to #udge closeness and distance,
e)traocular muscle function, evaluating visual fields and pupil function, and measuring
intraocular pressure&
5uditory assessment notes head posturing and appropriateness of responses ,hen
spea'ing to the patient and alance& Prolems ,ith alance may present as n.stagmus or
!ertigo(
3isual and auditory e)ternal structures are assessed y inspection for symmetry and
deformity& Bome eye structures must e visualized ,ith an ophthalmoscope! an otoscope
is used for further assessment of certain ear structures&
3isual assessment can include color vision and stereopsis ,ith auditory assessment often
including ,hisper1spo'en ,ord testing, audiometry, and tuning for' tests&
th
edition
Key Points
Chapter "": Nursing :anagement: 3isual and 5uditory Prolems
1+%9
Key Points
P-$/LMS $+ ,) 6
-+-AC,'2 --$-S
-efracti!e errors are the most common visual prolems& They occur ,hen light rays do
not converge into a single focus on the retina&
M.o"ia, or nearsightedness, is the most prevalent refractive error&
)."ero"ia refers to farsightedness&
Presb.o"ia is farsightedness due to decreased accommodative aility of the aging eye&
:ost refractive errors are corrected y lenses (eyeglasses or contact lenses), refractive
surgery, or surgical implantation of an artificial lens&
8,-A$C5LA- D'S$-D-S
5 hordeolum (sty) is an infection of seaceous glands in the lid margin&
5 chala#ion is a chronic inflammatory granuloma of meiomian (seaceous) glands in
the lid&
/le"haritis is a common chronic ilateral inflammation of the lid margins&
Con*uncti!itis is infection or inflammation of the con#unctiva&
o 5cute acterial con#unctivitis (pin'eye) is common&
o .t occurs initially in one eye and can spread rapidly to the unaffected eye&
o .t is usually self+limiting, ut antiiotic drops shorten the course of the disorder&
Trachoma is a chronic con#unctivitis caused y Chlamydia trachomatis&
o .t is a gloal cause of lindness&
o .t is preventale and transmitted mainly y hands and flies&
9eratitis is corneal inflammation or infection&
o The cornea can ecome infected y acteria, viruses, or fungi&
o Topical antiiotics are generally effective, ut eradicating infection may re<uire
antiiotics administered y sucon#unctival in#ection or .3&
o ;ther causes are chemical damage, contact lens ,ear, and contaminated products
(e&g&, lens care solutions, cosmetics)&
o Tissue loss due to infection produces corneal ulcers&
o Treatment is aggressive to avoid permanent loss of vision& 5n untreated ulcer can
result in corneal scarring and perforation&
CA,A-AC,
5 cataract is an opacity ,ithin the lens&
1+%F
Key Points
Bymptoms of cataracts are decreased vision, anormal color perception, and glare&
?emoval of the cataract is the most common surgery for older adults& :ost patients
undergoing cataract removal have an intraocular lens implanted during surgery&
5fter cataract surgery, the eyes are temporarily covered ,ith a patch and protective
shield&
Postoperative nursing goals include teaching aout eye care, activity restrictions,
medications, follo,+up visit schedule, and signs1symptoms of possile complications&
>ealing is complete around D to F ,ee's postoperatively&
-,'N$PA,)6
-etino"ath. is microvascular damage to the retina that can lead to lurred and
progressive vision loss&
.t is often associated ,ith diaetes mellitus and hypertension&
Nonproliferative diaetic retinopathy is characterized y capillary microaneuryms, retinal
s,elling, and hard e)udates&
o :acular edema represents a ,orsening as plasma lea's from macular lood
vessels&
o .t may e treated ,ith laser photocoagulation&
>ypertensive retinopathy is caused y high lood pressure that creates loc'ages in
retinal lood vessels&
o ;n e)amination, retinal hemorrhages and macula s,elling are noted&
o Bustained, severe hypertension can cause sudden visual loss ,ith optic disc and
nerve s,elling&
o Treatment focuses on lo,ering the lood pressure&
-,'NAL D,AC)MN,
-etinal detachment is a separation of the retina and underlying epithelium ,ith fluid
accumulation et,een the t,o layers&
=etachment is caused y a retinal rea', ,hich is interruption in the full thic'ness of
retinal tissue&
4ntreated, symptomatic retinal detachment results in lindness&
6rea's are classified as tears or holes&
1+%E
Key Points
Bymptoms are light flashes, floaters, and1or rings in vision& ;nce detached, painless loss
of peripheral or central vision occurs&
Treatment of retinal detachment is to first seal retinal rea's and then relieve in,ard
traction on retina&
Beveral types of surgery used include laser photocoagulation and cryope)y and then
scleral uc'ling&
3isual prognosis varies, depending on the e)tent, length, and area of detachment&
=ischarge planning and teaching are important, ,ith the nurse eginning this process
early as the patient is not hospitalized for long&
A4--LA,D MAC5LA- D4N-A,'$N
Age-related macular degeneration (5:=) is the most common cause of irreversile
central vision loss in older adults&
5:= is related to retinal aging& @amily history is another strong predictor of ris'&
5:= has t,o forms: dry (none)udative) and ,et (e)udative)&
o =ry 5:= is more common, ,ith close vision tas's ecoming more difficult&
5trophy of macular cells leads to slo,, progressive, and painless vision loss&
o -et 5:= is more severe, ,ith rapid onset and development of anormal lood
vessels related to the macula& Bymptoms are lurred, distorted, and dar'ened
vision ,ith visual field lind spots&
o -et 5:= treatment includes laser photocoagulation, photodynamic therapy, and
intravitreous in#ectale drugs& 3itamin and mineral supplements may e
considered&
4LA5C$MA
4laucoma is associated ,ith increased intraocular pressure (.;P), optic nerve atrophy,
and peripheral visual field loss&
Alaucoma often occurs ,ith advanced age and is a ma#or cause of permanent lindness&
*tiology is due to conse<uences of elevated .;P& Alaucoma is largely preventale ,ith
early detection and treatment&
T,o types of glaucoma include: primary angle+closure glaucoma (P5CA) and primary
open+angle glaucoma (P;5A), ,hich is the more common&
o -ith P;5A, fe, symptoms e)ist and it is often not noticed until peripheral vision
is severely compromised&
o Bymptoms of P5CA include sudden, e)cruciating eye pain along ,ith nausea and
vomiting&
1+C8
Key Points
o Therapy is to lo,er .;P to prevent optic nerve damage through drugs, argon laser
traeculoplasty, traeculectomy, and iridotomy& The nurse should teach aout
glaucoma ris' and the importance of early detection and treatment&
P-$/LMS $+ ,) A-
8,-NAL $,','S
1ternal otitis involves inflammation or infection of the auricle and ear canal epithelium
due to infection&
Bymptoms are pain, ear canal s,elling, and drainage&
Therapy is analgesics, antiiotics, and compresses&
AC5, $,','S MD'A
4ntreated or repeated attac's of acute otitis media in early childhood may lead to chronic
middle ear infection&
Bymptoms include purulent e)udate and inflammation that can involve the ossicles,
eustachian tue, and mastoid one&
.t is often painless&
Treatment may include antiiotics and surgery&
M:N';-<S D'SAS
M=ni>re<s disease is characterized y symptoms of inner ear disease ,ith episodic
vertigo, tinnitus, fluctuating sensorineural hearing loss, and aural fullness&
The cause is un'no,n, ut results in e)cessive accumulation of endolymph&
5ttac's may egin ,ith sense of ear fullness, tinnitus, and decreased hearing acuity&
The duration of attac's is hours to days, and attac's occur several times a year&
;ther symptoms are pallor, s,eating, nausea, and vomiting&
>earing loss fluctuates, and ,ith continued attac's, recovery lessens, eventually leading
to permanent hearing loss&
=rugs are used et,een and during attac's&
.f not relieved, surgeries include endolymphatic sac decompression and vestiular nerve
1+C1
Key Points
resection&
Nursing care minimizes vertigo and provides for patient safety ,ith acute attac's&
)A-'N4 D'S$-D-S
>earing disorders are the primary handicapping disaility in the 4nited Btates&
Conductive hearing loss:
o ;ccurs in outer and middle ear and impairs the sound eing conducted from outer
to inner ear&
o .t is caused y conditions interfering ,ith air conduction, such as otitis media
,ith effusion, impacted cerumen and foreign odies, middle ear disease, and
otosclerosis(
Sensorineural hearing loss:
o .s due to impairment of inner ear or vestiulocochlear nerve (CN 3...)&
o Causes include congenital and hereditary factors, noise trauma, aging, :RniSre(s
disease, and ototo)icity&
o The main prolems are the aility to hear sound ut not to understand speech and
lac' of understanding of the prolem&
Bigns of hearing loss include as'ing others to spea' up, ans,ering <uestions
inappropriately, not responding ,hen not loo'ing at spea'er, straining to hear, and
increasing sensitivity to slight increases in noise level&
;ften the patient is una,are of minimal hearing loss& 5ssistive devices and techni<ues
include hearing aids, speech reading, and a cochlear implant&
Prevention of hearing loss focuses on participation in hearing conservation programs in
the ,or' environment, monitoring for side effects and level of ototo)ic drugs (e&g&,
salicylates, diuretics, antineoplastics), and avoidance of oth continued e)posure to high
noise levels (aove FC to EC deciels) and industrial drugs and chemicals (e&g&, toluene,
caron disulfide, mercury)&
Presb.cusis (hearing loss associated ,ith aging) includes loss of peripheral auditory
sensitivity, decline in ,ord recognition aility, and associated psychologic and
communication issues&
th
edition
Key Points
1+C"
Key Points
Chapter "$: Nursing 5ssessment: .ntegumentary Bystem
The e"idermis is the outermost s'in layer& The dermis is the second s'in layer! it
contains the collagen undles ,hile it supports the nerve and vascular net,or'&
The sucutaneous layer is composed of fat and loose connective tissue&
The primary function of s'in is to protect underlying ody tissues y serving as a surface
arrier to the e)ternal environment& B'in also is a arrier against acteria, viruses, and
e)cessive ,ater loss& @at in the sucutaneous layer insulates the ody and provides
protection from trauma&
T,o ma#or types of epidermal cells include melanocytes (CK) and 'eratinocytes (E8K)&
o Melanoc.tes contain melanin, a pigment giving color to s'in and hair and
protecting the ody from damaging ultraviolet (43) sunlight& :ore melanin
results in dar'er s'in color&
o 9eratinoc.tes produce firous protein, 'eratin, ,hich is vital to protective arrier
function of s'in&
The dermis is the connective tissue elo, the epidermis& .t is highly vascular and assists
in the regulation of ody temperature and lood pressure&
The dermis is divided into t,o layers: upper thin papillary layer and deeper, thic'er
reticular layer&
Collagen forms the largest part of the dermis and is responsile for the mechanical
strength of the s'in&
B'in appendages include hair, nails, and glands (seaceous, apocrine, and eccrine)& These
structures develop from the epidermal layer and receive nutrients, electrolytes, and fluids
from the dermis& >air and nails form from specialized 'eratin that ecomes hardened&
Nail color ranges from pin' to yello, or ro,n, depending on the s'in color& Pigmented
longitudinal ands (melanonychea striata) may occur in the nail ed in most people ,ith
dar' s'in&
Sebaceous glands secrete seum, ,hich is emptied into hair follicles& Beum prevents
s'in and hair from ecoming dry&
A"ocrine sweat glands are located in the a)illae, reast areolae, umilical and
anogenital areas, e)ternal auditory canals, and eyelids& They secrete a thic', mil'y
sustance that ecomes odoriferous ,hen altered y s'in surface acteria&
ccrine sweat glands are ,idely distriuted over the ody, e)cept in a fe, areas such as
1+C$
Key Points
lips& These glands cool the ody y evaporation, e)crete ,aste products through s'in
pores, and moisturize surface cells&
-ith aging, the follo,ing changes occur in the s'in: fe,er melanocytes (gray and ,hite
hair), less volume in the dermis, nail plate thinning, nails ecome rittle and prone to
splitting and yello,ing, s'in ,rin'ling, decreased sucutaneous fat, hypothermia, and
s'in shearing&
ASSSSMN,
Bpecific s'in areas should e assessed during the e)amination of other ody sites, unless
the chief complaint is of dermatologic nature&
.nformation related to sensitivities should e otained& >istory of chronic or unprotected
e)posure to 43 light, including tanning ed use and radiation treatments, should e
noted&
The patient should e <uestioned aout s'in+related prolems occurring as result of
ta'ing medications, self+care haits related to daily hygiene, family history of any s'in
disease, and feelings related to altered ody image in relation to s'in condition&
Primary s'in lesions develop on previously unaltered s'in& These include macule, papule,
vesicle, pla<ue, ,heal, and pustule&
Becondary s'in lesions change ,ith time or occur ecause of factors such as scratching or
infection and include fissure, scale, scar, ulcer, and e)coriation&
The s'in should e inspected for general color and pigmentation, vascularity, ruising,
and presence of lesions or discolorations, and palpated for information aout temperature,
turgor and moility, moisture, and te)ture&
Btructures of dar' s'in are often more difficult to assess& 5ssessment is easier ,here the
epidermis is thin and pigmentation is not influenced y sun e)posure such as lips,
mucous memranes, nail eds, and protected areas such as uttoc's&
Palmar and plantar surfaces are lighter than other s'in areas in dar'er+s'inned
individuals& ?ashes are often difficult to oserve and may need palpation&

.ndividuals ,ith dar' s'in are predisposed to "seudofolliculitis, 0eloids, and mongolian
s"ots( Cyanosis may e difficult to determine ecause normal luish hue occurs in dar'+
s'inned persons&
D'A4N$S,'C S,5D'S
6iopsy is one of most common diagnostic tests in evaluation of s'in lesions& Techni<ues
include punch, incisional, e)cisional, and shave iopsies&
1+C%
Key Points
;ther diagnostic procedures include stains and cultures for fungal, acterial, and viral
infections&
th
edition
Key Points
Chapter "%: Nursing :anagement: .ntegumentary Prolems
>ealth promotion activities for good s'in health include asvoidance of environmental
hazards, ade<uate rest and e)ercise, and proper hygiene and nutrition&
Bun safety includes sun avoidance, especially during midday hours, protective clothing,
and sunscreen&
5ctinic 'eratoses, asal cell carcinoma, s<uamous cell carcinoma, and malignant
melanoma are prolems associated ,ith sun e)posure&
Actinic 0eratosis:
o .s a premalignant form of s<uamous cell carcinoma affecting nearly all the older
,hite population&
o 5 typical lesion is an irregularly shaped, flat, slightly erythematous papule ,ith
indistinct orders and an overlying hard 'eratotic scale or horn&
o Treatment includes cryosurgery, fluorouracil (C+@4), surgical removal, tretinoin
(?etin+5), chemical peeling agents, and dermarasion&
B'in cancer is the most common malignant condition& Patients should e taught to self+
e)amine their s'in monthly&
The cornerstone of self+s'in e)amination is the 56C= rule& *)amine s'in lesions for
Asymmetry, /order irregularity, Color change1variation, and Diameter of D mm or more&
?is' factors for s'in cancer include fair s'in type (londe or red hair and lue or green
eyes), history of chronic sun e)posure, family history of s'in cancer, and e)posure to tar
and systemic arsenicals&
Nonmelanoma s'in cancers do not develop from melanocytes, as melanoma s'in cancers
do& .nstead, they are a neoplasm of the epidermis& :ost common sites are in sun+e)posed
areas&
/asal cell carcinoma (6CC):
o .s a locally invasive malignancy from epidermal asal cells&
1+CC
Key Points
o .s the most common type of s'in cancer and the least deadly&
o Tissue iopsy is needed to confirm the diagnosis&
o Treatments of electrodessication and curettage, cr.osurger., and e)cision all
have cure rate of more than E8K&
S3uamous cell carcinoma (BCC):
o .s a malignant neoplasm of 'eratinizing epidermal cells&
o .s less common than 6CC&
o Can e very aggressive, has the potential to metastasize, and may lead to death if
not treated early&
o Pipe, cigar, and cigarette smo'ing area are also ris' factors for BCC! therefore
BCC is also found on mouth and lips&
o 6iopsy is performed ,hen a lesion is suspected of eing BCC&
o Treatment includes electrodesiccation and curettage, e)cision, radiation therapy,
intralesional in#ection of C+@4 or methotre)ate, and :ohs( surgery&
Malignant melanoma:
o .s a tumor arising in melanocytes&
o :elanomas can metastasize to any organ&
o .s the most deadly s'in cancer, and its incidence is increasing faster than that of
any other cancer&
o .ndividuals should consult health care provider if moles or lesions sho, any
clinical signs (56C=s) of melanoma&
o :elanoma can also occur in eyes, meninges, and lymph nodes&
o Buspicious lesions should e iopsied using e)cisional iopsy&
o .mportant prognostic factor of melanoma is tumor thic'ness at time of diagnosis&
o .nitial treatment for melanoma is surgery&
o :elanoma spread to lymph nodes or neary sites often re<uires chemotherapy,
iologic therapy (e&g&, T+interferon, interleu'in+"), and1or radiation therapy&
o Btage . is 188K curale ,ith stage .3 eing mostly palliative care&
5normal nevus pattern called dysplastic nevus syndrome identifies individual at
increased ris' of melanoma& D.s"lastic ne!i (=N), or atypical moles, are nevi UC mm
across ,ith irregular orders and varying color&
Staphylococcus aureus and group 5 V+hemolytic streptococci are ma#or types of acteria
responsile for primary and secondary s'in infections& >erpes simple), herpes zoster, and
,arts are the most common viral infections affecting the s'in&
4ltraviolet light, or a comination of t,o types (435 and 436), is used to treat many
conditions& 43 ,avelengths cause erythema, des<uamation, and pigmentation and may
cause temporary suppression of asal cell mitosis follo,ed y reound increase in cell
turnover&
?adiation use for treatment of cutaneous malignancies varies greatly& 2asers are used for
1+CD
Key Points
many dermatologic prolems&
5ntiiotics are used topically and systemically to treat dermatologic prolems, and are
often used in comination& Common ;TC topical antiiotics include acitracin and
polymy)in 6&
Corticosteroids are particularly effective in treating a ,ide variety of dermatologic
conditions and are used topically, intralesionally, or systemically& >igh+potency
corticosteroids may produce side effects ,hen use is prolonged, including s'in atrophy,
rosacea eruptions, severe e)acerations of acne vulgaris, and dermatophyte infections&
;ral antihistamines are used to treat conditions that e)hiit urticaria, angioedema, and
pruritus& Topical immune response modifiers such as pimecrolimus (*lidel) and
tacrolimus (Protopic) are ne,er nonsteroidal medications used in atopic dermatitis&
=iagnostic and surgical therapy techni<ues include s'in scraping, electrodesiccation and
electrocoagulation, curettage, punch iopsy, cryosurgery, and e)cision&
-et dressings are commonly used ,hen s'in is oozing from infection and1or
inflammation, and to relieve itching, suppress inflammation, and deride a ,ound&
6aths are used ,hen large ody areas need to e treated& They also have sedative and
antipruritic effects&
Careful hand ,ashing and safe disposal of soiled dressings are the est means of
preventing spread of s'in prolems&
Cosmetic procedures include chemical peels, to)in in#ections, collagen fillers, laser
surgery, reast enlargement and reduction, laser surgery, face+lift, eyelid+lift, and
liposuction& Preoperative management includes informed consent and realistic
e)pectations of ,hat cosmetic surgery can accomplish&
B'in grafts may e necessary to provide protection to underlying structures or to
reconstruct areas for cosmetic or functional purposes& .deally, ,ounds heal y primary
intention&
T,o types of grafts are free grafts and s'in flaps& Boft tissue e)pansion is a techni<ue for
resurfacing a defect, such as a urn scar, removing a disfiguring mar', such as a tattoo, or
as a preliminary step in reast reconstruction&
th
edition
Key Points
1+C9
Key Points
Chapter "C: Nursing :anagement: 6urns
/urns are ody tissue in#uries due to heat, cold, chemicals, electrical current, or
radiation&
Smo0e and inhalation in*uries result from inhalation of hot air or no)ious chemicals&
The resulting effect of urns is influenced y the temperature of the urning agent, the
duration of contact time, and the tissue type in#ured&
6urn prevention programs focus on child+resistant lighters! nonflammale children(s
clothing! stricter uilding codes! smo'e detectors1alarms! and fire sprin'lers&

Nurses need to advocate for scald+ and fire ris'Nreduction strategies in the home&
;ccupational health nurses need to educate ,or'ers to reduce scald, chemical, electrical,
and thermal in#uries in the ,or' setting&
6urn treatment is related to in#ury severity determined y depth& The e)tent is calculated
y the percent of the total ody surface area (T6B5), location, and patient ris' factors&
6urns are defined y degrees: first degree (same as sunurn), second degree, and third
degree& 5 more precise definition of second+ and third+degree urns includes the depth of
s'in destruction: "artial-thic0ness and full-thic0ness(
Becond+ and third+degree urn e)tent can e determined using total ody surface area
ased on t,o guides: 2und+6ro,der chart and ?ule of Nines& 6urn e)tent is often revised
after edema susides and demarcation of in#ury zones occurs&
@ace, nec', and circumferential urns to the chest1ac' area may inhiit respiratory
function ,ith mechanical ostruction secondary to edema or leathery, devitalized tissue
(eschar) formation& These in#uries may cause inhalation in#ury and respiratory mucosal
damage&
>ands, feet, and eye urns may ma'e self+care difficult and #eopardize future function&
6uttoc's or genitalia urns are susceptile to infection& Circumferential urns to
e)tremities can cause circulatory compromise distal to the urn&
6urn management is organized chronologically into three phases: emergent
(resuscitative), acute (,ound healing), and rehailitation (restorative)& ;verlaps in care
e)ist from one phase to another&
M-4N, P)AS
Period of time re<uired to resolve immediate, life+threatening prolems& Phase may last
from time of urn to $ or more days, ut it usually lasts "% to %F hours&
1+CF
Key Points
5 primary concern is the onset of hypovolemic shoc' and edema formation& To,ard the
end of the phase, if fluid replacement is ade<uate, the capillary memrane permeaility is
restored& @luid loss and edema formation cease& The interstitial fluid gradually returns to
the vascular space& =iuresis occurs ,ith lo, urine specific gravities&
:anifestations include shoc' from the pain and hypovolemia& 5reas of full+thic'ness and
deep partial+thic'ness urns are initially anesthetic ecause the nerve endings are
destroyed& Buperficial to moderate partial+thic'ness urns are painful&
Bhivering occurs as a result of chilling, and most patients are alert& 4nconsciousness or
altered mental status is usually a result of hypo)ia associated ,ith smo'e inhalation, head
trauma, or e)cessive sedation or pain medication&
Complications:
o Cardiovascular system dysrhythmias and hypovolemic shoc'
o !espiratory system vulnerale to upper air,ay in#ury causing edema formation
and ostruction of air,ay, and inhalation in#ury
o !enal system if patient is hypovolemic, 'idney lood flo, may decrease, causing
renal ischemia& .f it continues, acute renal failure may develop& -ith full+
thic'ness and electrical burns, myogloin and hemogloin are released into the
loodstream and occlude the renal tuules&
:anagement includes a rapid and thorough assessment and intervention of air,ay
management, fluid therapy, and ,ound care& 5nalgesics are ordered to promote patient
comfort& *arly in the posturn period, .3 pain medications are given&
*arly and aggressive nutritional support decreases mortality and complications, optimizes
healing of urn, and minimizes negative effects of h."ermetabolism and cataolism&
AC5, P)AS
6egins ,ith the moilization of e)tracellular fluid and suse<uent diuresis& Phase
concludes ,hen urned area is completely covered y s'in grafts or ,hen ,ounds are
healed& This may ta'e ,ee's or many months&
:anifestations include eschar from partial+thic'ness ,ounds& ;nce removed, re+
epithelialization appears as red or pin' scar tissue&
:argins of full+thic'ness eschar ta'e longer to separate& 5s a result, they re<uire surgical
debridement and s'in grafting for healing&
6ecause the ody is trying to reestalish fluid and electrolyte homeostasis, it is important
for the nurse to follo, the patient(s serum electrolyte levels closely (hypo+ or
hypernatremia, hypo+ or hyper'alemia)&
Complications include ,ound infection progressing to transient acteremia as result of
1+CE
Key Points
manipulation (e&g&, after hydrotherapy and deridement)& Bame cardiovascular and
respiratory system complications as in emergent phase may continue&
Patient can ecome e)tremely disoriented, ,ithdra,, or e comative&

This is a transient state, lasting from a day to several ,ee's& ?ange of motion may e
limited and contractures can occur& Paralytic ileus results from sepsis& =iarrhea and
constipation may also occur&
:anagement involves ,ound care ,ith daily oservation, assessment, cleansing,
deridement, and dressing reapplication&
.ndividualized and consistent pain assessment and care are essential& Note t,o 'inds of
pain: continuous, ac'ground pain e)isting throughout day and night, and treatment pain
associated ,ith dressing changes, amulation, and rehailitation activities&
@irst line of treatment is pharmacologic& Then use nonpharmacologic strategies, such as
rela)ation tapes, visualization, hypnosis, guided imagery, and iofeedac'& ?igorous
physical therapy throughout recovery is imperative to maintain #oint function& Nutritional
therapy provides ade<uate calories and protein to promote healing&
-)A/'L',A,'$N P)AS
6egins ,hen ,ounds have healed and patient is ale to resume self+care activity& Phase
occurs as early as " ,ee's or as long as 9 to F months after the urn&
Aoals are to assist the patient in resuming a functional role in society and accomplish
functional and cosmetic reconstructive surgery&
:anifestations include ne, s'in appearing flat and pin', then raised and hyperemic!
itching occurs ,ith healing& Complications are s'in and #oint contractures and
hypertrophic scarring&
:anagement includes positioning, splinting, and e)ercise to minimize contracture&
6urned legs may e ,rapped ,ith elastic (e&g&, tensor15ce) andages to assist the
circulation to the leg graft and donor sites& Patient education and /hands+on0 instruction
need to e provided in dressing changes and ,ound care&
Continuous e)ercise and physical1occupational therapy cannot e overemphasized&
*ncouragement and reassurance are necessary for patient morale, attaining independence,
and returning to preurn activities&
@or patient ,ith emotional needs, it is important that the nurse have understanding of
circumstances of urn, family relationships, and prior coping e)periences ,ith stressful
situations& Patient may e)perience fear, an)iety, anger, guilt, and depression&
1+D8
Key Points
th
edition
Key Points
Chapter "D: Nursing 5ssessment: ?espiratory Bystem
The primary purpose of the respiratory system is gas e)change, ,hich involves the
transfer of o)ygen and caron dio)ide et,een the atmosphere and the lood&
The upper respiratory tract includes the nose, pharyn), adenoids, tonsils, epiglottis,
laryn), and trachea&
The lo,er respiratory tract consists of the ronchi, ronchioles, alveolar ducts, and
alveoli&
.n adults, a normal tidal !olume (3T), or volume of air e)changed ,ith each reath, is
aout C88 ml&
2entilation involves ins"iration (movement of air into the lungs) and e1"iration
(movement of air out of the lungs)&
56As are measured to determine o)ygenation status and acid+ase alance& 56A
analysis includes measurement of the Pa;
"
, PaC;
"
, acidity (p>), and icaronate
(>C;
$
N
) in arterial lood&
5rterial o)ygen saturation can e monitored continuously using a pulse o"imetry proe
on the finger, toe, ear, or ridge of the nose&
The respiratory center in the rainstem medulla responds to chemical and mechanical
signals from the ody&
5 chemorece"tor is a receptor that responds to a change in the chemical composition
(PaC;
"
and p>) of the fluid around it&
Mechanical rece"tors are stimulated y a variety of physiologic factors, such as
irritants, muscle stretching, and alveolar ,all distortion&
The respiratory defense mechanisms include filtration of air, the mucociliary clearance
system, the cough refle), refle) ronchoconstriction, and alveolar macrophages&
1+D1
Key Points
ASSSSMN,
=uring nursing assessment, a cough should e evaluated y the <uality of the cough and
sputum&
=uring physical e)amination, the nose, mouth, pharyn), nec', thora), and lungs should
e assessed and the respiratory rate, depth, and rhythm should e oserved&
-hen listening to the lung sounds, there are three normal reath sounds: vesicular,
ronchovesicular, and ronchial&
Ad!entitious sounds are e)tra reath sounds that are anormal and include crac0les,
rhonchi, whee#es, and "leural friction rub(
D'A4N$S,'C S,5D'S
5 chest )+ray is the most commonly used test for assessment of the respiratory system, as
,ell as the progression of disease and response to treatment&
6ronchoscopy is a procedure in ,hich the ronchi are visualized through a fieroptic
tue and may e used for diagnostic purposes to otain iopsy specimens and assess
changes resulting from treatment&
Thoracentesis is the insertion of a large+ore needle through the chest ,all into the
pleural space to otain specimens for diagnostic evaluation, remove pleural fluid, or
instill medication into the pleural space&
Pulmonary function tests (P@Ts) measure lung volumes and airflo,&
The results of P@Ts are used to diagnose pulmonary disease, monitor disease progression,
evaluate disaility, and evaluate response to ronchodilators&
th
edition
Key Points
Chapter "9: Nursing :anagement: 4pper ?espiratory Prolems
Prolems of the upper respiratory tract include disorders of the nose, pharyn), adenoids,
tonsils, epiglottis, laryn), and trachea&
1+D"
Key Points
5 de!iated se"tum is a deflection of the normally straight nasal septum that is most
commonly caused y trauma to the nose or congenital disproportion&
-hino"last., the surgical reconstruction of the nose, is performed for cosmetic reasons or
to improve air,ay function ,hen trauma or developmental deformities result in nasal
ostruction&
Allergic rhinitis is the reaction of the nasal mucosa to a specific allergen and is classified
as either intermittent or persistent&
o .ntermittent means that the symptoms are present less than % days a ,ee' or less
than % ,ee's per year&
o Persistent means that the symptoms are present more than % days a ,ee' and for
more than % ,ee's per year&
o The most important step in managing allergic rhinitis involves identifying and
avoiding triggers of allergic reactions&
5cute viral rhinitis (also 'no,n as the common cold or acute coryza):
o .s caused y an adenovirus that invades the upper respiratory tract and often
accompanies an acute upper respiratory infection&
o ?est, fluids, proper diet, antipyretics, and analgesics are the recommended
management of acute viral rhinitis&
.n contrast to acute viral rhinitis, the onset of influenza is typically arupt ,ith systemic
symptoms of cough, fever, and myalgia often accompanied y a headache and sore throat&
o To comat the li'elihood of developing influenza, there are t,o types of flu
vaccines availale: inactivated and live, attenuated&
o The nurse should advocate the use of inactivated influenza vaccination in all
patients greater than C8 years of age or ,ho are at high ris' during routine office
visits or, if hospitalized, at the time of discharge&
Chronic and acute sinusitis develop ,hen the ostia (e)it) from the sinuses is narro,ed or
loc'ed y inflammation or hypertrophy (s,elling) of the mucosa& Chronic sinusitis lasts
longer than $ ,ee's and is a persistent infection usually associated ,ith allergies and nasal
"ol."s(
Acute "har.ngitis:
o .s an acute inflammation of the pharyngeal ,alls that may include the tonsils,
palate, and uvula&
o The goals of nursing management for acute pharyngitis are infection control,
symptomatic relief, and prevention of secondary complications&
$bstructi!e slee" a"nea, also called ostructive sleep apnea+hypopnea syndrome, is a
condition characterized y partial or complete upper air,ay ostruction during sleep&
A"nea is the cessation of spontaneous respirations lasting longer than "8 seconds&
1+D$
Key Points
5 tracheotom. is a surgical incision into the trachea for the purpose of estalishing an
air,ay&
5 tracheostom.:
o .s the stoma (opening) that results from the tracheotomy&
o .ndications for a tracheostomy are to (1) ypass an upper air,ay ostruction, (")
facilitate removal of secretions, ($) permit long+term mechanical ventilation, and
(%) permit oral inta'e and speech in the patient ,ho re<uires long+term
mechanical ventilation&
)AD AND NC9 CANC-
5rises from mucosal surfaces and is typically s<uamous cell in origin&
This category of tumors can involve paranasal sinuses, the oral cavity, and the nasopharyn),
oropharyn), and laryn)&
The choice of treatment for head and nec' cancer is ased on medical history, e)tent of
disease, cosmetic considerations, urgency of treatment, and patient choice&
5ppro)imately one third of patients ,ith head and nec' cancers have highly confined
lesions that are stages . or .. at diagnosis& Buch patients can undergo radiation therapy or
surgery ,ith the goal of cure&
5dvanced lesions are treated y a total laryngectomy in ,hich the entire laryn) and
preepiglottic region is removed and a permanent tracheostomy performed&
5fter radical nec' surgery, the patient may e unale to ta'e in nutrients through the normal
route of ingestion ecause of s,elling, the location of sutures, or difficulty ,ith
s,allo,ing& Parenteral fluids ,ill e given for the first "% to %F hours&
th
edition
Key Points
Chapter "F: Nursing :anagement: 2o,er ?espiratory Prolems
PN5M$N'A
.s an acute inflammation of the lung parenchyma&
.s caused y a microial organism&
1+D%
Key Points
:ore li'ely to result ,hen defense mechanisms ecome incompetent or are over,helmed
y the virulence or <uantity of infectious agents&
Pneumonia can e classified according to the causative organism, such as acteria,
viruses, Mycoplasma, fungi, parasites, and chemicals&
5 clinically effective ,ay to classify pneumonia is as follo,s:
o Communit.-ac3uired "neumonia is defined as a lo,er respiratory tract
infection of the lung parenchyma ,ith onset in the community or during the first "
days of hospitalization&
o )os"ital-ac3uired "neumonia is pneumonia occurring %F hours or longer after
hospital admission and not incuating at the time of hospitalization&
5spiration pneumonia refers to the se<uelae occurring from anormal entry of secretions
or sustances into the lo,er air,ay&
;pportunistic pneumonia presents in certain patients ,ith altered immune responses ,ho
are highly susceptile to respiratory infections&
There are four characteristic stages of pneumonia: congestion, red hepatization, gray
hepatization, and resolution&
Nursing management:
o .n the hospital, the nursing role involves identifying the patient at ris' and ta'ing
measures to prevent the development of pneumonia&
o The essential components of nursing care for patients ,ith pneumonia include
monitoring physical assessment parameters, facilitating laoratory and diagnostic
tests, providing treatment, and monitoring the patient(s response to treatment&
,5/-C5L$S'S %,/&
.s an infectious disease caused y Mycobacterium tuberculosis, a gram+positive, acid+fast
acillus that is usually spread from person to person via airorne droplets&
=espite the decline in T6 nation,ide, rates have increased in certain states and high rates
continue to e reported in certain populations&
The ma#or factors that have contriuted to the resurgence of T6 have een (1) high rates
of T6 among patients ,ith >.3 infection and (") the emergence of multidrug resistant
strains of M# tuberculosis#
Can present ,ith a numer of complications: the spread of the disease ,ith involvement
of many organs simultaneously (miliary T6), pleural effusion, emphysema, and
pneumonia&
1+DC
Key Points
The tuerculin s'in test (:antou) test) using purified protein derivative (PP=) is the est
,ay to diagnose latent M# tuberculosis infection, ,hereas the diagnosis of tuerculosis
disease re<uires demonstration of tuercle acilli acteriologically&
:ost T6 patients are treated on an outpatient asis& The mainstay of T6 treatment is drug
therapy& =rug therapy is used to treat an individual ,ith active disease and to prevent
disease in a T6+infected person&
Patients strongly suspected of having T6 should (1) e placed on airorne isolation, (")
receive appropriate drug therapy, and ($) receive an immediate medical ,or'up,
including chest )+ray, sputum smear, and culture&
P5LM$NA-6 +5N4AL 'N+C,'$NS
5re found fre<uently in seriously ill patients eing treated ,ith corticosteroids,
antineoplastic and immunosuppressive drugs, or multiple antiiotics&
5re also found in patients ,ith 5.=B and cystic firosis&
Community+ac<uired pulmonary lung infections include aspergillosis, cryptococcosis,
and candidiasis& These infections are not transmitted from person to person, and the
patient does not have to e placed in isolation&
L5N4 A/SCSS
.s a pus+containing lesion of the lung parenchyma that gives rise to a cavity&
.n many cases the causes and pathogenesis of lung ascess are similar to those of
pneumonia&
The onset of a lung ascess is usually insidious, especially if anaeroic organisms are the
primary cause& 5 more acute onset occurs ,ith aeroic organisms&
5ntiiotics given for a prolonged period (up to " to % months) are usually the primary
method of treatment&
N2'-$NMN,AL L5N4 D'SASS
*nvironmental or occupational lung diseases are caused or aggravated y ,or'place or
environmental e)posure and are preventale&
Pneumoconiosis is a general term for a group of lung diseases caused y inhalation and
retention of dust particles&
The est approach to management of environmental lung diseases is to try to prevent or
decrease environmental and occupational ris's&
L5N4 CANC-
1+DD
Key Points
Cigarette smo'ing is the most important ris' factor in the development of lung cancer&
Bmo'ing is responsile for appro)imately F8K to E8K of all lung cancers&
Primary lung cancers are often categorized into t,o road sutypes: nonNsmall cell lung
cancer (F8K) and small cell lung cancer ("8K)&
CT scanning is the single most effective noninvasive techni<ue for evaluating lung
cancer& 6iopsy is necessary for a definitive diagnosis&
Btaging of nonNsmall cell lung cancer is performed according to the TN: staging
system& Btaging of small cell lung cancer y TN: has not een useful ecause the cancer
is very aggressive and al,ays considered systemic&
Treatment options for lung cancer include:
o Burgical resection is the treatment of choice in nonNsmall cell lung cancer Btages .
and .., ecause the disease is potentially curale ,ith resection&
o ?adiation therapy used ,ith the intent to cure may e moderated in the individual
,ho is unale to tolerate surgical resection due to comoridities& .t may also e
used as ad#uvant therapy after resection of the tumor&
o Chemotherapy may e used in the treatment of nonresectale tumors or as
ad#uvant therapy to surgery in nonNsmall cell lung cancer&
The overall goals of nursing management of a patient ,ith lung cancer ,ill include (1)
effective reathing patterns, (") ade<uate air,ay clearance, ($) ade<uate o)ygenation of
tissues, (%) minimal to no pain, and (C) a realistic attitude to,ard treatment and
prognosis&
PN5M$,)$-A8
?efers to air in the pleural space& 5s a result of the air in the pleural space, there is partial
or complete collapse of the lung&
Types of pneumothora) include:
o Closed "neumothora1 has no associated e)ternal ,ound& The most common
form is a spontaneous pneumothora), ,hich is accumulation of air in the pleural
space ,ithout an apparent antecedent event&
o $"en "neumothora1 occurs ,hen air enters the pleural space through an
opening in the chest ,all& *)amples include sta or gunshot ,ounds and surgical
thoracotomy&
o ,ension "neumothora1 is a pneumothora) ,ith rapid accumulation of air in the
pleural space causing severely high intrapleural pressures ,ith resultant tension
on the heart and great vessels& .t may result from either an open or a closed
pneumothora)&
o )emothora1 is an accumulation of lood in the intrapleural space& .t is fre<uently
found in association ,ith open pneumothora) and is then called a
hemopneumothora)&
1+D9
Key Points
o Ch.lothora1 is lymphatic fluid in the pleural space due to a lea' in the thoracic
duct& Causes include trauma, surgical procedures, and malignancy&
Treatment depends on the severity of the pneumothora) and the nature of the underlying
disease&
+LA'L C)S,
?esults from multiple ri fractures, causing an unstale chest ,all& The diagnosis of flail
chest is made on the asis of fracture of t,o or more ris, in t,o or more separate locations,
causing an unstale segment&
.nitial therapy consists of air,ay management, ade<uate ventilation, supplemental o)ygen
therapy, careful administration of .3 solutions, and pain control&
The definitive therapy is to ree)pand the lung and ensure ade<uate o)ygenation&
C)S, ,5/S AND PL5-AL D-A'NA4
The purpose of chest tues and pleural drainage is to remove the air and fluid from the
pleural space and to restore normal intrapleural pressure so that the lungs can ree)pand&
Chest tue malposition is the most common complication&
?outine monitoring is done y the nurse to evaluate if the chest drainage is successful y
oserving for tidaling in the ,ater+seal chamer, listening for reath sounds over the lung
fields, and measuring the amount of fluid drainage&
C)S, S5-4-6
,horacotom. (surgical opening into the thoracic cavity) surgery is considered ma#or
surgery ecause the incision is large, cutting into one, muscle, and cartilage& The t,o types
of thoracic incisions are median sternotomy, performed y splitting the sternum, and lateral
thoracotomy&
3ideo+assisted thoracic surgery (35TB) is a thorascopic surgical procedure that in many
cases can avoid the impact of a full thoracotomy& The procedure involves three to four 1+
inch incisions made on the chest that allo, the thorascope (a special fieroptic camera) and
instruments to e inserted and manipulated&
PL5-AL ++5S'$N
Pleural effusion is a collection of fluid in the pleural space& .t is not a disease ut rather a
sign of a serious disease&
Pleural effusion is fre<uently classified as transudative or e)udative according to ,hether
the protein content of the effusion is lo, or high, respectively&
o 5 transudate occurs primarily in noninflammatory conditions and is an
accumulation of protein+poor, cell+poor fluid&
1+DF
Key Points
o 5n e)udative effusion is an accumulation of fluid and cells in an area of
inflammation&
o 5n em".ema is a pleural effusion that contains pus&
The type of pleural effusion can e determined y a sample of pleural fluid otained via
thoracentesis (a procedure done to remove fluid from the pleural space)&
The main goal of management of pleural effusions is to treat the underlying cause&
PL5-'S6
Pleuris. %"leuritis& is an inflammation of the pleura& The most common causes are
pneumonia, T6, chest trauma, pulmonary infarctions, and neoplasms&
Treatment of pleurisy is aimed at treating the underlying disease and providing pain
relief&
A,LC,AS'S
.s a condition of the lungs characterized y collapsed, airless alveoli&
The most common cause of atelectasis is air,ay ostruction that results from retained
e)udates and secretions& This is fre<uently oserved in the postoperative patient&
'D'$PA,)'C P5LM$NA-6 +'/-$S'S
.diopathic pulmonary firosis is characterized y scar tissue in the connective tissue of
the lungs as a se<uela to inflammation or irritation&
The clinical course is variale and the prognosis poor, ,ith a C+year survival rate of $8K
to C8K after diagnosis&
SA-C$'D$S'S
Barcoidosis is a chronic, multisystem granulomatous disease of un'no,n cause that
primarily affects the lungs&

The disease may also involve the s'in, eyes, liver, 'idney,
heart, and lymph nodes&
The disease is often acute or suacute and self+limiting, ut in others it is chronic ,ith
remissions and e)acerations&
P5LM$NA-6 DMA
Pulmonar. edema is an anormal accumulation of fluid in the alveoli and interstitial
spaces of the lungs&
.t is considered a medical emergency and may e life+threatening&
The most common cause of pulmonary edema is left+sided heart failure&
1+DE
Key Points
P5LM$NA-6 M/$L'SM
Pulmonar. embolism (P*) is the loc'age of pulmonary arteries y a thromus, fat, or
air emoli, or tumor tissue&
:ost pulmonary emolisms arise from thromi in the deep veins of the legs&
The most common ris' factors for pulmonary emolism are immoilization, surgery
,ithin the last $ months, stro'e, history of deep vein thromosis, and malignancy&
Pulmonary infarction (death of lung tissue) and pulmonary hypertension are common
complications of pulmonary emolism&
The o#ectives of treatment are to (1) prevent further gro,th or multiplication of thromi
in the lo,er e)tremities, (") prevent emolization from the upper or lo,er e)tremities to
the pulmonary vascular system, and ($) provide cardiopulmonary support if indicated&
P5LM$NA-6 )6P-,NS'$N
Pulmonar. h."ertension can occur as a primary disease (primary pulmonary
hypertension) or as a secondary complication of a respiratory, cardiac, autoimmune,
hepatic, or connective tissue disorder (secondary pulmonary hypertension)&
Primary pulmonary hypertension is a severe and progressive disease& .t is characterized
y mean pulmonary arterial pressure greater than "C mm >g at rest (normal 1" to 1D mm
>g) or greater than $8 mm >g ,ith e)ercise in the asence of a demonstrale cause&
Primary pulmonary hypertension is a diagnosis of e)clusion& 5ll other conditions must e
ruled out&
5lthough there is no cure for primary pulmonary hypertension, treatment can relieve
symptoms, increase <uality of life, and prolong life&
Becondary pulmonary hypertension (BP>) occurs ,hen a primary disease causes a
chronic increase in pulmonary artery pressures& Becondary pulmonary hypertension can
develop as a result of parenchymal lung disease, left ventricular dysfunction, intracardiac
shunts, chronic pulmonary thromoemolism, or systemic connective tissue disease&
C$- P5LM$NAL
Cor "ulmonale is enlargement of the right ventricle secondary to diseases of the lung,
thora), or pulmonary circulation& Pulmonary hypertension is usually a pree)isting
condition in the individual ,ith cor pulmonale&
The most common cause of cor pulmonale is C;P=&
The primary management of cor pulmonale is directed at treating the underlying
pulmonary prolem that precipitated the heart prolem&
1+98
Key Points
L5N4 ,-ANSPLAN,A,'$N
There are four types of transplant procedures availale: single lung transplant, ilateral
lung transplant, heart+lung transplant, and transplant of loes from living related donor&
2ung transplant recipients are at high ris' for acterial, viral, fungal, and protozoal
infections& .nfections are the leading cause of death in the early period after the
transplant&
.mmunosuppressive therapy usually includes a three+drug regimen of cyclosporine or
tacrolimus, azathioprine (.muran) or mycophenolate mofetil (CellCept), and prednisone&
th
edition
Key Points
Chapter "E: Nursing :anagement: ;structive Pulmonary =iseases
AS,)MA
Asthma is a chronic inflammatory lung disease that results in recurrent episodes of airflo,
ostruction, ut it is usually reversile& The chronic inflammation causes an increase in
air,ay hyperresponsiveness that leads to recurrent episodes of ,heezing, reathlessness,
chest tightness, and cough, particularly at night or in the early morning&
5lthough the e)act mechanisms that cause asthma remain un'no,n, triggers are involved&
o 5llergic asthma may e related to allergies, such as tree or ,eed pollen, dust
mites, molds, animals, feathers, and coc'roaches&
o 5sthma that is induced or e)acerated during physical e)ertion is called e)ercise+
induced asthma& Typically, this type of asthma occurs after vigorous e)ercise, not
during it&
o 3arious air pollutants, cigarette or ,ood smo'e, vehicle e)haust, elevated ozone
levels, sulfur dio)ide, and nitrogen dio)ide can trigger asthma attac's&
o ;ccupational asthma occurs after e)posure to agents of the ,or'place& These
agents are diverse such as ,ood and vegetale dusts (flour), pharmaceutical
agents, laundry detergents, animal and insect dusts, secretions and serums (e&g&,
chic'ens, cras), metal salts, chemicals, paints, solvents, and plastics&
o ?espiratory infections (i&e&, viral and not acterial) or allergy to microorganisms is
the ma#or precipitating factor of an acute asthma attac'&
o Bensitivity to specific drugs may occur in some asthmatic persons, especially
those ,ith nasal polyps and sinusitis, resulting in an asthma episode&
o Aastroesophageal reflu) disease can also trigger asthma&
1+91
Key Points
o Crying, laughing, anger, and fear can lead to hyperventilation and hypocapnia
,hich can cause air,ay narro,ing&
The characteristic clinical manifestations of asthma are ,heezing, cough, dyspnea, and
chest tightness after e)posure to a precipitating factor or trigger& *)piration may e
prolonged&
5sthma can e classified as mild intermittent, mild persistent, moderate persistent, or
severe persistent&
Bevere acute asthma can result in complications such as ri fractures, pneumothora),
pneumomediastinum, atelectasis, pneumonia, and status asthmaticus& Status asthmaticus is
a severe, life+threatening asthma attac' that is refractory to usual treatment and places the
patient at ris' for developing respiratory failure&
=iagnosis: there is some controversy aout ho, to est diagnose asthma& .n general, the
health care provider should consider the diagnosis of asthma if various indicators (i&e&,
clinical manifestations, health history, and pea' flo, variaility) are positive&
Patient education remains the cornerstone of asthma management and should e carried out
y health care providers providing asthma care& =esirale therapeutic outcomes include (1)
control or elimination of chronic symptoms such as cough, dyspnea, and nocturnal
a,a'enings! (") attainment of normal or nearly normal lung function! ($) restoration or
maintenance of normal levels of activity! (%) reduction in the numer or elimination of
recurrent e)acerations! (C) reduction in the numer or elimination of emergency
department visits and acute care hospitalizations! and (D) elimination or reduction of side
effects of medications&
:edications are divided into t,o general classifications: (1) long+termNcontrol medications
to achieve and maintain control of persistent asthma, and (") <uic'+relief medications to
treat symptoms and e)acerations&
o 6ecause chronic inflammation is a primary component of asthma, corticosteroids,
,hich suppress the inflammatory response, are the most potent and effective
antiinflammatory medication currently availale to treat asthma
o :ast cell stailizers are nonsteroidal antiinflammatory drugs that inhiit the .g*+
mediated release of inflammatory mediators from mast cells and suppress other
inflammatory cells (e&g&, eosinophils)&
o The use of leu'otriene modifiers can successfully e used as add+on therapy to
reduce (not sustitute for) the doses of inhaled corticosteroids&
o Bhort+acting inhaled V
"
+adrenergic agonists are the most effective drugs for
relieving acute ronchospasm& They are also used for acute e)acerations of
asthma&
o :ethyl)anthine (theophylline) preparations are less effective long+term control
ronchodilators as compared to V
"
+adrenergic agonists&
1+9"
Key Points
o 5nticholinergic agents (e&g&, ipratropium H5troventI, tiotropium HBpirivaI) loc'
the ronchoconstricting influence of parasympathetic nervous system&
;ne of the ma#or factors for determining success in asthma management is the correct
administration of drugs&
.nhalation devices include metered+dose inhalers, dry po,der inhalers, and neulizers&
Beveral nonprescription comination drugs are availale over the counter& 5n important
teaching responsiility is to ,arn the patient aout the dangers associated ,ith
nonprescription comination drugs&
5 goal in asthma care is to ma)imize the aility of the patient to safely manage acute
asthma episodes via an asthma action plan developed in con#unction ,ith the health care
provider& 5n important nursing goal during an acute attac' is to decrease the patient(s sense
of panic&
-ritten asthma action plans

should e developed together ,ith the patient and family,
especially for those ,ith moderate or severe persistent asthma or a history of severe
e)acerations&
C)-$N'C $/S,-5C,'2 P5LM$NA-6 D'SAS
Chronic obstructi!e "ulmonar. disease (C;P=) is a preventale and treatale disease
state characterized y airflo, limitation that is not fully reversile& The airflo, limitation is
usually progressive and associated ,ith an anormal inflammatory response of the lungs to
no)ious particles or gases, primarily caused y cigarette smo'ing&
.n addition to cigarette smo'e, occupational chemicals, and air pollution, infections are ris'
factors for developing C;P=& Bevere recurring respiratory tract infections in childhood
have een associated ,ith reduced lung function and increased respiratory symptoms in
adulthood&

?
-Antitr."sin deficienc., an autosomal recessive disorder, is a genetic ris' factor that can
lead to C;P=&
5ging results in changes in the lung structure, the thoracic cage, and the respiratory
muscles, and as people age there is gradual loss of the elastic recoil of the lung& Therefore
some degree of emphysema is common in the lungs of the older person, even a nonsmo'er&
The term chronic ostructive pulmonary disease encompasses t,o types of ostructive
air,ay diseases, chronic ronchitis and emphysema&
o Chronic bronchitis is the presence of chronic productive cough for $ months in
each of " consecutive years in a patient in ,hom other causes of chronic cough
have een e)cluded&
1+9$
Key Points
o m"h.sema is an anormal permanent enlargement of the airspaces distal to the
terminal ronchioles, accompanied y destruction of their ,alls and ,ithout
ovious firosis&
5 diagnosis of C;P= should e considered in any patient ,ho has symptoms of cough,
sputum production, or dyspnea, and1or a history of e)posure of ris' factors for the disease&
5n intermittent cough, ,hich is the earliest symptom, usually occurs in the morning ,ith
the e)pectoration of small amounts of stic'y mucus resulting from outs of coughing&
C;P= can e classified as at ris', mild, moderate, severe, and very severe&
Complications of C;P= include the follo,ing:
o Cor "ulmonale is hypertrophy of the right side of the heart, ,ith or ,ithout heart
failure, resulting from pulmonary hypertension and is a late manifestation of
chronic pulmonary heart disease&
o *)acerations of C;P= are signaled y a change in the patient(s usual dyspnea,
cough, and1or sputum that is different than the usual daily patterns& These flares
re<uire changes in management&
o Patients ,ith severe C;P= ,ho have e)acerations are at ris' for the
development of respiratory failure&
o The incidence of peptic ulcer disease is increased in the person ,ith C;P=&
o 5n)iety and depression can complicate respiratory compromise and may
precipitate dyspnea and hyperventilation&
The diagnosis of C;P= is confirmed y pulmonary function tests& Aoals of the diagnostic
,or'up are to confirm the diagnosis of C;P= via spirometry, evaluate the severity of the
disease, and determine the impact of disease on the patient(s <uality of life& -hen the
@*3
1
1@3C ratio is less than 98K, it suggests the presence of ostructive lung disease&
The primary goals of care for the C;P= patient are to (1) prevent disease progression, (")
relieve symptoms and improve e)ercise tolerance, ($) prevent and treat complications, (%)
promote patient participation in care, (C) prevent and treat e)acerations, and (D) improve
<uality of life and reduce mortality&
Cessation of cigarette smo'ing in all stages of C;P= is the single most effective and cost+
effective intervention to reduce the ris' of developing C;P= and stop the progression of
the disease&
5lthough patients ,ith C;P= do not respond as dramatically as those ,ith asthma to
ronchodilator therapy, a reduction in dyspnea and an increase in @*3
1
are usually
achieved& Presently no drug modifies the decline of lung function ,ith C;P=&
;
"
therapy is fre<uently used in the treatment of C;P= and other prolems associated ,ith
hypo)emia& 2ong+term ;
"
therapy improves survival, e)ercise capacity, cognitive
performance, and sleep in hypo)emic patients&
1+9%
Key Points
o ;
"
delivery systems are classified as lo,+ or high+flo, systems& :ost methods of
;
"
administration are lo,+flo, devices that deliver ;
"
in concentrations that vary
,ith the person(s respiratory pattern&
o =ry ;
"
has an irritating effect on mucous memranes and dries secretions&
Therefore it is important that ;
"
e humidified ,hen administered, either y
humidification or neulization&
Three different surgical procedures have een used in severe C;P=:
o 2ung volume reduction surgery is used to reduce the size of the lungs y
removing aout $8K of the most diseased lung tissue so the remaining healthy
lung tissue can perform etter&
o 5 ullectomy is used for certain patients and can result in improved lung function
and reduction in dyspnea&
o .n appropriately selected patients ,ith very advanced C;P=, lung transplantation
improves functional capacity and enhances <uality of life&
?espiratory therapy (?T) and physical therapy (PT) rehailitation activities are performed
y respiratory therapists or physical therapists, depending on the institution& ?T and1or PT
activities include reathing retraining, effective cough techni<ues, and chest physiotherapy&
o Pursed-li" breathing is a techni<ue that is used to prolong e)halation and
therey prevent ronchiolar collapse and air trapping& ;ften instinctively patients
,ill perform this techni<ue&
o The main goals of effective coughing are to conserve energy, reduce fatigue, and
facilitate removal of secretions& >uff coughing is an effective techni<ue that the
patient can e easily taught&
o Chest "h.siothera". consists of percussion, viration, and postural drainage&
-eight loss and malnutrition are commonly seen in the patient ,ith severe emphysematous
C;P=& The patient ,ith C;P= should try to 'eep the ody mass inde) (6:.) et,een "1
and "C 'g1m
"
&
The patient ,ith C;P= ,ill re<uire acute intervention for complications such as
e)acerations of C;P=, pneumonia, cor pulmonale, and acute respiratory failure&
Pulmonary rehailitation should e considered for all patients ,ith symptomatic C;P= or
having functional limitations& The overall goal is to increase the <uality of life&
-al'ing is y far the est physical e)ercise for the C;P= patient& 5de<uate sleep is also
e)tremely important&
C6S,'C +'/-$S'S
C.stic fibrosis (C@) is an autosomal recessive, multisystem disease characterized y
altered function of the e)ocrine glands primarily involving the lungs, pancreas, and s,eat
glands&
1+9C
Key Points
.nitially, C@ is an ostructive lung disease caused y the overall ostruction of the air,ays
,ith mucus& 2ater, C@ also progresses to a restrictive lung disease ecause of the firosis,
lung destruction, and thoracic ,all changes&
The ma#or o#ectives of therapy in C@ are to (1) promote clearance of secretions, (") control
infection in the lungs, and ($) provide ade<uate nutrition&
/-$NC)'C,AS'S
/ronchiectasis is characterized y permanent, anormal dilation of one or more large
ronchi& The pathophysiologic change that results in dilation is destruction of the elastic
and muscular structures supporting the ronchial ,all&
The hallmar' of ronchiectasis is persistent or recurrent cough ,ith production of large
amounts of purulent sputum, ,hich may e)ceed C88 ml1day&
6ronchiectasis is difficult to treat& Therapy is aimed at treating acute flare+ups and
preventing decline in lung function&
5ntiiotics are the mainstay of treatment and are often given empirically, ut attempts are
made to culture the sputum& 2ong+term suppressive therapy ,ith antiiotics is reserved for
those patients ,ho have symptoms that recur a fe, days after stopping antiiotics&
5n important nursing goal is to promote drainage and removal of ronchial mucus&
th
edition
Key Points
C>5PT*? $8: N4?B.NA 5BB*BB:*NT: >*:5T;2;A.C BWBT*:
)ematolog. is the study of lood and lood+forming tissues& This includes the one
marro,, lood, spleen, and lymph system&
6lood cell production (hemato"oiesis) occurs ,ithin the one marro,& /one marrow is
the soft material that fills the central core of ones&
6lood is a type of connective tissue that performs three ma#or functions: transportation,
regulation, and protection& There are t,o ma#or components to lood: plasma and lood
cells&
1+9D
Key Points
Plasma is composed primarily of ,ater, ut it also contains proteins, electrolytes, gases,
nutrients, and ,aste&
There are three types of lood cells: erythrocytes (?6Cs), leu'ocytes (-6Cs), and
thromocytes (platelets)&
r.throc.tes are primarily composed of a large molecule called hemogloin&
)emoglobin, a comple) protein+iron compound composed of heme (an iron compound)
and gloin (a simple protein), functions to ind ,ith o)ygen and caron dio)ide&
Leu0oc.tes (-6Cs) appear ,hite ,hen separated from lood& There are five different
types of leu'ocytes, each of ,hich has a different function&
o Aranulocytes (neutrophils, eosinophils, asophils): the primary function of the
granulocytes is "hagoc.tosis, a process y ,hich -6Cs ingest or engulf any
un,anted organism and then digest and 'ill it& The neutrophil is the most common
type of granulocyte&
o 2ymphocytes: the main function of lymphocytes is related to the immune
response& 2ymphocytes form the asis of the cellular and humoral immune
responses&
o :onocytes: monocytes are phagocytic cells& They can ingest small or large
masses of matter, such as acteria, dead cells, tissue deris, and old or defective
?6Cs&
The primary function of thromboc.tes, or platelets, is to initiate the clotting process y
producing an initial platelet plug in the early phases of the clotting process&
)emostasis is a term used to descrie the lood clotting process& This process is
important in minimizing lood loss ,hen various ody structures are in#ured&
@our components contriute to normal hemostasis: vascular response, platelet plug
formation, the development of the firin clot on the platelet plug y plasma clotting
factors, and the ultimate lysis of the clot&
5nother component of the hematologic system is the spleen, ,hich is located in the upper
left <uadrant of the adomen& The functions of the spleen can e classified into four
ma#or functions: hematopoietic, filtration, immunologic, and storage&
The lymph systemGconsisting of lymph fluid, lymphatic capillaries, ducts, and lymph
nodesGcarries fluid from the interstitial spaces to the lood&
ASSSSMN,
:uch of the evaluation of the hematologic system is ased on a thorough health history,
and a numer of health patterns should e assessed&
1+99
Key Points
5 complete physical e)amination is necessary to accurately e)amine all systems that
affect or are affected y the hematologic system, including an assessment of lymph
nodes, liver, spleen, and s'in&
D'A4N$S,'C S,5D'S
The most direct means of evaluating the hematologic system is through laoratory
analysis and other diagnostic studies&
The complete lood count (C6C) involves several laoratory tests, each of ,hich serves
to assess the three ma#or lood cells formed in the one marro,&
*rythrocyte sedimentation rate (*B? or /sed rate0) measures the sedimentation or settling
of ?6Cs and is used as a nonspecific measure of many diseases, especially inflammatory
conditions&
The laoratory tests used in evaluating iron metaolism include serum iron, total iron+
inding capacity (T.6C), serum ferritin, and transferrin saturation&
?adiologic studies for the hematology system involve primarily the use of computed
tomography (CT) or magnetic resonance imaging (:?.) for evaluating the spleen, liver,
and lymph nodes&
6one marro, e)amination is important in the evaluation of many hematologic disorders&
The e)amination of the marro, may involve aspiration only or aspiration ,ith iopsy&
2ymph node iopsy involves otaining lymph tissue for histologic e)amination to
determine the diagnosis, and to help for planning therapy&
Testing for specific genetic or chromosomal variations in hematologic conditions is often
helpful in assisting in diagnosis and staging& These results also help to determine the
treatment options and prognosis&
th
edition
Key Points
Chapter $1: Nursing :anagement: >ematologic Prolems
ANM'A
1+9F
Key Points
Anemia is a deficiency in the numer of erythrocytes (red lood cells H?6CsI), the
<uantity of hemogloin, and1or the volume of pac'ed ?6Cs (hematocrit), ,hich can lead
to tissue hypo)ia&
>emogloin (>) levels are often used to determine the severity of anemia&
Correcting the cause of the anemia is ultimately the goal of therapy&
.nterventions may include lood or lood product transfusions, drug therapy, volume
replacement, o)ygen therapy, dietary modifications, and lifestyle changes&
Anemia Caused /. Decreased r.throc.te Production
Iron-Deficiency Anemia
'ron-deficienc. anemia may develop from inade<uate dietary inta'e, malasorption,
lood loss, or hemolysis& 5lso, pregnancy contriutes to iron deficiency ecause of the
diversion of iron to the fetus for erythropoiesis, lood loss at delivery, and lactation&
The main goal of collaorative care for iron+deficiency anemia is to treat the underlying
disease causing reduced inta'e (e&g&, malnutrition, alcoholism) or asorption of iron& .n
addition, efforts are directed to,ard replacing iron ,ith dietary changes or
supplementation&
.t is important for a nurse to recognize groups of individuals ,ho are at an increased ris'
for the development of iron+deficiency anemia& These include premenopausal and
pregnant ,omen, persons from lo,erclass socioeconomic ac'grounds, older adults,
and individuals e)periencing lood loss&
Thalassemia
,halassemia is a group of diseases that has an autosomal+recessive genetic asis that
involves inade<uate production of normal hemogloin&
5n individual ,ith thalassemia may have a heterozygous or homozygous form of the
disease, ased on the numer of thalassemic genes the individual has&
Thalassemia minor re<uires no treatment ecause the ody adapts to the reduced level of
normal hemogloin&
The symptoms of thalassemia ma#or are managed ,ith lood transfusions or e)change
transfusions in con#unction ,ith .3 defero)amine to reduce the iron overloading
(hemochromatosis) that occurs ,ith chronic transfusion therapy&
M4AL$/LAS,'C ANM'AS
Megaloblastic anemias are a group of disorders caused y impaired =N5 synthesis and
characterized y the presence of large ?6Cs&
1+9E
Key Points
:acrocytic (large) ?6Cs are easily destroyed ecause they have fragile cell memranes&
T,o common forms of megalolastic anemia are coalamin deficiency and folic acid
deficiency&
o Coalamin (vitamin 6
1"
) deficiency is most commonly caused y "ernicious
anemia, ,hich results in poor coalamin asorption through the A. tract&
Parenteral or intranasal administration of coalamin is the treatment of choice&
o @olic acid (folate) is re<uired for =N5 synthesis leading to ?6C formation
and maturation and therefore can lead to megalolastic anemia& @olic acid
deficiency is treated y replacement therapy&
Aplastic Anemia
A"lastic anemia is a disease in ,hich the patient has peripheral lood pancytopenia
(decrease of all lood cell types) and hypocellular one marro,&
:anagement of aplastic anemia is ased on identifying and removing the causative agent
(,hen possile) and providing supportive care until the pancytopenia reverses&
Anemia Caused /. /lood Loss
Acute Bloo !oss
5cute lood loss occurs as a result of sudden hemorrhage&
Causes of acute lood loss include trauma, complications of surgery, and conditions or
diseases that disrupt vascular integrity&
Collaorative care is initially concerned ,ith replacing lood volume to prevent shoc'
and identifying the source of the hemorrhage and stopping the lood loss&
"hronic Bloo !oss
The sources of chronic lood loss are similar to those of iron+deficiency anemia (e&g&,
leeding ulcer, hemorrhoids, menstrual and postmenopausal lood loss)&
:anagement of chronic lood loss anemia involves identifying the source and stopping
the leeding& Bupplemental iron may e re<uired&
Anemia Caused /. 'ncreased r.throc.te Destruction %)emol.tic Anemia&
S'C9L CLL D'SAS
Sic0le cell disease is a group of inherited, autosomal recessive disorders characterized y
the presence of an anormal form of hemogloin in the erythrocyte&
The ma#or pathophysiologic event of this disease is the sic'ling of ?6Cs& Bic'ling
episodes are most commonly triggered y lo, o)ygen tension in the lood&
-ith repeated episodes of sic'ling there is gradual involvement of all ody systems,
especially the spleen, lungs, 'idneys, and rain&
1+F8
Key Points
Collaorative care for a patient ,ith sic'le cell disease is directed to,ard alleviating the
symptoms from the complications of the disease and minimizing end target+organ
damage& There is no specific treatment for the disease&
Ac#uire Hemolytic Anemia
*)trinsic causes of hemolysis can e separated into three categories: (1) physical factors,
(") immune reactions, and ($) infectious agents and to)ins&
Physical destruction of ?6Cs results from the e)ertion of e)treme force on the cells&
5ntiodies may destroy ?6Cs y the mechanisms involved in antigen+antiody
reactions&
.nfectious agents foster hemolysis in four ,ays: (1) y invading the ?6C and destroying
its contents, (") y releasing hemolytic sustances, ($) y generating an antigen+antiody
reaction, and (%) y contriuting to splenomegaly as a means of increasing removal of
damaged ?6Cs from the circulation&
)M$C)-$MA,$S'S
)emochromatosis is an autosomal recessive disease characterized y increased intestinal
iron asorption and, as a result, increased tissue iron deposition&
The goal of treatment is to remove e)cess iron from the ody and minimize any
symptoms the patient may have&
P$L6C6,)M'A
Pol.c.themia is the production and presence of increased numers of ?6Cs& The
increase in ?6Cs can e so great that lood circulation is impaired as a result of the
increased lood viscosity and volume&
Treatment is directed to,ard reducing lood volume1viscosity and one marro, activity&
Phleotomy is the mainstay of treatment&
,)-$M/$C6,$PN'A
,hromboc.to"enia is a reduction of platelets elo, 1C8,8881Xl (1C8 Y 18
E
12)&
Platelet disorders can e inherited, ut the vast ma#ority of them are ac<uired& The causes
of ac<uired disorders include autoimmune diseases, increased platelet consumption,
splenomegaly, marro, suppression, and one marro, failure&
The most common ac<uired thromocytopenia is a syndrome of anormal destruction of
circulating platelets termed immune thrombocytopenic purpura (.TP)& :ultiple therapies
are used to manage the patient ,ith .TP, such as corticosteroids or splenectomy&
1+F1
Key Points
;ne of the ris's associated ,ith the road and increasing use of heparin is the
development of the life+threatening condition called heparin$induced thrombocytopenia
and thrombosis syndrome (>.TTB)& >eparin must e discontinued ,hen >.TTB is first
recognized, ,hich is usually if the patient(s platelet count has fallen C8K or more from its
aseline or if a thromus forms ,hile the patient is on heparin therapy&
@or the nurse, the overall goals are that the patient ,ith thromocytopenia ,ill (1) have
no gross or occult leeding, (") maintain vascular integrity, and ($) manage home care to
prevent any complications related to an increased ris' for leeding&
HEMOPHILIA AND VON WILLEBRAND DISEASE
)emo"hilia is a se)+lin'ed recessive genetic disorder caused y defective or deficient
coagulation factor& The t,o ma#or forms of hemophilia, ,hich can occur in mild to severe
forms, are hemophilia 5 and hemophilia 6&
3on -illerand disease is a related disorder involving a deficiency of the von -illerand
coagulation protein&
?eplacement of deficient clotting factors is the primary means of supporting a patient
,ith hemophilia& .n addition to treating acute crises, replacement therapy may e given
efore surgery and efore dental care as a prophylactic measure&
>ome management is a primary consideration for the patient ,ith hemophilia ecause the
disease follo,s a progressive, chronic course&
The patient ,ith hemophilia must e taught to recognize disease+related prolems and to
learn ,hich prolems can e resolved at home and ,hich re<uire hospitalization&
D'SSM'NA,D 'N,-A2ASC5LA- C$A45LA,'$N
Disseminated intra!ascular coagulation (=.C) is a serious leeding and thromotic
disorder&
.t results from anormally initiated and accelerated clotting& Buse<uent decreases in
clotting factors and platelets ensue, ,hich may lead to uncontrollale hemorrhage&
=.C is al,ays caused y an underlying disease or condition& The underlying prolem
must e treated for the =.C to resolve&
.t is important to diagnose =.C <uic'ly, stailize the patient if needed (e&g&, o)ygenation,
volume replacement), institute therapy that ,ill resolve the underlying causative disease
or prolem, and provide supportive care for the manifestations resulting from the
pathology of =.C itself&
N5,-$PN'A
1+F"
Key Points
Neutro"enia is a reduction in neutrophils, a type of granulocyte, and therefore is
sometime referred to as granulocytopenia& The neutrophilic granulocytes are closely
monitored in clinical practice as an indicator of a patient(s ris' for infection&
Neutropenia is a clinical conse<uence that occurs ,ith a variety of conditions or diseases&
.t can also e an e)pected effect, a side effect, or an unintentional effect of ta'ing certain
drugs&
;ccasionally the cause of the neutropenia can e easily treated (e&g&, nutritional
deficiencies)& >o,ever, neutropenia can also e a side effect that must e tolerated as a
necessary step in therapy (e&g&, chemotherapy, radiation therapy)& .n some situations the
neutropenia resolves ,hen the primary disease is treated (e&g&, tuerculosis)&
The nurse needs to monitor the neutropenic patient for signs and symptoms of infection
and early septic shoc'&
M6L$D6SPLAS,'C S6ND-$M
M.elod.s"lastic s.ndrome (:=B) is a group of related hematologic disorders
characterized y a change in the <uantity and <uality of one marro, elements& 5lthough
it can occur in all age groups, the highest prevalence is in people over D8 years of age&
Bupportive treatment consists of hematologic monitoring, antiiotic therapy, or
transfusions ,ith lood products& The overall goal is to improve hematopoiesis and
ensure age+related <uality of life&
L59M'A
Leu0emia is the general term used to descrie a group of malignant disorders affecting
the lood and lood+forming tissues of the one marro,, lymph system, and spleen&

Classification of leu'emia can e done ased on acute versus chronic and on the type of
-6C involved, ,hether it is of myelogenous origin or of lymphocytic origin&
o The onset of acute myelogenous leu'emia (5:2) is often arupt and dramatic&
5:2 is characterized y uncontrolled proliferation of myelolasts, the precursors
of granulocytes&
o 5cute lymphocytic leu'emia (522) is the most common type of leu'emia in
children&
o Chronic myelogenous leu'emia (C:2) is caused y e)cessive development of
mature neoplastic granuloctyes in the one marro,, ,hich move into the
peripheral lood in massive numers and ultimately infiltrate the liver and spleen&
The natural history of C:2 is a chronic stale phase, follo,ed y the
development of a more acute, aggressive phase referred to as the lastic phase#
o Chronic lymphocytic leu'emia (C22) is characterized y the production and
accumulation of functionally inactive ut long+lived, small, mature+appearing
lymphocytes& The lymphocytes infiltrate the one marro,, spleen, and liver, and
lymph node enlargement is present throughout the ody&
1+F$
Key Points
o >airy cell leu'emia is a chronic disease of lymphoproliferation predominantly
involving 6 lymphocytes that infiltrate the one marro, and spleen& Cells have a
/hairy0 appearance under the microscope&
;nce a diagnosis of leu'emia has een made, collaorative care is focused on the initial
goal of attaining remission& .n some cases, such as nonsymptomatic patients ,ith C22,
,atchful ,aiting ,ith active supportive care may e appropriate&
Cytoto)ic chemotherapy is the mainstay of the treatment for leu'emia& >ematopoietic
stem cell transplantation is another type of therapy used for patients ,ith different forms
of leu'emia&
The overall nursing goals are that the patient ,ith leu'emia ,ill (1) understand and
cooperate ,ith the treatment plan, (") e)perience minimal side effects and complications
associated ,ith oth the disease and its treatment, and ($) feel hopeful and supported
during the periods of treatment, relapse, or remission&
L6MP)$MAS
L.m"homas are malignant neoplasms originating in the one marro, and lymphatic
structures resulting in the proliferation of lymphocytes&
There are t,o ma#or types of lymphomasG>odg'in(s lymphoma and non+>odg'in(s
lymphoma (N>2)&
)odg0in<s L.m"homa
)odg0in<s l.m"homa, also called >odg'in(s disease, is a malignant condition
characterized y proliferation of anormal giant, multinucleated cells, called !eed$
Sternberg cells, ,hich are located in lymph nodes&
5lthough the cause of >odg'in(s lymphoma remains un'no,n, the main interacting
factors include infection ,ith *pstein+6arr virus, genetic predisposition, and e)posure to
occupational to)ins& The incidence of >odg'in(s lymphoma is increased in incidence
among human immunodeficiency virus infected patients&
The nursing care for >odg'in(s lymphoma is largely ased on managing prolems related
to the disease (e&g&, pain due to tumor), pancytopenia, and other side effects of therapy&
Non-)odg0in<s L.m"homas
Non-)odg0in<s l.m"homas (N>2s) are a heterogeneous group of malignant neoplasms
of primarily 6 or T cell origin affecting all ages& 5 variety of clinical presentations and
courses are recognized from indolent (slo,ly developing) to rapidly progressive disease&
N>2s can originate outside the lymph nodes, the method of spread can e unpredictale,
and the ma#ority of patients have ,idely disseminated disease at the time of diagnosis&
1+F%
Key Points
Treatment for N>2 involves chemotherapy and sometimes radiation therapy& Nursing
care is largely ased on managing prolems related to the disease (e&g&, pain due to the
tumor, spinal cord compression, tumor lysis syndrome), pancytopenia, and other side
effects of therapy&
MULTIPLE MYELOMA
Multi"le m.eloma, or plasma cell myeloma, is a condition in ,hich neoplastic plasma
cells infiltrate the one marro, and destroy one&
:ultiple myeloma develops slo,ly and insidiously& The patient often does not manifest
symptoms until the disease is advanced&
:ultiple myeloma is seldom cured, ut treatment can relieve symptoms, produce
remission, and prolong life& Chemotherapy is usually the first treatment recommended for
multiple myeloma&
:aintaining ade<uate hydration is a primary nursing consideration to minimize prolems
from hypercalcemia& 6ecause of the potential for pathologic fractures, the nurse must e
careful ,hen moving and amulating the patient&
/L$$D C$MP$NN, ,)-AP6
6lood component therapy is fre<uently used in managing hematologic diseases&
>o,ever, lood component therapy only temporarily supports the patient until the
underlying prolem is resolved&
-hen the lood or lood components have een otained from the lood an', positive
identification of the donor lood and recipient must e made& .mproper product+to+patient
identification causes E8K of hemolytic transfusion reactions&
The lood should e administered as soon as it is rought to the patient& .t should not e
refrigerated on the nursing unit&
5utotranfusion, or autologous transfusion, consists of removing ,hole lood from a
person and transfusing that lood ac' into the same person& The prolems of
incompatiility, allergic reactions, and transmission of disease can e avoided&
5 lood transfusion reaction is an adverse reaction to lood transfusion therapy that can
range in severity from mild symptoms to a life+threatening condition& 6lood transfusion
reactions can e classified as acute or delayed&
Acute ,ransfusion -eactions
The most common cause of hemolytic reactions is transfusion of 56;+incompatile
lood&
1+FC
Key Points
@erile reactions are most commonly caused y leu'ocyte incompatiility& :any
individuals ,ho receive five or more transfusions develop circulating antiodies to the
small amount of -6Cs in the lood product&
5llergic reactions result from the recipient(s sensitivity to plasma proteins of the donor(s
lood& These reactions are more common in an individual ,ith a history of allergies&
5n individual ,ith cardiac or renal insufficiency is at ris' for developing circulatory
overload& This is especially true if a large <uantity of lood is infused in a short period of
time, particularly in an elderly patient&
Transfusion+related lung in#ury is characterized y the sudden development of
noncardiogenic pulmonary edema (acute lung in#ury)&
5n acute complication of transfusing large volumes of lood products is termed massive
lood transfusion reaction# :assive lood transfusion reactions can occur ,hen
replacement of ?6Cs or lood e)ceeds the total lood volume ,ithin "% hours&
Dela.ed ,ransfusion -eactions
=elayed transfusion reactions include delayed hemolytic reactions, infections, iron
overload, and graft+versus+host disease&
.nfectious agents transmitted y lood transfusion include hepatitis 6 and C viruses, >.3,
human herpesvirus type D, *pstein+6arr virus, human T cell leu'emia, cytomegalovirus,
and malaria&
th
edition
Key Points
Chapter $": Nursing 5ssessment: Cardiovascular Bystem
The heart is a four+chamered organ that lies in the mediastinal space in the thora)&
The heart is divided y the septum, forming the right and left atrium and the right and left
ventricle&
3alves separate the chamers of the heart:
o :itral valve separates the left atrium and the left ventricle&
o 5ortic valve separates the left ventricle and the aorta&
1+FD
Key Points
o Tricuspid valve separates the right atrium and the right ventricle&
o Pulmonic valve separates the right ventricle and the pulmonary artery&
The heart is:
o Composed of three layers: endocardium, myocardium, and epicardium&
o Burrounded y a firoserous sac called the pericardium&
The right side of the heart receives lood from the ody (via the vena cava) and pumps it
to the lungs ,here it is o)ygenated& 6lood returns to the left side of the heart (via the
pulmonary arteries) and is pumped to the ody via the aorta&
The coronary circulation provides lood to the myocardium& The right and left coronary
arteries are the first ranches of the aorta&
The conduction system consists of specialized cells that create and transport electrical
impulses& These electrical impulses initiate depolarization (contraction) of the
myocardium and ultimately a cardiac contraction&
*ach electrical impulse starts at the B5 node (located in the right atrium), travels to the
53 node (located at the atrioventricular #unction), through the undle of >is, do,n the
right and left undle ranches (located in the ventricular septum), terminating in the
Pur'in#e fiers&
The electrical activity of the heart is recorded on the electrocardiogram (*CA)&
S.stole, contraction of the myocardium, results in e#ection of lood from the ventricles&
?ela)ation of the myocardium, or diastole, allo,s for filling of the ventricles&
Cardiac out"ut (C;) is the amount of lood pumped y each ventricle in 1 minute& .t is
calculated y multiplying the amount of lood e#ected from the ventricle ,ith each
hearteat, the stro'e volume (B3), y the heart rate (>?) per minute: C; Z B3 >?&
@actors affecting B3 are preload, afterload, and contractility& Preload is the volume of
lood in the ventricles at the end of diastole, and afterload represents the peripheral
resistance against ,hich the left ventricle must pump&
Cardiac reser!e refers to the heart(s aility to alter the C; in response to an increase in
demand (e&g&, e)ercise, hypovolemia)&
Btimulation of the sympathetic nervous system increases >?, speed of conduction
through the 53 node, and force of atrial and ventricular contractions, ,hereas stimulation
of the parasympathetic nervous system decreases >?&
1+F9
Key Points
6aroreceptors, located in the aortic arch and carotid sinus, respond to stretch or pressure
,ithin the arterial system& Btimulation of these receptors results in temporary inhiition
of the sympathetic nervous system and an increase in parasympathetic influence&

Chemoreceptors, located in the aortic arch and carotid ody, can initiate changes in >?
and arterial pressure in response to decreased arterial ;
"
pressure, increased arterial C;
"
pressure, and decreased plasma p>&
Arterial blood "ressure (6P) measures the pressure e)erted y lood against the ,alls
of the arterial system&
The s.stolic blood "ressure (B6P) is the pea' pressure e)erted against the arteries ,hen
the heart contracts& The diastolic blood "ressure (=6P) is the residual pressure of the
arterial system during ventricular rela)ation (or filling)& Normal lood pressure is systolic
6P less than 1"8 mm >g and diastolic 6P less than F8 mm >g&
The t,o main factors influencing 6P are cardiac output (C;) and systemic vascular
resistance (B3?), ,hich is the force opposing the movement of lood&
6P can e measured y invasive (catheter inserted in an artery) and noninvasive
techni<ues (using a sphygmomanometer and a stethoscope)&
Pulse "ressure is the difference et,een the B6P and =6P and it is normally aout one
third of the B6P&
Mean arterial "ressure %MAP& is the perfusion pressure felt y organs in the ody, and
a :5P of greater than D8 is necessary to sustain the vital organs of an average person
under most conditions&
ASSSSMN,
Health History
-hen conducting a health assessment of the cardiovascular system, a thorough history should
include the follo,ing:
5ny past history of chest pain, shortness of reath, alcoholism and1or toacco use,
anemia, rheumatic fever, streptococcal sore throat, congenital heart disease, stro'e,
syncope, hypertension, thromophleitis, intermittent claudication, varicosities, and
edema
Current and past use of medications
.nformation aout specific treatments, past surgeries, or hospital admissions related to
cardiovascular prolems
1+FF
Key Points
.nformation aout cardiovascular ris' factors (i&e&, elevated serum lipids, hypertension)
@amily history ,ith cardiovascular illnesses of lood relatives
The patient(s current ,eight and ,eight history
5 typical day(s diet
Prolems ,ith urinary (e&g&, nocturia) or o,el elimination (e&g&, constipation)
The types of e)ercise performed and the occurrence of any un,anted effects
.dentification of paro)ysmal nocturnal dyspnea, sleep apnea, and the numer of pillo,s
needed for comfort
.nformation aout the patient(s gender, race, and age
5ny prolems in se)ual performance
.nformation aout stressful situations should e e)plored (e&g&, marital relationships)
.nformation aout a patient(s values and eliefs
Physical Examination
-hen conducting a health assessment of the cardiovascular system, a thorough physical
e)amination should include the follo,ing:
Aeneral appearance, vital signs, including orthostatic (postural) 6Ps and >?s
.nspection of the s'in, e)tremities, and the large veins of the nec'
6ilateral and simultaneous palpation of the upper and lo,er e)tremities
6ilateral and simultaneous palpation of the pulses in the e)tremities

Capillary refill
5uscultation of carotid arteries, adominal aorta, and femoral arteries
.nspection and palpation of the thora), epigastric area, and mitral valve area
5uscultation of the heart ,ith the ell and diaphragm of the stethoscope
5uscultation for e)tra heart sounds (B
$
or B
%
) ,ith the ell of the stethoscope
1+FE
Key Points
D'A4N$S,'C S,5D'S
The most common procedures used to diagnose cardiovascular disease include the follo,ing:
6lood studies
o Creatine 'inase (CK)+:6: levels increase ,ith myocardial infarction (:.)
o Cardiac+specific troponin: levels rise ,ith myocardial in#ury
o :yogloin: sensitive indicator of early myocardial in#ury
o Berum lipoproteins: including triglycerides, cholesterol, and phospholipids
o C+reactive protein (C?P): emerging as an independent ris' factor for C5= and a
predictor of cardiac events
o >omocysteine (>cy): elevated levels have een lin'ed to an increased ris' of a
first cardiac event and should e measured in patients ,ith a familial
predisposition for early cardiovascular disease
o Cardiac natriuretic peptide mar'ers: emerged as the mar'er of choice for
distinguishing a cardiac or respiratory cause of dyspnea
Chest )+ray
*lectrocardiogram
o =eviations from the normal sinus rhythm can indicate anormalities in heart
function&
o Continuous amulatory *CA (>olter monitoring): recorder is ,orn for "% to %F
hours, and the resulting *CA information is then stored until it is played ac' for
printing and evaluation&
o Transtelephonic event recorders: portale monitor uses electrodes to transmit a
limited *CA over the phone to a receiving device&
*)ercise or stress testing
o 4sed to evaluate the cardiovascular response to physical stress
D+:inute ,al' test
o 4sed for patients ,ith heart or peripheral arterial disease to measure response to
medical interventions and determine functional capacity for daily physical
activities
*chocardiogram
o 4ses ultrasound ,aves to record the movement of the structures of the heart&
o Provides information aout (1) valvular structure and motion, (") cardiac chamer
size and contents, ($) ventricular muscle and septal motion and thic'ness, (%)
pericardial sac, (C) ascending aorta, and (D) e*ection fraction (*@) (percentage of
end+diastolic lood volume that is e#ected during systole)&
Nuclear cardiology
o :ultigated ac<uisition (:4A5) or cardiac lood pool scan
1+E8
Key Points
Provides information on ,all motion during systole and diastole, cardiac
valves, and *@&
o Bingle+photon emission computed tomography (BP*CT)
4sed to evaluate the myocardium at ris' of infarction and to determine
infarction size&
o Positron emission tomography (P*T) scanning
4ses t,o isotopes to distinguish viale and nonviale myocardial tissue&
o Perfusion imaging ,ith e)ercise testing
=etermines ,hether the coronary lood flo, changes ,ith increased
activity&
4sed to diagnose C5=, determine the prognosis in already diagnosed
C5=, assess the physiologic significance of a 'no,n coronary lesion, and
assess the effectiveness of various therapeutic modalities such as coronary
artery ypass surgery, percutaneous coronary intervention, or thromolytic
therapy&
o :agnetic resonance imaging (:?.)
5llo,s detection and localization of areas of :. in a $+= vie,& .t is
sensitive enough to detect small :.s not apparent ,ith BP*CT imaging
and can assist in the final diagnosis of :.&
o :agnetic resonance angiography (:?5)
4sed for imaging vascular occlusive disease and adominal aortic
aneurysms&
Computed tomography (CT) ,ith spiral technology
o 5 noninvasive scan used to <uantify calcium deposits in coronary arteries&
*lectron eam computed tomography (*6CT), also 'no,n as ultrafast CT, uses a
scanning electron eam to <uantify the calcification in the coronary arteries and
the heart valves&
Cardiac catheterization and coronary angiography
o Contrast media (introduced via a catheter inserted in a large peripheral artery) and
fluoroscopy are used to otain information aout the coronary arteries, heart
chamers and valves, ventricular function, intracardiac pressures, ;
"
levels in
various parts of the heart, C;, and *@&
.ntracoronary ultrasound (.C4B) or intravascular ultrasound (.34B)
o Performed during coronary angiography& ;tains "+= or $+= ultrasound images to
provide a cross+sectional vie, of the arterial ,alls of the coronary arteries&
*lectrophysiology study (*PB)
o Btudies and manipulates the electrical activity of the heart using electrodes placed
inside the cardiac chamers& Provides information on B5 node function, 53 node
conduction, ventricular conduction, and source treatment dysrhythmias&
=uple) imaging
1+E1
Key Points
o 4ses contrast media, in#ected into arteries or veins (arteriography and
venography) to diagnose occlusive disease in the peripheral lood vessels and
thromophleitis&
>emodynamic monitoring
4ses intraarterial and pulmonary artery catheters to monitor arterial 6P, intracardiac pressures,
C;, and central venous pressure (C3P
th
edition
Key Points
Chapter $$: Nursing :anagement: >ypertension
)."ertension, or high blood "ressure (6P), is defined as a persistent systolic lood
pressure (B6P) greater than or e<ual to 1%8 mm >g, diastolic lood pressure (=6P)
greater than or e<ual to E8 mm >g, or current use of antihypertensive medication& There
is a direct relationship et,een hypertension and cardiovascular disease (C3=)&
Contriuting factors to the development of hypertension include cardiovascular ris'
factors comined ,ith socioeconomic conditions and ethnic differences&
>ypertension is generally an asymptomatic condition& .ndividuals ,ho remain
undiagnosed and untreated for hypertension present the greatest challenge and
opportunity for health care providers&
-45LA,'$N $+ /L$$D P-SS5-
6P is the force e)erted y the lood against the ,alls of the lood vessel& .t must e
ade<uate to maintain tissue perfusion during activity and rest&
1+E"
Key Points
?egulation of 6P involves nervous, cardiovascular, endothelial, renal, and endocrine
functions&
o Bympathetic nervous system (BNB) activation increases heart rate (>?) and
cardiac contractility, produces ,idespread vasoconstriction in the peripheral
arterioles, and promotes the release of renin from the 'idneys&
o 6aroreceptors, located in the carotid artery and the arch of the aorta, sense
changes in 6P& -hen 6P is increased, these receptors send inhiitory impulses to
the sympathetic vasomotor center in the rainstem resulting in decreased >?,
decreased force of contraction, and vasodilation in peripheral arterioles&
o 5 decrease in 6P leads to activation of the BNB resulting in constriction of the
peripheral arterioles, increased >?, and increased contractility of the heart&
o .n the presence of long+standing hypertension, the aroreceptors ecome ad#usted
to elevated levels of 6P and recognize this level as /normal&0
o Norepinephrine (N*), released from BNB nerve endings, activates receptors
located in the sinoatrial node, myocardium, and vascular smooth muscle&
o 3ascular endothelium produces vasoactive sustances and gro,th factors&
Nitric o)ide, an endothelium+derived rela)ing factor (*=?@), helps
maintain lo, arterial tone at rest, inhiits gro,th of the smooth muscle
layer, and inhiits platelet aggregation&
*ndothelin (*T), produced y the endothelial cells, is an e)tremely potent
vasoconstrictor&
o Kidneys contriute to 6P regulation y controlling sodium e)cretion and
e)tracellular fluid (*C@) volume&
Bodium retention results in ,ater retention, ,hich causes an increased
*C@ volume& This increases the venous return to the heart, increasing the
stro'e volume, ,hich elevates the 6P through an increase in C;&
o *ndocrine system:
The adrenal medulla releases epinephrine in response to BNB stimulation&
*pinephrine activates
"
+adrenergic receptors causing vasodilation& .n
peripheral arterioles ,ith only
1
+adrenergic receptors (s'in and 'idneys),
epinephrine causes vasoconstriction&
The adrenal corte) is stimulated y 5+.. to release aldosterone&
5ldosterone stimulates the 'idneys to retain sodium and ,ater& This
increases 6P y increasing C;&
5=> is released from the posterior pituitary gland in response to an
increased lood sodium and osmolarity level& 5=> increases the *C@
volume y promoting the reasorption of ,ater in the distal and collecting
tuules of the 'idneys resulting in an increase in lood volume and 6P&
CLASS'+'CA,'$N $+ )6P-,NS'$N
>ypertension is classified as follo,s:
o Preh."ertension: 6P 1"8 to 1$E 1 F8 to FE mm >g
o >ypertension, Btage 1: 6P 1%8 to 1CE 1 E8 to EE mm >g
o >ypertension, Btage ": systolic 6P greater than or e<ual to 1D8 or diastolic 6P
greater than or e<ual to 188 mm >g&
1+E$
Key Points
Butypes of hypertension:
o .solated systolic hypertension (.B>): average B6P greater than or e<ual to 1%8
mm >g coupled ,ith an average =6P less than E8 mm >g& .B> is more common
in older adults& Control of .B> decreases the incidence of stro'e, heart failure,
cardiovascular mortality, and total mortality&
o Pseudohypertension (false hypertension) occurs ,ith advanced arteriosclerosis&
Pseudohypertension is suspected if arteries feel rigid or ,hen fe, retinal or
cardiac signs are found relative to the pressures otained y cuff&
,'$L$46 $+ )6P-,NS'$N
Primar. %essential or idio"athic& h."ertension: elevated 6P ,ithout an identified
cause! accounts for E8K to ECK of all cases of hypertension&

Secondar. h."ertension: elevated 6P ,ith a specific cause! accounts for CK to 18K of
hypertension in adults&
PA,)$P)6S'$L$46 $+ P-'MA-6 )6P-,NS'$N
The hemodynamic hallmar' of hypertension is persistently increased B3?&
-ater and sodium retention:
o 5 high+sodium inta'e may activate a numer of pressor mechanisms and cause
,ater retention&
5ltered renin+angiotensin mechanism:
o >igh plasma renin activity (P?5) results in the increased conversion of
angiotensinogen to angiotensin . causing arteriolar constriction, vascular
hypertrophy, and aldosterone secretion&
Btress and increased BNB activity:
o 5rterial pressure is influenced y factors such as anger, fear, and pain&
o Physiologic responses to stress, ,hich are normally protective, may persist to a
pathologic degree, resulting in prolonged increase in BNB activity&
o .ncreased BNB stimulation produces increased vasoconstriction, increased >?,
and increased renin release&
.nsulin resistance and hyperinsulinemia:
o 5normalities of glucose, insulin, and lipoprotein metaolism are common in
primary hypertension&
o >igh insulin concentration in the lood stimulates BNB activity and impairs nitric
o)ideNmediated vasodilation&
o 5dditional pressor effects of insulin include vascular hypertrophy and increased
renal sodium reasorption&
*ndothelial cell dysfunction:
1+E%
Key Points
o Bome hypertensive people have a reduced vasodilator response to nitric o)ide&
o *ndothelin produces pronounced and prolonged vasoconstriction&
CL'N'CAL MAN'+S,A,'$NS $+ )6P-,NS'$N
;ften called the /silent 'iller0 ecause it is fre<uently asymptomatic until it ecomes
severe and target organ disease occurs&
Target organ diseases occur in the heart (hypertensive heart disease), rain
(cererovascular disease), peripheral vasculature (peripheral vascular disease), 'idney
(nephrosclerosis), and eyes (retinal damage)&
>ypertension is a ma#or ris' factor for coronary artery disease (C5=)&
Bustained high 6P increases the cardiac ,or'load and produces left ventricular
hypertrophy (23>)& Progressive 23>, especially in association ,ith C5=, is associated
,ith the development of heart failure&
>ypertension is a ma#or ris' factor for cereral atherosclerosis and stro'e&
>ypertension speeds up the process of atherosclerosis in the peripheral lood vessels,
leading to the development of peripheral vascular disease, aortic aneurysm, and aortic
dissection&
.ntermittent claudication (ischemic muscle pain precipitated y activity and relieved ,ith
rest) is a classic symptom of peripheral vascular disease involving the arteries&
>ypertension is one of the leading causes of end+stage renal disease, especially among
5frican 5mericans& The earliest manifestation of renal dysfunction is usually nocturia&
The retina provides important information aout the severity and duration of
hypertension& =amage to retinal vessels provides an indication of concurrent vessel
damage in the heart, rain, and 'idney& :anifestations of severe retinal damage include
lurring of vision, retinal hemorrhage, and loss of vision&
D'A4N$S,'C S,5D'S
6asic laoratory studies are performed to (1) identify or rule out causes of secondary
hypertension, (") evaluate target organ disease, ($) determine overall cardiovascular ris',
or (%) estalish aseline levels efore initiating therapy&
?outine urinalysis, 64N, serum creatinine, and creatinine clearance levels are used to
screen for renal involvement and to provide aseline information aout 'idney function&
:easurement of serum electrolytes, especially potassium levels, is done to detect
hyperaldosteronism, a cause of secondary hypertension&
1+EC
Key Points
6lood glucose levels assist in the diagnosis of diaetes mellitus&
2ipid profile provides information aout additional ris' factors that predispose to
atherosclerosis and cardiovascular disease&
4ric acid levels are determined to estalish a aseline, ecause the levels often rise ,ith
diuretic therapy&
*CA and echocardiography provide information aout the cardiac status&
5mulatory lood pressure monitoring (56P:) is a noninvasive, fully automated system
that measures 6P at preset intervals over a "%+hour period&
o Bome patients ,ith hypertension do not sho, a normal, nocturnal dip in 6P and
are referred to as /nondippers&0
o The asence of diurnal variaility has een associated ,ith more target organ
damage and an increased ris' for cardiovascular events& The presence or asence
of diurnal variaility can e determined y 56P:&
N5-S'N4 AND C$LLA/$-A,'2 MANA4MN,
Treatment goals are to lo,er 6P to less than 1%8 mm >g systolic and less than E8 mm >g
diastolic for most persons ,ith hypertension (less than 1$8 mm >g systolic and less than
F8 mm >g diastolic for those ,ith diaetes mellitus and chronic 'idney disease)&
2ifestyle modifications are indicated for all patients ,ith prehypertension and
hypertension and include the follo,ing:
o -eight reduction& 5 ,eight loss of 18 'g ("" l) may decrease B6P y
appro)imately C to "8 mm >g&
o =ietary 5pproaches to Btop >ypertension (=5B>) eating plan& .nvolves eating
several servings of fish each ,ee', eating plenty of fruits and vegetales,
increasing fier inta'e, and drin'ing a lot of ,ater& The =5B> diet significantly
lo,ers 6P&
o ?estriction of dietary sodium to less than D g of salt (NaCl) or less than "&% g of
sodium per day&
o This involves avoiding foods 'no,n to e high in sodium (e&g&, canned soups) and
not adding salt in the preparation of foods or at meals&
o There is evidence that greater levels of dietary potassium, calcium, vitamin =, and
omega+$ fatty acids are associated ,ith lo,er 6P in those ,ith hypertension&
o ?estriction of alcohol to no more than t,o drin's per day for men and no more
than one drin' per day for ,omen
o ?egular aeroic physical activity (e&g&, ris' ,al'ing) at least $8 minutes a day
most days of the ,ee'& :oderately intense activity such as ris' ,al'ing,
#ogging, and s,imming can lo,er 6P, promote rela)ation, and decrease or control
ody ,eight&
o .t is strongly recommended that toacco use e avoided&
o Btress can raise 6P on a short+term asis and has een implicated in the
1+ED
Key Points
development of hypertension& ?ela)ation therapy, guided imagery, and
iofeedac' may e useful in helping patients manage stress, thus decreasing 6P&
Drug ,hera".
=rug therapy is not recommended for those persons ,ith prehypertension unless it is
re<uired y another condition, such as diaetes mellitus or chronic 'idney disease&
The overall goals for the patient ,ith hypertension include (1) achievement and
maintenance of the goal 6P! (") acceptance and implementation of the therapeutic plan!
($) minimal or no unpleasant side effects of therapy! and (%) aility to manage and cope
,ith illness&
=rugs currently availale for treating hypertension ,or' y (1) decreasing the volume of
circulating lood, and1or (") reducing B3?&
o =iuretics promote sodium and ,ater e)cretion, reduce plasma volume, decrease
sodium in the arteriolar ,alls, and reduce the vascular response to
catecholamines&
o 5drenergic+inhiiting agents act y diminishing the BNB effects that increase 6P&
5drenergic inhiitors include drugs that act centrally on the vasomotor center and
peripherally to inhiit norepinephrine release or to loc' the adrenergic receptors
on lood vessels&
o =irect vasodilators decrease the 6P y rela)ing vascular smooth muscle and
reducing B3?&
o Calcium channel loc'ers increase sodium e)cretion and cause arteriolar
vasodilation y preventing the movement of e)tracellular calcium into cells&
o 5ngiotensin+converting enzyme (5C*) inhiitors prevent the conversion of
angiotensin . to angiotensin .. and reduce angiotensin .. (5+..)Nmediated
vasoconstriction and sodium and ,ater retention&
o 5+.. receptor loc'ers (5?6s) prevent angiotensin .. from inding to its receptors
in the ,alls of the lood vessels&
o Thiazide+type diuretics are used as initial therapy for most patients ,ith
hypertension, either alone or in comination ,ith one of the other classes&
o -hen 6P is more than "8118 mm >g aove B6P and =6P goals, a second drug
should e considered& :ost patients ,ho are hypertensive ,ill re<uire t,o or
more antihypertensive medications to achieve their 6P goals&
o Bide effects and adverse effects of antihypertensive drugs may e so severe or
undesirale that the patient does not comply ,ith therapy&
>yperuricemia, hyperglycemia, and hypo'alemia are common side effects
,ith oth thiazide and loop diuretics&
5C* inhiitors lead to high levels of rady'inin, ,hich can cause
coughing& 5n individual ,ho develops a cough ,ith the use of 5C*
inhiitors may e s,itched to an 5?6&
>yper'alemia can e a serious side effect of the potassium+sparing
diuretics and 5C* inhiitors&
Be)ual dysfunction may occur ,ith some of the diuretics&
1+E9
Key Points
;rthostatic hypotension and se)ual dysfunction are t,o undesirale
effects of adrenergic+inhiiting agents&
Tachycardia and orthostatic hypotension are potential adverse effects of
oth vasodilators and angiotensin inhiitors&
Patient and family teaching related to drug therapy is needed to identify
and minimize side effects and to cope ,ith therapeutic effects& Bide effects
may e an initial response to a drug and may decrease ,ith continued use
of the drug&
?esistant hypertension is the failure to reach goal 6P in patients ,ho are adhering to full
doses of an appropriate three+drug therapy regimen that includes a diuretic&
/lood Pressure Monitoring
The ma#ority of cases of hypertension are identified through routine screening procedures
such as insurance, preemployment, and military physical e)aminations&
The auscultatory method of 6P measurement is recommended& .nitially, the 6P is ta'en at
least t,ice, at least 1 minute apart, ,ith the average pressure recorded as the value for
that visit& Bize and placement of 6P cuff are important for accurate measurement& The
forearm is supported at heart level and Korot'off sounds are auscultated over the radial
artery&
6P measurements of oth arms should e performed initially to detect any differences
et,een arms& The arm ,ith the higher reading should e used for all suse<uent 6P
measurements&
;rthostatic (or postural) changes in 6P and pulse should e measured in older adults, in
people ta'ing antihypertensive drugs, and in patients ,ho report symptoms consistent
,ith reduced 6P upon standing (e&g&, light+headedness, dizziness, syncope)&
$rthostatic h."otension is defined as a decrease of "8 mm >g or more in B6P, a
decrease of 18 mm >g or more in =6P, and1or an increase of "8 eats1minute or more in
pulse from supine to standing&
6P monitoring should focus on controlling 6P in the person already identified as having
hypertension! identifying and controlling 6P in at+ris' groups such as 5frican 5mericans,
oese people, and lood relatives of people ,ith hypertension! and screening those ,ith
limited access to the health care system&
N5-S'N4 MANA4MN,
The primary nursing responsiilities for long+term management of hypertension are to
assist the patient in reducing 6P and complying ,ith the treatment plan& Nursing actions
include patient and family teaching, detection and reporting of adverse treatment effects,
compliance assessment and enhancement, and evaluation of therapeutic effectiveness&
1+EF
Key Points
Patient and family teaching includes the follo,ing: (1) nutritional therapy, (") drug
therapy, ($) physical activity, (%) home monitoring of 6P (if appropriate), and (C) toacco
cessation (if applicale)&
o >ome monitoring of 6P should include daily 6P readings ,hen treatment is
initiated or medications are ad#usted and ,ee'ly once the 6P has stailized& 5 log
of the 6P measurements should e maintained y the patient& =evices that have
memory or printouts of the readings are recommended to facilitate accurate
reporting&
o 5 ma#or prolem in the long+term management of the patient ,ith hypertension is
poor compliance ,ith the prescried treatment plan& The reasons include
inade<uate patient teaching, unpleasant side effects of drugs, return of 6P to
normal range ,hile on medication, lac' of motivation, high cost of drugs, lac' of
insurance, and lac' of a trusting relationship et,een the patient and the health
care provider&
The prevalence of hypertension increases ,ith age& The lifetime ris' of developing
hypertension is appro)imately E8K for middle+aged (age CC to DC) and older (age UDC)
normotensive men and ,omen&
5 numer of age+related physical changes contriute to the pathophysiology of
hypertension in the older adult&
.n some older people, there is a ,ide gap et,een the first Korot'off sound and
suse<uent eats (auscultatory gap)& @ailure to inflate the cuff high enough may result in
underestimating the B6P&
;lder adults are sensitive to 6P changes& ?educing B6P to less than 1"8 mm >g in a
person ,ith long+standing hypertension could lead to inade<uate cereral lood flo,&
;lder adults produce less renin and are more resistant to the effects of 5C* inhiitors and
angiotensin .. receptor loc'ers&
;rthostatic hypotension occurs often in older adults ecause of impaired aroreceptor
refle) mechanisms&
;rthostatic hypotension in older adults is often associated ,ith volume depletion or
chronic disease states, such as decreased renal and hepatic function or electrolyte
imalance&
To reduce the li'elihood of orthostatic hypotension, antihypertensive drugs should e
started at lo, doses and increased cautiously&
)6P-,NS'2 C-'S'S
)."ertensi!e crisis is a severe and arupt elevation in 6P, aritrarily defined as a =6P
1+EE
Key Points
more than 1%8 mm >g&
o >ypertensive crisis occurs most often in patients ,ith a history of hypertension
,ho have failed to comply ,ith their prescried medications or ,ho have een
undermedicated&
o >ypertensive crisis related to cocaine or crac' use is ecoming a more fre<uent
prolem& ;ther drugs such as amphetamines, phencyclidine (PCP), and lysergic
acid diethylamide (2B=) may also precipitate hypertensive crisis that may e
complicated y drug+induced seizures, stro'e, :., or encephalopathy&
>ypertensive emergency develops over hours to days and is defined as 6P that is severely
elevated (more than 1F811"8 mm >g) ,ith evidence of acute target organ damage&
o >ypertensive emergencies can precipitate encephalopathy, intracranial or
suarachnoid hemorrhage, acute left ventricular failure ,ith pulmonary edema,
:., renal failure, dissecting aortic aneurysm, and retinopathy&
o >ypertensive emergencies re<uire hospitalization, intravenous (.3) administration
of antihypertensive drugs, and intensive care monitoring&
5ntihypertensive drugs include vasodilators, adrenergic inhiitors, and the 5C* inhiitor
enalaprilat& Bodium nitroprusside is the most effective .3 drug for the treatment of
hypertensive emergencies&
:ean arterial pressure (:5P) is generally used instead of systolic and diastolic readings
to guide therapy& :5P is calculated as follo,s: :5P Z (B6P O " =6P) $&
The use of an intraarterial line or an automated, noninvasive 6P machine to monitor the
:5P and 6P is re<uired& The rate of drug administration is titrated according to the level
of :5P or 6P&
The initial treatment goal is to decrease :5P y no more than "CK ,ithin minutes to 1
hour& .f the patient is stale, the target goal for 6P is 1D81188 to 118 mm >g over the ne)t
" to D hours&
2o,ering 6P e)cessively may decrease cereral, coronary, or renal perfusion and could
precipitate a stro'e, acute :., or renal failure&
5dditional gradual reductions to,ard a normal 6P should e implemented over the ne)t
"% to %F hours if the patient is clinically stale&
?egular, ongoing assessment (e&g&, *CA monitoring, vital signs, urinary output, level of
consciousness, visual changes) is essential to evaluate the patient ,ith severe
hypertension&
>ypertensive urgency develops over days to ,ee's and is defined as a 6P that is severely
elevated ut ,ith no clinical evidence of target organ damage&
o >ypertensive urgencies usually do not re<uire .3 medications ut can e managed
1+188
Key Points
,ith oral agents&
o .f a patient ,ith hypertensive urgency is not hospitalized, outpatient follo,+up
should e arranged ,ithin "% hours&
th
edition
Key Points
Chapter $%: Nursing :anagement: Coronary 5rtery =isease and 5cute Coronary
Byndrome
Coronar. arter. disease (C5=) is a type of lood vessel disorder included in the
general category of atherosclerosis&
Atherosclerosis is characterized y a focal deposit of cholesterol and lipids ,ithin the
intimal ,all of the artery& .nflammation and endothelial in#ury play a central role in the
development of atherosclerosis&
C5= is a progressive disease that develops in stages and ,hen it ecomes symptomatic,
the disease process is usually ,ell advanced&
Normally some arterial anastomoses or connections, termed collateral circulation, e)ist
,ithin the coronary circulation& The gro,th and e)tent of collateral circulation are
attriuted to t,o factors: (1) the inherited predisposition to develop ne, lood vessels
(angiogenesis), and (") the presence of chronic ischemia&
:any ris' factors have een associated ,ith C5=&
o Nonmodifiale ris' factors are age, gender, ethnicity, family history, and genetic
inheritance&
o :odifiale ris' factors include elevated serum lipids, hypertension, toacco use,
physical inactivity, oesity, diaetes, metaolic syndrome, psychologic states, and
homocysteine level&
*levated serum lipid levels are one of the four most firmly estalished ris'
factors for C5=&
2ipids comine ,ith proteins to form lipoproteins and are vehicles for fat
moilization and transport& The different types of lipoproteins are
classified as high+density lipoproteins (>=2s), lo,+density lipoproteins
(2=2s), and very+lo,+density lipoproteins (32=2s)&
>=2s carry lipids a,ay from arteries and to the liver for
metaolism& >igh serum >=2 levels are desirale&
>=2 levels are increased y physical activity, moderate alcohol
consumption, and estrogen administration&
*levated 2=2 levels correlate most closely ,ith an increased
incidence of atherosclerosis and C5=&
>ypertension, defined as a 6P greater than or e<ual to 1%81E8 mm >g, is a
1+181
Key Points
ma#or ris' factor in C5=&
Toacco use is also a ma#or ris' factor in C5=& The ris' of developing
C5= is t,o to si) times higher in those ,ho smo'e toacco than in those
,ho do not&
;esity is defined as a ody mass inde) (6:.) of less than $8 'g1m
"
& The
increased ris' for C5= is proportional to the degree of oesity&
o =iaetes, metaolic syndrome, and certain ehavioral states (i&e&, stress) have also
een found to e contriuting ris' factors for C5=&
C$-$NA-6 A-,-6 D'SAS
Prevention and early treatment of C5= must involve a multifactorial approach and needs
to e ongoing throughout the lifespan
5 complete lipid profile is recommended every C years eginning at age "8& Persons ,ith
a serum cholesterol level greater than "88 mg1dl are at high ris' for C5=&
:anagement of high+ris' persons starts ,ith controlling or changing the additive effects
of modifiale ris' factors&
o 5 regular physical activity program should e implemented&
o Therapeutic lifestyle changes to reduce the ris' of C5= include lo,ering 2=2
cholesterol y adopting a diet that limits saturated fats and cholesterol and
emphasizes comple) carohydrates (e&g&, ,hole grains, fruit, vegetales)&
o 2o,+dose aspirin is recommended for people at ris' for C5=& 5spirin therapy is
not recommended for ,omen ,ith lo, ris' for C5= efore age DC& Common side
effects of aspirin therapy include A. upset and leeding& @or people ,ho are
aspirin intolerant, clopidogrel (Plavi)) can e considered&
.f levels remain elevated despite modifiale changes, drug therapy is considered&
o Btatin drugs ,or' y inhiiting the synthesis of cholesterol in the liver& 2iver
enzymes must e regularly monitored&
o Niacin, a ,ater+solule 6 vitamin, is highly effective in lo,ering 2=2 and
triglyceride levels y interfering ,ith their synthesis& Niacin also increases >=2
levels etter than many other lipid+lo,ering drugs&
o @iric acid derivatives ,or' y accelerating the elimination of 32=2s and
increasing the production of apoproteins 5+. and 5+..&
o 6ile+acid se<uestrants increase conversion of cholesterol to ile acids and
decrease hepatic cholesterol content& The primary effect is a decrease in total
cholesterol and 2=2s&
o Certain drugs selectively inhiit the asorption of dietary and iliary cholesterol
across the intestinal ,all&
The incidence of cardiac disease is greatly increased in the elderly and is the leading
cause of death in older persons& Btrategies to reduce C5= ris' are effective in this age
group ut are often underprescried&
5ggressive treatment of hypertension and hyperlipidemia ,ill stailize pla<ues in the
coronary arteries of older adults, and cessation of toacco use helps decrease the ris' for
C5= at any age&
C)-$N'C S,A/L AN4'NA
1+18"
Key Points
Chronic stable angina refers to chest pain that occurs intermittently over a long
period ,ith the same pattern of onset, duration, and intensity of symptoms&
o 5ngina is rarely sharp or staing, and it usually does not change ,ith
position or reathing& :any people ,ith angina complain of indigestion or a
urning sensation in the epigastric region&
o 5nginal pain usually lasts for only a fe, minutes ($ to C minutes) and
commonly susides ,hen the precipitating factor is relieved& Pain at rest is
unusual&
The treatment of chronic stale angina is aimed at decreasing o)ygen demand and1or
increasing o)ygen supply and reducing C5= ris' factors&
o .n addition to antiplatelet and cholesterol+lo,ering drug therapy, the most
common drugs used to manage chronic stale angina are nitrates&
Bhort+acting nitrates are first+line therapy for the treatment of angina&
Nitrates produce their principal effects y dilating peripheral lood
vessels, coronary arteries, and collateral vessels&
2ong acting nitrates are also used to reduce the incidence of anginal
attac's&
+5drenergic loc'ers are the preferred drugs for the management of
chronic stale angina&
Calcium channel loc'ers are used if +adrenergic loc'ers are
contraindicated, are poorly tolerated, or do not control anginal
symptoms& The primary effects of calcium channel loc'ers are (1)
systemic vasodilation ,ith decreased B3?, (") decreased myocardial
contractility, and ($) coronary vasodilation&
Certain high+ris' patients (e&g&, patients ,ith diaetes) ,ith chronic
stale angina may enefit from the addition of an angiotensin+
converting enzyme (5C*) inhiitor&
Common diagnostic tests for a patient ,ith a history of C5= or C5= include a chest
)+ray, a 1"+lead *CA, laoratory tests (e&g&, lipid profile)! nuclear imaging! e)ercise
stress testing, and coronary angiography&
AC5, C$-$NA-6 S6ND-$M
Acute coronar. s.ndrome (5CB) develops ,hen ischemia is prolonged and not
immediately reversile& 5CB encompasses the spectrum of unstale angina, nonNBT+
segment+elevation myocardial infarction (NBT*:.), and BT+segment+elevation
myocardial infarction (BT*:.)&
5CB is associated ,ith deterioration of a once stale atherosclerotic pla<ue& This
unstale lesion may e partially occluded y a thromus (manifesting as 45 or
NBT*:.) or totally occluded y a thromus (manifesting as BT*:.)&
5nstable angina (45) is chest pain that is ne, in onset, occurs at rest, or has a
,orsening pattern& 45 is unpredictale and represents an emergency&
M.ocardial infarction %M'& occurs as a result of sustained ischemia, causing
irreversile myocardial cell death& *ighty percent to E8K of all :.s are due to the
development of a thromus that halts perfusion to the myocardium distal to the
occlusion& Contractile function of the heart stops in the infracted area(s)&
1+18$
Key Points
o Cardiac cells can ,ithstand ischemic conditions for appro)imately "8
minutes& .t ta'es appro)imately % to D hours for the entire thic'ness of the
heart muscle to infarct&
o .nfarctions are descried ased on the location of damage (e&g&, anterior,
inferior, lateral, or posterior ,all infarction)&
o Bevere, immoilizing chest pain not relieved y rest, position change, or
nitrate administration is the hallmar' of an :.& The pain is usually descried
as a heaviness, pressure, tightness, urning, constriction, or crushing&
o Complications after :.
The most common complication after an :. is dysrhythmias, and
dysrhythmias are the most common cause of death in patients in the
prehospital period&
>@ is a complication that occurs ,hen the pumping po,er of the heart
has diminished&
Cardiogenic shoc' occurs ,hen inade<uate o)ygen and nutrients are
supplied to the tissues ecause of severe left ventricular failure& -hen
it occurs, it has a high mortality rate&
Papillary muscle dysfunction may occur if the infarcted area includes
or is ad#acent to the papillary muscle that attaches to the mitral valve&
Papillary muscle dysfunction causes mitral valve regurgitation and is
detected y a systolic murmur at the cardiac ape) radiating to,ard the
a)illa&
Papillary muscle rupture is a rare ut life+threatening complication that
causes massive mitral valve regurgitation, resulting in dyspnea,
pulmonary edema, and decreased C;&
3entricular aneurysm results ,hen the infarcted myocardial ,all
ecomes thinned and ulges out during contraction&
Pericarditis may occur " to $ days after an acute :. as a common
complication of the infarction&
Primary diagnostic studies used to determine ,hether a person has 45 or an :.
include an *CA and serum cardiac mar'ers&
Drug ,hera".
.nitial management of the patient ,ith chest pain includes aspirin, sulingual
nitroglycerin, morphine sulfate for pain unrelieved y nitroglycerin, and o)ygen&
.3 nitroglycerin, aspirin, +adrenergic loc'ers, and systemic anticoagulation ,ith
either lo, molecular ,eight heparin given sucutaneously or .3 unfractionated
heparin (4>) are the initial drug treatments of choice for 5CB&
.3 antiplatelet agents (e&g&, glycoprotein ..1...a inhiitor) may also e used if
percutaneous coronary intervention (PC.) is anticipated&
5C* inhiitors help prevent ventricular remodeling and prevent or slo, the
progression of >@& They are recommended follo,ing anterior ,all :.s or :.s that
result in decreased left ventricular function (e#ection fraction H*@I less than %8K) or
pulmonary congestion and should e continued indefinitely& @or patients ,ho cannot
tolerate 5C* inhiitors, angiotensin receptor loc'ers should e considered&
1+18%
Key Points
Calcium channel loc'ers or long+acting nitrates can e added if the patient is already
on ade<uate doses of +adrenergic loc'ers or cannot tolerate +adrenergic loc'ers,
or has Prinzmetal(s angina&
Btool softeners are given to facilitate and promote the comfort of o,el evacuation&
This prevents straining and the resultant vagal stimulation from the 3alsalva
maneuver& 3agal stimulation produces radycardia and can provo'e dysrhythmias&
.nitially, patients may e NP; (nothing y mouth) e)cept for sips of ,ater until stale
(e&g&, pain free, nausea resolved)& =iet is advanced as tolerated to a lo,+salt, lo,+
saturated+fat, and lo,+cholesterol diet&
Surgical ,hera".
Coronar. re!asculari#ation ,ith coronary artery ypass graft (C56A) surgery is
recommended for patients ,ho (1) fail medical management, (") have left main
coronary artery or three+vessel disease, ($) are not candidates for PC. (e&g&, lesions
are long or difficult to access), or (%) have failed PC. ,ith ongoing chest pain&
:inimally invasive direct coronary artery ypass (:.=C56) surgery can e used for
patients ,ith single+vessel disease&
The off+pump coronary artery ypass (;PC56) procedure uses full or partial
sternotomy to enale access to all coronary vessels& ;PC56 is also performed on a
eating heart using mechanical stailizers and ,ithout cardiopulmonary ypass
(CP6)&
Transmyocardial laser revascularization (T:?) is an indirect revascularization
procedure used for patients ,ith advanced C5= ,ho are not candidates for traditional
ypass surgery and ,ho have persistent angina after ma)imum medical therapy&
Nursing Management: Chronic Stable Angina and Acute Coronar. S.ndrome
The follo,ing nursing measures should e instituted for a patient e)periencing
angina: (1) administration of supplemental o)ygen, (") determination of vital signs,
($) 1"+lead *CA, (%) prompt pain relief first ,ith a nitrate follo,ed y an opioid
analgesic if needed, (C) auscultation of heart sounds, and (D) comfortale positioning
of the patient&
.nitial treatment of a patient ,ith 5CB includes pain assessment and relief,
physiologic monitoring, promotion of rest and comfort, alleviation of stress and
an)iety, and understanding of the patient(s emotional and ehavioral reactions&
o Nitroglycerin, morphine sulfate, and supplemental o)ygen should e provided
as needed to eliminate or reduce chest pain&
o Continuous *CA monitoring is initiated and maintained throughout the
hospitalization&
o @re<uent vital signs, inta'e and output (at least once a shift), and physical
assessment should e done to detect deviations from the patient(s aseline
parameters& .ncluded is an assessment of lung sounds and heart sounds and
inspection for evidence of early >@ (e&g&, dyspnea, tachycardia, pulmonary
congestion, distended nec' veins)&
6ed rest may e ordered for the first fe, days after an :. involving a large portion of
the ventricle& 5 patient ,ith an uncomplicated :. (e&g&, angina resolved, no signs of
1+18C
Key Points
complications) may rest in a chair ,ithin F to 1" hours after the event& The use of a
commode or edpan is ased on patient preference&
.t is important to plan nursing and therapeutic actions to ensure ade<uate rest periods
free from interruption& Comfort measures that can promote rest include fre<uent oral
care, ade<uate ,armth, a <uiet atmosphere, use of rela)ation therapy (e&g&, guided
imagery), and assurance that personnel are neary and responsive to the patient(s
needs&
Cardiac ,or'load is gradually increased through more demanding physical tas's so
that the patient can achieve a discharge activity level ade<uate for home care&
5n)iety is present in all patients ,ith 5CB to various degrees& The nurse(s role is to
identify the source of an)iety and assist the patient in reducing it&
The emotional and ehavioral reactions of a patient are varied and fre<uently follo, a
predictale response pattern& The role of the nurse is to understand ,hat the patient is
currently e)periencing, to assist the patient in testing reality, and to support the use of
constructive coping styles& =enial may e a positive coping style in the early phase of
recovery from 5CB&
The ma#or nursing responsiilities for the care of the patient follo,ing PC. involves
monitoring for signs of recurrent angina! fre<uent assessment of vital signs, including
>? and rhythm! evaluation of the groin site for signs of leeding! and maintenance of
ed rest per institution policy&
@or patients having C56A surgery, care is provided in the intensive care unit for the
first "% to $D hours, ,here ongoing monitoring of the patient(s *CA and
hemodynamic status is critical&
Cardiac rehailitation restores a person to an optimal state of function in si) areas:
physiologic, psychologic, mental, spiritual, economic, and vocational&
Patient teaching egins ,ith the *= nurse and progresses through the staff nurse to
the community health nurse& Careful assessment of the patient(s learning needs helps
the nurse set goals and o#ectives that are realistic&
Physical activity is necessary for optimal physiologic functioning and psychologic
,ell+eing& 5 regular schedule of physical activity, even after many years of
sedentary living, is eneficial&
o 5ctivity level is gradually increased so that y the time of discharge the
patient can tolerate moderate+energy activities of $ to D :*Ts&
o Patients ,ith 45 that has resolved or an uncomplicated :. are in the hospital
for appro)imately $ to % days and y day " can amulate in the hall,ay and
egin limited stair climing (e&g&, three to four steps)&
o 6ecause of the short hospital stay, it is critical to give the patient specific
guidelines for physical activity so that overe)ertion ,ill not occur& Patients
should /listen to ,hat the ody is saying&0
o Patients should e taught to chec' their pulse rate and the parameters ,ithin
,hich to e)ercise& The more important factor is the patient(s response to
physical activity in terms of symptoms rather than asolute >?, especially
since many patients are on +adrenergic loc'ers and may not e ale to reach
a target >?&
:any patients ,ill e referred to an outpatient or home+ased cardiac rehailitation
1+18D
Key Points
program& :aintaining contact ,ith the patient appears to e the 'ey to the success of
these programs&
;ne factor that has een lin'ed to poor adherence to a physical activity program after
:. is depression& 6oth men and ,omen e)perience mild to moderate depression post+
:. that should resolve in 1 to % months&
Be)ual counseling for cardiac patients and their partners should e provided& The
patient(s concern aout resumption of se)ual activity after hospitalization for 5CB
often produces more stress than the physiologic act itself&
o 6efore the nurse provides guidelines on resumption of se)ual activity, it is
important to 'no, the physiologic status of the patient, the physiologic effects
of se)ual activity, and the psychologic effects of having a heart attac'& Be)ual
activity for middle+aged men and ,omen ,ith their usual partners is no more
strenuous than climing t,o flights of stairs&
o The inaility to perform se)ually after :. is common and se)ual dysfunction
usually disappears after several attempts&
o Patients should 'no, that drugs used for erectile dysfunction should not e
used ,ith nitrates as severe hypotension and even death have een reported&
o Typically, it is safe to resume se)ual activity 9 to 18 days after an
uncomplicated :.&
S5DDN CA-D'AC DA,)
Sudden cardiac death (BC=) is une)pected death from cardiac causes&
C5= is the most common cause of BC= and accounts for F8K of all BC=s&
BC= involves an arupt disruption in cardiac function, producing an arupt loss of
cardiac output and cereral lood flo,& =eath usually occurs ,ithin 1 hour of the
onset of acute symptoms (e&g&, angina, palpitations)&
The ma#ority of cases of BC= are caused y acute ventricular dysrhythmias (e&g&,
ventricular tachycardia, ventricular firillation)&
Persons ,ho e)perience BC= as a result of C5= fall into t,o groups: (1) those ,ho
had an acute :. and (") those ,ho did not have an acute :.& The latter group
accounts for the ma#ority of cases of BC=& .n this instance, victims usually have no
,arning signs or symptoms&
Patients ,ho survive are at ris' for recurrent BC= due to the continued electrical
instaility of the myocardium that caused the initial event to occur&
?is' factors for BC= include left ventricular dysfunction (*@ less than $8K),
ventricular dysrhythmias follo,ing :., male gender (especially 5frican 5merican
men), family history of premature atherosclerosis, toacco use, diaetes mellitus,
hypercholesterolemia, hypertension, and cardiomyopathy&
:ost BC= patients have a lethal ventricular dysrhythmia and re<uire "%+hour >olter
monitoring or other type of event recorder, e)ercise stress testing, signal+averaged
*CA, and electrophysiologic study (*PB)&
The most common approach to preventing a recurrence and improving survival is the
use of an implantale cardioverter+defirillator (.C=)&
=rug therapy may e used in con#unction ,ith an .C= to decrease episodes of
ventricular dysrhythmias&
1+189
Key Points
Burvivors of BC= develop a /time om0 mentality, fearing the recurrence of
cardiopulmonary arrest& They and their families may ecome an)ious, angry, and
depressed&
Patients and families also may need to deal ,ith additional issues such as possile
driving restrictions and change in occupation& The grief response varies among BC=
survivors and their families&
th
edition
Key Points
1+18F
Key Points
Chapter $C: Nursing :anagement: >eart @ailure
,'$L$46 AND PA,)$P)6S'$L$46
)eart failure (>@) is an anormal clinical condition involving impaired cardiac pumping
that results in the characteristic pathophysiologic changes of vasoconstriction and fluid
retention&
>@ is characterized y ventricular dysfunction, reduced e)ercise tolerance, diminished
<uality of life, and shortened life e)pectancy&
?is' factors include coronary artery disease (C5=) and advancing age& >ypertension,
diaetes, cigarette smo'ing, oesity, and high serum cholesterol also contriute to the
development of >@&
CLASS'+'CA,'$N
>eart failure is classified as systolic or diastolic failure&
o S.stolic failure, the most common cause of >@, results from an inaility of the
heart to pump lood&
o Diastolic failure is an impaired aility of the ventricles to rela) and fill during
diastole& =ecreased filling of the ventricles ,ill result in decreased stro'e volume
and cardiac output (C;)&
CL'N'CAL MAN'+S,A,'$NS
>@ can have an arupt onset or it can e an insidious process resulting from slo,,
progressive changes& Compensatory mechanisms are activated to maintain ade<uate C;&
To maintain alance in >@, several counter regulatory processes are activated, including
the production of hormones from the heart muscle to promote vasodilation&
Cardiac compensation occurs ,hen compensatory mechanisms succeed in maintaining an
ade<uate C; that is needed for tissue perfusion&
Cardiac decompensation occurs ,hen these mechanisms can no longer maintain ade<uate
C; and inade<uate tissue perfusion results&
The most common form of >@ is left+sided failure from left ventricular dysfunction& 6lood
ac's up into the left atrium and into the pulmonary veins causing pulmonary congestion
and edema& >@ is usually manifested y iventricular failure&
5cute decompensated heart failure (5=>@) typically manifests as "ulmonar. edema, an
acute, life+threatening situation&
Clinical manifestations of chronic >@ depend on the patient(s age and the underlying type
and e)tent of heart disease& Common symptoms include fatigue, dyspnea, tachycardia,
1+18E
Key Points
edema, and unusual ehavior&
Pleural effusion, atrial firillation, thromus formation, renal insufficiency, and
hepatomegaly are all complications of >@&
D'A4N$S,'C S,5D'S
The primary goal in diagnosis of >@ is to determine the underlying etiology of >@&
o 5 thorough history, physical e)amination, chest )+ray, electrocardiogram (*CA),
laoratory data (cardiac enzymes, +type natriuretic protein (6NP), serum
chemistries, liver function studies, thyroid function studies, and complete lood
count), hemodynamic assessment, echocardiogram, stress testing, and cardiac
catheterization are performed&
N5-S'N4 AND C$LLA/$-A,'2 MANA4MN,: AD)+ AND P5LM$NA-6
DMA
The goals of therapy for oth 5=>@ and chronic >@ are to decrease patient symptoms,
reverse ventricular remodeling, improve <uality of life, and decrease mortality and
moridity&
Treatment strategies should include the follo,ing:
o =ecreasing intravascular volume ,ith the use of diuretics to reduce venous return
and preload&
o =ecreasing venous return (preload) to reduce the amount of volume returned to
the 23 during diastole&
o =ecreasing afterload (the resistance against ,hich the 23 must pump) improves
C; and decreases pulmonary congestion&
o Aas e)change is improved y the administration of .3 morphine sulfate and
supplemental o)ygen&
o .notropic therapy and hemodynamic monitoring may e needed in patients ,ho
do not respond to conventional pharmacotherapy (e&g&, diuretics, vasodilators,
morphine sulfate)&
o ?eduction of an)iety is an important nursing function, since an)iety may increase
the BNB response and further increase myocardial ,or'load&
C$LLA/$-A,'2 CA-: C)-$N'C )A-, +A'L5-
The main goal in the treatment of chronic >@ is to treat the underlying cause and
contriuting factors, ma)imize C;, provide treatment to alleviate symptoms, improve
ventricular function, improve <uality of life, preserve target organ function, and improve
mortality and moridity&
5dministration of o)ygen improves saturation and assists greatly in meeting tissue
o)ygen needs and helps relieve dyspnea and fatigue&
Physical and emotional rest allo,s the patient to conserve energy and decreases the need
for additional o)ygen& The degree of rest recommended depends on the severity of >@&
1+118
Key Points
Nonpharmacologic therapies used in the management of >@ patients ,ho are receiving
ma)imum medical therapy, continue to have NW>5 @unctional Class ... or .3
symptoms, and have a ,idened P?B interval include the follo,ing:
o Cardiac resynchronization therapy (C?T) or iventricular pacing& .nvolves pacing
oth the right and left ventricles to achieve coordination of right and left ventricle
contractility&
o Cardiac transplantation& Btrict criteria are used to select the fe, patients ,ith
advanced >@ ,ho can even hope to receive a transplanted heart&
o .ntraaortic alloon pump (.56P) therapy& The .56P can e useful in the
hemodynamically unstale >@ patient ecause it decreases B3?, P5-P, and P5P
as much as "CK, leading to improved C;& >o,ever, the limitations of ed rest,
infection, and vascular complications preclude long+term use&
o 3entricular assist devices (35=s)& 35=s provide highly effective long+term
support for up to " years and have ecome standard care in many heart transplant
centers& 35=s are used as a ridge to transplantation&
o =estination therapy& The use of a permanent, implantale 35=, 'no,n as
destination therapy, is an option for patients ,ith advanced NW>5 @unctional
Class .3 >@ ,ho are not candidates for heart transplantation&
Aeneral therapeutic o#ectives for drug management of chronic >@ include: (1)
identification of the type of >@ and underlying causes, (") correction of sodium and
,ater retention and volume overload, ($) reduction of cardiac ,or'load, (%) improvement
of myocardial contractility, and (C) control of precipitating and complicating factors&
o =iuretics are used in >@ to moilize edematous fluid, reduce pulmonary venous
pressure, and reduce preload&
Thiazide diuretics may e the first choice in chronic >@ ecause of their
convenience, safety, lo, cost, and effectiveness& They are particularly
useful in treating edema secondary to >@ and in controlling hypertension&
2oop diuretics are potent diuretics& These drugs act on the ascending loop
of >enle to promote sodium, chloride, and ,ater e)cretion& Prolems in
using loop diuretics include reduction in serum potassium levels,
ototo)icity, and possile allergic reaction in the patient ,ho is sensitive to
sulfa+type drugs&
Bpironolactone (5ldactone) is an ine)pensive, potassium+sparing diuretic
that promotes sodium and ,ater e)cretion ut loc's potassium e)cretion&
This aldosterone receptor antagonist also loc's the harmful
neurohormonal effects of aldosterone on the heart lood vessels&
Bpironolactone adds to the enefits of angiotensin+converting
enzyme (5C*) inhiitors, and is appropriate to use ,hile renal
function is ade<uate&
Bpironolactone may also e used in con#unction ,ith other
diuretics, such as furosemide&
3asodilator drugs have een sho,n to improve survival in >@& The goals
of vasodilator therapy in the treatment of >@ include (1) increasing venous
1+111
Key Points
capacity, (") improving *@ through improved ventricular contraction, ($)
slo,ing the process of ventricular dysfunction, (%) decreasing heart size,
(C) avoiding stimulation of the neurohormonal responses initiated y the
compensatory mechanisms of >@, and (D) enhancing neurohormonal
loc'ade&
5C* inhiitors (e&g&, captopril HCapotenI, enazepril H2otensinI,
enalapril H3asotecI) are useful in oth systolic and diastolic >@,
and they are the first+line therapy in the treatment of chronic >@&
5ngiotensin .. receptor loc'ers (e&g&, losartan HCozaarI, valsartan
H=iovanI) may e used in patients ,ho are 5C* inhiitor
intolerant&
Nitrates are used to treat >@ y acting directly on the smooth
muscle of the vessel ,all& :a#or effects include a decrease in
preload and vasodilation of coronary arteries&
Nesiritide, a synthetic form of human 6NP, eing studied for its
use in the ongoing treatment of patients ,ith chronic >@&
+5drenegic loc'ers, specifically carvedilol (Coreg) and
metoprolol (Toprol+M2), have improved survival of patients ,ith
>@&
Positive inotropic agents improve cardiac contractility and C;, decrease
23 diastolic pressure, and decrease B3?&
=igitalis glycosides He&g&, digo)in (2ano)in)I remain the mainstay
in the treatment of >@, ho,ever, they have not een sho,n to
prolong life&
Calcium sensitizers are novel positive inotropic agents in the
treatment of >@& They improve cardiac performance y interacting
directly ,ith contractile proteins ,ithout affecting intracellular
calcium concentrations or increasing myocardial o)ygen demand&
6i=il, a comination drug containing isosoride dinitrate and
hydralazine, approved only for the treatment of >@ in 5frican
5mericans ,ho are already eing treated ,ith standard therapy&
o =iet education and ,eight management are critical to the patient(s control of
chronic >@&
=iet and ,eight management recommendations must e individualized
and culturally sensitive if the necessary changes are to e realized&
5 detailed diet history should e otained and should include the
sociocultural value of food to the patient&
The =ietary 5pproaches to Btop >ypertension (=5B>) diet is effective as
a first+line therapy for many individuals ,ith hypertension, and this diet is
,idely used for the patient ,ith >@&
The edema of chronic >@ is often treated y dietary restriction of sodium&
@luid restrictions are not commonly prescried for the patient ,ith mild to
moderate >@& >o,ever, in moderate to severe >@ and renal insufficiency,
fluid restrictions are usually implemented&
Patients should ,eigh themselves daily to monitor fluid retention, as ,ell
1+11"
Key Points
as ,eight reduction& .f a patient e)periences a ,eight gain of $ l (1&% 'g)
over " days or a $+ to C+l ("&$ 'g) gain over a ,ee', the primary care
provider should e called&
N5-S'N4 MANA4MN,: C)-$N'C )A-, +A'L5-
The overall goals for the patient ,ith >@ include (1) a decrease in symptoms (e&g&,
shortness of reath, fatigue), (") a decrease in peripheral edema, ($) an increase in
e)ercise tolerance, (%) compliance ,ith the medical regimen, and (C) no complications
related to >@&
Treatment or control of underlying heart disease is 'ey to preventing >@ and episodes of
5=>@&
o @or e)ample, valve replacement should e planned efore lung congestion
develops, and early and continued treatment of C5= and hypertension is critical&
o The use of antidysrhythmic agents or pacema'ers is indicated for people ,ith
serious dysrhythmias or conduction disturances&
Patients ,ith >@ should e counseled to otain vaccinations against the flu and
pneumonia&
Preventive care should focus on slo,ing the progression of the disease&
o Patient teaching must include information on medications, diet, and e)ercise
regimens& *)ercise training (e&g&, cardiac rehailitation) does improve symptoms
of chronic >@ ut is often underprescried&
o >ome nursing care for follo,+up care and to monitor the patient(s response to
treatment may e re<uired&
Buccessful >@ management is dependent on the follo,ing principles: (1) >@ is a
progressive disease, and treatment plans are estalished ,ith <uality+of+life goals! (")
symptom management is controlled y the patient ,ith self+management tools (e&g&, daily
,eights, drug regimens, diet and e)ercise plans)! ($) salt and ,ater must e restricted! (%)
energy must e conserved! and (C) support systems are essential to the success of the
entire treatment plan&
.mportant nursing responsiilities in the care of a patient ,ith >@ include (1) teaching the
patient aout the physiologic changes that have occurred, (") assisting the patient to adapt
to oth the physiologic and psychologic changes, and ($) integrating the patient and the
patient(s family or support system in the overall care plan&
o :any patients ,ith >@ are at high ris' for an)iety and depression, and ma#or
depression is more prevalent in female patients and patients less than D8 years of
age&
o Patients ,ith >@ can live productive lives ,ith chronic >@&
o *ffective home health care can prevent or limit future hospitalization& :anaging
>@ patients out of the hospital is a priority of care&
o Patients ,ith >@ ,ill ta'e medication for the rest of their lives& This can ecome
1+11$
Key Points
difficult ecause a patient may e asymptomatic ,hen >@ is under control&
o Patients should e taught to evaluate the action of the prescried drugs and to
recognize the manifestations of drug to)icity&
Patients should e taught ho, to ta'e their pulse rate and to 'no, under
,hat circumstances drugs, especially digitalis and +adrenergic loc'ers,
should e ,ithheld and a health care provider consulted&
.t may e appropriate to instruct patients in home 6P monitoring,
especially for those >@ patients ,ith hypertension&
Patients should e taught the symptoms of hypo+ and hyper'alemia if
diuretics that deplete or spare potassium are eing ta'en& @re<uently the
patient ,ho is ta'ing thiazide or loop diuretics is given supplemental
potassium&
o The nurse, physical therapist, or occupational therapist should instruct the patient
in energy+conserving and energy+efficient ehaviors after an evaluation of daily
activities has een done&
Patients may need a prescription for rest after an activity& :any hard+
driving persons need the /permission0 to not feel /lazy&0
Bometimes an activity that the patient en#oys may need to e eliminated&
.n such situations the patient should e helped to e)plore alternative
activities that cause less physical and cardiac stress&
The physical environment may re<uire modification in situations in ,hich
there is an increased cardiac ,or'load demand (e&g&, fre<uent climing of
stairs)& The nurse can help the patient identify areas ,here outside
assistance can e otained&
o >ome health nursing is an essential component in the care of the >@ patient and
family&
>ome health nurses conduct fre<uent physical assessments, including vital
signs and ,eight&
Protocols enale the nurse and patient to identify prolems, such as
evidence of ,orsening >@, and institute interventions to prevent
hospitalization& This may include altering medications and initiating fluid
restrictions&
CA-D'AC ,-ANSPLAN,A,'$N
Cardiac trans"lantation has ecome the treatment of choice for patients ,ith refractory
end+stage >@, cardiomyopathy, and inoperale C5=&
;nce a patient meets the criteria for cardiac transplantation, the goal of the evaluation
process is to identify patients ,ho ,ould most enefit from a ne, heart&
o 5fter a complete physical e)amination and diagnostic ,or'up, the patient and
family then undergo a comprehensive psychologic profile&
o The comple)ity of the transplant process may e over,helming to a patient ,ith
inade<uate support systems and a poor understanding of the lifestyle changes
re<uired after transplant&
1+11%
Key Points
;nce a patient is accepted as a transplant candidate (this may happen rapidly during an
acute illness or over a longer period), he or she is placed on a transplant list&
o Btale patients ,ait at home and receive ongoing medical care&
o 4nstale patients may re<uire hospitalization for more intensive therapy&
o The overall ,aiting period for a transplant is long, and many patients die ,hile
,aiting for a transplant&
:ost donor hearts are otained at sites distant from the institution performing the
transplant& The ma)imum acceptale time from harvesting the donor heart to
transplantation is % to D hours&
The heart recipient is prepared for surgery, and cardiopulmonary ypass is used&
o The surgical procedure involves removing the recipient(s heart, e)cept for the
posterior right and left atrial ,alls and their venous connections&
o The recipient(s heart is then replaced ,ith the donor heart& Care is ta'en to
preserve the integrity of the donor sinoatrial (B5) node so that a sinus rhythm may
e achieved postoperatively&
o .mmunosuppressive therapy usually egins in the operating room&

*ndomyocardial iopsies are typically otained from the right ventricle (via the right
internal #ugular vein) on a ,ee'ly asis for the first month, monthly for the follo,ing D
months, and yearly thereafter to detect re#ection&
o The >eartsreath test is used along ,ith endomyocardial iopsy to assess organ
re#ection in heart transplant patients&
The test ,or's y measuring the amount of methylated al'anes (natural
chemicals found in the reath and air) in a patient[s reath& The value is
compared ,ith the results of a iopsy performed during the previous
month to measure the proaility of the transplanted heart eing re#ected&
The >eartsreath test is used in the first year follo,ing heart
transplantation and along ,ith the results of a heart iopsy to help guide
short+term and long+term medical care of heart transplant patients&
The test helps to separate less severe organ re#ection (grades 8, 1, and ")
from more severe re#ection (grade $)&
o Peripheral lood T lymphocyte monitoring is also done to assess the recipient(s
immune status&
Nursing management throughout the posttransplant period focuses on promoting patient
adaptation to the transplant process, monitoring cardiac function, managing lifestyle
changes, and providing ongoing teaching of the patient and family&
Beveral devices are availale as a ridge to transplantation
o The 56C888 Circulatory Bupport Bystem and the 63B C888 6iventricular
Bupport Bystem provide temporary support for one or oth sides of the heart in
circumstances in ,hich the heart has failed ut has the potential to recover (e&g&,
reversile >@, myocarditis, and acute :.)&
1+11C
Key Points
o The Thoratec 3entricular 5ssist =evice (35=) system can support one or oth
ventricles, and it has een approved as a ridging device for transplantation and
for recovery of the heart after cardiac surgery&
A-,'+'C'AL )A-,
The lac' of availale transplant hearts and the increasing numer of patients in need have
triggered the movement to develop artificial hearts&
o T,o implantale artificial hearts, the Cardio-est Total 5rtificial >eart and the
5ioCor .mplantale ?eplacement >eart, have een developed&
o 6oth are designed ,ith materials that minimize coagulation and contain motor+
driven pumping systems (artificial ventricles) that operate on oth internal and
e)ternal atteries&
5n electronic pac'age in the adomen monitors the system, including
ad#usting the heart rate ased on the patient(s activity&
5n e)ternal attery pac' allo,s for periods of independence from the
console&
The total artificial heart re<uires no immunosuppression and may hold
promise for short+term survival in patients ,ith end+stage >@&
th
edition
Key Points
Chapter $D: Nursing :anagement: =ysrhythmias
The aility to recognize normal and anormal cardiac rhythms, called d.srh.thmias, is
an essential s'ill for the nurse&
@our properties of cardiac cells (automaticity, e)citaility, conductivity, and contractility)
enale the conduction system to initiate an electrical impulse, transmit it through the
cardiac tissue, and stimulate the myocardial tissue to contract&
o 5 normal cardiac impulse egins in the sinoatrial (B5) node in the upper right
atrium&
o The signal is transmitted over the atrial myocardium via 6achmann(s undle and
internodal path,ays, causing atrial contraction&
o The impulse then travels to the atrioventricular (53) node through the undle of
>is and do,n the left and right undle ranches, ending in the Pur'in#e fiers,
,hich transmit the impulse to the ventricles, resulting in ventricular contraction&
1+11D
Key Points
The autonomic nervous system plays an important role in the rate of impulse formation,
the speed of conduction, and the strength of cardiac contraction&
o Components of the autonomic nervous system that affect the heart are the right
and left vagus nerve fiers of the parasympathetic nervous system and fiers of
the sympathetic nervous system&
C4 M$N',$-'N4
The electrocardiogram (*CA) is a graphic tracing of the electrical impulses produced in
the heart&
*CA ,aveforms are produced y the movement of charged ions across the
semipermeale memranes of myocardial cells&
There are 1" recording leads in the standard *CA&
o Bi) of the 1" *CA leads measure electrical forces in the frontal plane (leads ., ..,
..., a3?, a32, and a3@)&
o The remaining si) leads (3
1
through 3
D
) measure the electrical forces in the
horizontal plane (precordial leads)&
o The 1"+lead *CA may sho, changes that are indicative of structural changes,
damage such as ischemia or infarction, electrolyte imalance, dysrhythmias, or
drug to)icity&
Continuous *CA monitoring is done using leads .., 3
1
, and :C2
1
&
o :C2
1
is a modified chest lead that is similar to 3
1
and is used ,hen only three
leads are availale for monitoring&
o :onitoring leads should e selected ased on the patient(s clinical situation&
The *CA can e visualized continuously on a monitor oscilloscope, and a recording of
the *CA (i&e&, rhythm strip) can e otained on *CA paper attached to the monitor&
*CA leads are attached to the patient(s chest ,all via an electrode pad fi)ed ,ith
electrical conductive paste&
,elemetr. monitoring involves the oservation of a patient(s >? and rhythm to rapidly
diagnose dysrhythmias, ischemia, or infarction&
Normal sinus rhythm refers to a rhythm that originates in the B5 node and follo,s the
normal conduction pattern of the cardiac cycle&
o The P ,ave represents the depolarization of the atria (passage of an electrical
impulse through the atria), causing atrial contraction&
o The P? interval represents the time period for the impulse to spread through the
atria, 53 node, undle of >is, and Pur'in#e fiers&
o The P?B comple) represents depolarization of the ventricles (ventricular
contraction), and the P?B interval represents the time it ta'es for depolarization&
o The BT segment represents the time et,een ventricular depolarization and
1+119
Key Points
repolarization& This segment should e flat or isoelectric and represents the
asence of any electrical activity et,een these t,o events&
o The T ,ave represents repolarization of the ventricles&
o The PT interval represents the total time for depolarization and repolarization of
the ventricles&
MC)AN'SMS $+ D6S-)6,)M'AS
Normally the main pacema'er of the heart is the B5 node, ,hich spontaneously
discharges D8 to 188 times per minute& =isorders of impulse formation can cause
dysrhythmias&
5 pacema'er from another site can lead to dysrhythmias and may e discharged in a
numer of ,ays&
o Becondary pacema'ers may originate from the 53 node or >is+Pur'in#e system&
o Becondary pacema'ers can originate ,hen they discharge more rapidly than the
normal pacema'er of the B5 node&
o Triggered eats (early or late) may come from an ectopic focus (area outside the
normal conduction path,ay) in the atria, 53 node, or ventricles&
2AL5A,'$N $+ D6S-)6,)M'AS
=ysrhythmias result from various anormalities and disease states, and the cause of a
dysrhythmia influences the treatment&
Beveral diagnostic tests are used to evaluate cardiac dysrhythmias and the effectiveness
of antidysrhythmia drug therapy&
o >olter monitoring records the *CA ,hile the patient is amulatory and
performing daily activities&
o *vent monitors have improved the evaluation of outpatient dysrhythmias&
o Bignal+averaged *CA (B5*CA) is a high+resolution *CA used to identify the
patient at ris' for developing comple) ventricular dysrhythmias&
o *)ercise treadmill testing is used for evaluation of cardiac rhythm response to
e)ercise&
o 5n electrophysiologic study (*PB) identifies different mechanisms of
tachydysrhythmias, heart loc's, radydysrhythmias, and causes of syncope&
,6PS $+ D6S-)6,)M'AS
$inus %raycaria has a normal sinus rhythm, ut the B5 node fires at a rate less than D8
eats1minute and is referred to as asolute radycardia&
o Clinical associations& Binus radycardia may e a normal sinus rhythm (e&g&, in
aeroically trained athletes), and it may occur in response to carotid sinus
massage, 3alsalva maneuver, hypothermia, and administration of
parasympathomimetic drugs&
o =isease states associated ,ith sinus radycardia are hypothyroidism, increased
intracranial pressure, ostructive #aundice, and inferior ,all myocardial infarction
(:.)&
1+11F
Key Points
o Treatment consists of administration of atropine (an anticholinergic drug) for the
patient ,ith symptoms& Pacema'er therapy may e re<uired&
$inus tachycaria has a normal sinus rhythm, ut the B5 node fires at a rate greater than
188 eats1minute as a result of vagal inhiition or sympathetic stimulation&
o Clinical associations& Binus tachycardia is associated ,ith physiologic and
psychologic stressors such as e)ercise, fever, pain, hypotension, hypovolemia,
anemia, hypo)ia, hypoglycemia, myocardial ischemia, heart failure (>@),
hyperthyroidism, an)iety, and fear& .t can also e an effect of certain drugs&
o 5ngina may result from sinus tachycardia due to the increased myocardial o)ygen
consumption that is associated ,ith an increased >?&
o Treatment is ased on the underlying cause& @or e)ample, if a patient is
e)periencing tachycardia from pain, tachycardia should resolve ,ith effective
pain management&
Premature atrial contraction (P5C) is a contraction originating from an ectopic focus in
the atrium in a location other than the sinus node& 5 P5C may e stopped (nonconducted
P5C), delayed (lengthened P? interval), or conducted normally through the 53 node&
o Clinical associations& P5Cs can result from emotional stress or physical fatigue!
from the use of caffeine, toacco, or alcohol! from hypo)ia or electrolyte
imalances! and from disease states such as hyperthyroidism, chronic ostructive
pulmonary disease (C;P=), and heart disease including coronary artery disease
(C5=) and valvular disease&
o .n healthy persons, isolated P5Cs are not significant& .n persons ,ith heart
disease, fre<uent P5Cs may indicate enhanced automaticit. of the atria or a
reentry mechanism and may ,arn of or initiate more serious dysrhythmias&
o Treatment depends on the patient(s symptoms& @or e)ample, ,ithdra,al of
sources of stimulation such as caffeine or sympathomimetic drugs may e
,arranted&
Paro&ysmal supra'entricular tachycaria (PB3T) is a dysrhythmia originating in an
ectopic focus any,here aove the ifurcation of the undle of >is&
o PB3T occurs ecause of a reentrant phenomenon (ree)citation of the atria ,hen
there is a one+,ay loc') and is usually triggered y a P5C&
o .n the normal heart, PB3T is associated ,ith overe)ertion, emotional stress, deep
inspiration, and stimulants such as caffeine and toacco& .t is also associated ,ith
rheumatic heart disease, digitalis to)icity, C5=, and cor pulmonale&
o Prolonged PB3T ,ith >? greater than 1F8 eats1minute may precipitate a
decreased C;, resulting in hypotension, dyspnea, and angina&
o Treatment for PB3T includes vagal stimulation and drug therapy (i&e&, .3
adenosine)&
Atrial flutter is an atrial tachydysrhythmia identified y recurring, regular, sa,tooth+
shaped flutter ,aves that originate from a single ectopic focus in the right atrium&
o 5trial flutter is associated ,ith C5=, hypertension, mitral valve disorders,
1+11E
Key Points
pulmonary emolus, chronic lung disease, cor pulmonale, cardiomyopathy,
hyperthyroidism, and the use of drugs such as digo)in, <uinidine, and
epinephrine&
o >igh ventricular rates (over 1881minute) and the loss of the atrial /'ic'0 (atrial
contraction reflected y a sinus P ,ave) can decrease C; and cause serious
conse<uences such as chest pain and >@&
o Patients ,ith atrial flutter are at increased ris' of stro'e ecause of the ris' of
thromus formation in the atria from the stasis of lood&
o The primary goal in treatment of atrial flutter is to slo, the ventricular response
y increasing 53 loc'&
Atrial fi%rillation is characterized y a total disorganization of atrial electrical activity
due to multiple ectopic foci resulting in loss of effective atrial contraction&
o 5trial firillation usually occurs in the patient ,ith underlying heart disease, such
as C5=, rheumatic heart disease, cardiomyopathy, hypertensive heart disease, >@,
and pericarditis& .t can e caused y thyroto)icosis, alcohol into)ication, caffeine
use, electrolyte disturances, stress, and cardiac surgery&
o 5trial firillation can often result in a decrease in C;, and thromi may form in
the atria as a result of lood stasis& 5n emolized clot may develop and pass to the
rain, causing a stro'e&
o The goals of treatment include a decrease in ventricular response and prevention
of cereral emolic events&

(unctional ysrhythmias refer to dysrhythmias that originate in the area of the 53 node,
primarily ecause the B5 node has failed to fire or the signal has een loc'ed& .n this
situation, the 53 node ecomes the pacema'er of the heart&
o \unctional premature eats are treated in a manner similar to that for P5Cs&
o ;ther #unctional dysrhythmias include #unctional escape rhythm, accelerated
#unctional rhythm, and #unctional tachycardia& These dysrhythmias are treated
according to the patient(s tolerance of the rhythm and the patient(s clinical
condition&
o \unctional dysrhythmias are often associated ,ith C5=, >@, cardiomyopathy,
electrolyte imalances, inferior :., and rheumatic heart disease& Certain drugs
(e&g&, digo)in, amphetamines, caffeine, nicotine) can also cause #unctional
dysrhythmias&
o Treatment varies according to the type of #unctional dysrhythmia&
)irst-e*ree A+ %lock is a type of 53 loc' in ,hich every impulse is conducted to the
ventricles ut the duration of 53 conduction is prolonged&
o @irst+degree 53 loc' is associated ,ith :., C5=, rheumatic fever,
hyperthyroidism, vagal stimulation, and drugs such as digo)in, +adrenergic
loc'ers, calcium channel loc'ers, and flecainide&
o @irst+degree 53 loc' is usually not serious ut can e a precursor of higher
degrees of 53 loc'& Patients ,ith first+degree 53 loc' are asymptomatic&
o There is no treatment for first+degree 53 loc'& Patients should continue to e
1+1"8
Key Points
monitored for any ne, changes in heart rhythm&
$econ-e*ree A+ %lock, Type . (:oitz . or -enc'each heart loc') is a gradual
lengthening of the P? interval& .t occurs ecause of a prolonged 53 conduction time until
an atrial impulse is nonconducted and a P?B comple) is loc'ed (missing)&
o Type . 53 loc' may result from use of drugs such as digo)in or +adrenergic
loc'ers& .t may also e associated ,ith C5= and other diseases that can slo, 53
conduction&
o Type . 53 loc' is usually a result of myocardial ischemia or infarction& .t is
almost al,ays transient and is usually ,ell tolerated& >o,ever, it may e a
,arning signal of a more serious 53 conduction disturance&
o .f the patient is symptomatic, atropine is used to increase >?, or a temporary
pacema'er may e needed&
$econ-e*ree A+ %lock, Type .. (:oitz .. heart loc'), involves a P ,ave that is
nonconducted ,ithout progressive antecedent P? lengthening& This almost al,ays occurs
,hen a loc' in one of the undle ranches is present&
o Type .. second+degree 53 loc' is a more serious type of loc' in ,hich a certain
numer of impulses from the B5 node are not conducted to the ventricles&
o Type .. 53 loc' is associated ,ith rheumatic heart disease, C5=, anterior :.,
and digitalis to)icity&
o Type .. 53 loc' often progresses to third+degree 53 loc' and is associated ,ith
a poor prognosis& The reduced >? often results in decreased C; ,ith suse<uent
hypotension and myocardial ischemia&
o Temporary treatment efore the insertion of a permanent pacema'er may e
necessary if the patient ecomes symptomatic (e&g&, hypotension, angina) and
involves the use of a temporary transvenous or transcutaneous pacema'er&
Thir-e*ree A+ %lock, or complete heart loc', constitutes one form of 53 dissociation
in ,hich no impulses from the atria are conducted to the ventricles&
o Third+degree 53 loc' is associated ,ith severe heart disease, including C5=,
:., myocarditis, cardiomyopathy, and some systemic diseases such as
amyloidosis and progressive systemic sclerosis (scleroderma)&
o Third+degree 53 loc' almost al,ays results in reduced C; ,ith suse<uent
ischemia, >@, and shoc'& Byncope from third+degree 53 loc' may result from
severe radycardia or even periods of asystole&
o Treatment& @or symptomatic patients, a transcutaneous pacema'er is used until a
temporary transvenous pacema'er can e inserted&
Premature 'entricular contraction (P3C) is a contraction originating in an ectopic focus
in the ventricles& .t is the premature occurrence of a P?B comple), ,hich is ,ide and
distorted in shape compared ,ith a P?B comple) initiated from the normal conduction
path,ay&
o P3Cs are associated ,ith stimulants such as caffeine, alcohol, nicotine,
aminophylline, epinephrine, isoproterenol, and digo)in& They are also associated
1+1"1
Key Points
,ith electrolyte imalances, hypo)ia, fever, e)ercise, and emotional stress&
=isease states associated ,ith P3Cs include :., mitral valve prolapse, >@, and
C5=&
o P3Cs are usually a enign finding in the patient ,ith a normal heart& .n heart
disease, depending on fre<uency, P3Cs may reduce the C; and precipitate angina
and >@&
o Treatment is often ased on the cause of the P3Cs (e&g&, o)ygen therapy for
hypo)ia, electrolyte replacement)& =rugs that can e considered include +
adrenergic loc'ers, procainamide, amiodarone, or lidocaine (Mylocaine)&

+entricular tachycaria (3T) is a run of three or more P3Cs& .t occurs ,hen an ectopic
focus or foci fire repetitively and the ventricle ta'es control as the pacema'er&
o 3T is a life+threatening dysrhythmia ecause of decreased C; and the possiility
of deterioration to ventricular firillation, ,hich is a lethal dysrhythmia&
o 3T is associated ,ith :., C5=, significant electrolyte imalances,
cardiomyopathy, mitral valve prolapse, long PT syndrome, digitalis to)icity, and
central nervous system disorders&
o 3T can e stale (patient has a pulse) or unstale (patient is pulseless)&
o Treatment& Precipitating causes must e identified and treated (e&g&, electrolyte
imalances, ischemia)&
+entricular fi%rillation (3@) is a severe derangement of the heart rhythm characterized
on *CA y irregular undulations of varying shapes and amplitude& :echanically the
ventricle is simply /<uivering,0 and no effective contraction, and conse<uently no C;,
occurs&
o 3@ occurs in acute :. and myocardial ischemia and in chronic diseases such as
C5= and cardiomyopathy&
o 3@ results in an unresponsive, pulseless, and apneic state& .f not rapidly treated,
the patient ,ill die&
o Treatment consists of immediate initiation of CP? and advanced cardiac life
support (5C2B) measures ,ith the use of defirillation and definitive drug
therapy&
Asystole represents the total asence of ventricular electrical activity& No ventricular
contraction occurs ecause depolarization does not occur&
o 5systole is usually a result of advanced cardiac disease, a severe cardiac
conduction system disturance, or end+stage >@&
o Patients are unresponsive, pulseless, and apneic&
o 5systole is a lethal dysrhythmia that re<uires immediate treatment consisting of
CP? ,ith initiation of 5C2B measures (e&g&, intuation, transcutaneous pacing,
and .3 therapy ,ith epinephrine and atropine)&
Pulseless electrical acti'ity (P*5) descries a situation in ,hich electrical activity can e
oserved on the *CA, ut there is no mechanical activity of the ventricles and the patient
has no pulse&
o Prognosis is poor unless the underlying cause can e identified and <uic'ly
1+1""
Key Points
corrected&
o Treatment egins ,ith CP? follo,ed y intuation and .3 therapy ,ith
epinephrine&
S5DDN CA-D'AC DA,)
Sudden cardiac death (BC=) refers to death from a cardiac cause&
The ma#ority of BC=s result from ventricular dysrhythmias, specifically ventricular
tachycardia or firillation&
P-$D6S-)6,)M'A
5ntidysrhythmia drugs may cause life+threatening dysrhythmias similar to those for ,hich
they are administered& This concept is termed prodysrhythmia&
o The patient ,ho has severe left ventricular dysfunction is the most susceptile to
prodysrhythmias&
o =igo)in and some antidysrhythmia drugs can cause a prodysrhythmic response&
D+'/-'LLA,'$N
=efirillation is the most effective method of terminating 3@ and pulseless 3T&
=efirillation is accomplished y the passage of a =C electrical shoc' through the heart to
depolarize the cells of the myocardium& The intent is that suse<uent repolarization of
myocardial cells ,ill allo, the B5 node to resume the role of pacema'er&
?apid defirillation can e performed using a manual or automatic device&
o :anual defirillators re<uire health care providers to interpret cardiac rhythms,
determine the need for a shoc', and deliver a shoc'&
o Automatic e1ternal defibrillators (5*=s) are defirillators that have rhythm
detection capaility and the aility to advise the operator to deliver a shoc' using
hands+free defirillator pads&
S6NC)-$N'@D CA-D'$2-S'$N
Bynchronized cardioversion is the therapy of choice for the patient ,ith hemodynamically
unstale ventricular or supraventricular tachydysrhythmias&
o 5 synchronized circuit in the defirillator is used to deliver a countershoc' that is
programmed to occur on the ? ,ave of the P?B comple) of the *CA&
o The synchronizer s,itch must e turned on ,hen cardioversion is planned&
The procedure for synchronized cardioversion is the same as for defirillation, ,ith some
e)ceptions&
'MPLAN,A/L CA-D'$2-,--D+'/-'LLA,$- %'CD&
The .C= is used for patients ,ho (1) have survived BC=, (") have spontaneous sustained 3T,
($) have syncope ,ith inducile ventricular tachycardia1firillation during *PB, and (%) are at
high ris' for future life+threatening dysrhythmias (e&g&, have cardiomyopathy)&
1+1"$
Key Points
The .C= consists of a lead system placed via a suclavian vein to the endocardium&
5 attery+po,ered pulse generator is implanted sucutaneously, usually over the pectoral
muscle on the patient(s nondominant side&
o The .C= sensing system monitors the >? and rhythm and identifies 3T or 3@&
5ppro)imately "C seconds after the sensing system detects a lethal
dysrhythmia, the defirillating mechanism delivers a shoc' to the patient(s
heart&
.f the first shoc' is unsuccessful, the generator recycles and can continue to
deliver shoc's&
.n addition to defirillation capailities, .C=s are e<uipped ,ith antitachycardia and
antiradycardia pacema'ers&
*ducation of the patient ,ho is receiving an .C= is of e)treme importance&
PACMA9-S
The artificial cardiac "acema0er is an electronic device used to pace the heart ,hen the
normal conduction path,ay is damaged or diseased&
Pacema'ers ,ere initially indicated for symptomatic radydysrhythmias& They no,
provide antitachycardia and overdrive pacing&
5 permanent pacema'er is one that is implanted totally ,ithin the ody&
5 specialized type of cardiac pacing has een developed for the management of >@&
o Cardiac resynchronization therapy (C?T) is a pacing techni<ue that
resynchronizes the cardiac cycle y pacing oth ventricles, thus promoting
improvement in ventricular function&
o Beveral devices are availale that have comined C?T ,ith an .C= for ma)imum
therapy&
5 temporary pacema'er is one that has the po,er source outside the ody& There are three
types of temporary pacema'ers: transvenous, epicardial, and transcutaneous pacema'ers&
Patients ,ith temporary or permanent pacema'ers ,ill e *CA monitored to evaluate the
status of the pacema'er&
Complications of invasive temporary (i&e&, transvenous) or permanent pacema'er
insertion include infection and hematoma formation at the site of insertion of the
pacema'er po,er source or leads, pneumothora), failure to sense or capture ,ith possile
symptomatic radycardia, perforation of the atrial or ventricular septum y the pacing
lead, and appearance of /end+of+life0 attery parameters on testing the pacema'er&
-AD'$+-A5NC6 CA,),- A/LA,'$N ,)-AP6
1+1"%
Key Points
?adiofre<uency catheter alation therapy is a relatively ne, development in the area of
antidysrhythmia therapy& 5lation therapy is done after *PB has identified the source of
the dysrhythmia&
5n electrode+tipped alation catheter is used to /urn0 or alate accessory path,ays or
ectopic sites in the atria, 53 node, and ventricles&
Catheter alation is considered the nonpharmacologic treatment of choice for 53 nodal
reentrant tachycardia or for reentrant tachycardia related to accessory ypass tracts, and
to control the ventricular response of certain tachydysrhythmias&
The alation procedure is a successful therapy ,ith a lo, complication rate& Care of the
patient follo,ing alation therapy is similar to that of a patient undergoing cardiac
catheterization&
C4 C)AN4S ASS$C'A,D 7',) AC5, C$-$NA-6 S6ND-$M
The 1"+lead *CA is the primary diagnostic tool used to evaluate patients presenting ,ith
5CB&
There are definitive *CA changes that occur in response to ischemia, in#ury, or infarction
of myocardial cells and ,ill e seen in the leads that face the area of involvement&
Typical *CA changes seen in myocardial ischemia include BT+segment depression and1or
T ,ave inversion&
The typical *CA change seen during myocardial in#ury is BT+segment elevation&
5n BT+segment elevation and a pathologic P ,ave may e seen on the *CA ,ith
myocardial infarction&
Patient monitoring guidelines for patients ,ith suspected 5CB include continuous,
multilead *CA and BT+segment monitoring& The leads selected for monitoring should
minimally include the leads that reflect the area of ischemia, in#ury, or infarction&
S6NC$P
Byncope, a rief lapse in consciousness accompanied y a loss in postural tone (fainting),
is a common diagnosis of patients coming into the emergency department&
The causes of syncope can e categorized as cardiovascular or noncardiovascular&
o Common cardiovascular causes of syncope include (1) neurocardiogenic syncope
or /vasovagal0 syncope (e&g&, carotid sinus sensitivity) and (") primary cardiac
dysrhythmias (e&g&, tachycardias, radycardias)&
o Noncardiovascular causes can include hypoglycemia, hysteria, un,itnessed
seizure, and verteroasilar transient ischemic attac'&
1+1"C
Key Points
The diagnostic ,or'up for a patient ,ith syncope from a suspected cardiac cause egins
,ith ruling out structural and1or ischemic heart disease&
o *chocardiography and stress testing are performed&
o .n the older patient, ,ho is more li'ely to have ischemic and structural heart disease,
*PB is used to diagnose atrial and ventricular tachydysrhythmias, as ,ell as
conduction system disease causing radydysrhythmias&
o .n patients ,ithout structural heart disease or in ,hom *PB testing is not diagnostic,
head+upright tilt tale testing may e performed&
o ;ther diagnostic tests for syncope include various recording devices&
>olter monitors and event monitors can e used&
5 sucutaneously implanted loop recording device can also e used to record
the *CA during presyncopal and syncopal events&
1+1"D
Key Points
th
edition
Key Points
Chapter $9: Nursing :anagement: .nflammatory and Btructural >eart =isorders
'N+C,'2 ND$CA-D','S
'nfecti!e endocarditis (.*) is an infection of the endocardial surface of the heart that
affects the cardiac valves& .t is treated ,ith penicillin&
T,o forms of .* include the suacute form (typically affecting those ,ith pree)isting
valve disease) and the acute form (typically affecting those ,ith healthy valves)&
The most common causative organisms of .* are Staphylococcus aureus and
Streptococcus viridans#
The principal ris' factors for .* are prior endocarditis, prosthetic valves, ac<uired
valvular disease, and cardiac lesions&
3egetations, the primary lesions of .*, adhere to the valve surface or endocardium and
can emolize to various organs (particularly the lungs, rain, 'idneys, and spleen) and to
the e)tremities, causing lim infarction&
The infection may spread locally to cause damage to the valves or to their supporting
structures resulting in dysrhythmias, valvular incompetence, and eventual invasion of the
myocardium, leading to heart failure (>@), sepsis, and heart loc'&
Clinical findings in .* are nonspecific and can include the follo,ing:
o 2o,+grade fever, chills, ,ea'ness, malaise, fatigue, and anore)ia
o 5rthralgias, myalgias, ac' pain, adominal discomfort, ,eight loss, headache,
and cluing of fingers
o Bplinter hemorrhages (lac' longitudinal strea's) in the nail eds
o Petechiae (a result of fragmentation and microemolization of vegetative lesions)
in the con#unctivae, the lips, the uccal mucosa, and the palate and over the
an'les, the feet, and the antecuital and popliteal areas
o $sler<s nodes (painful, tender, red or purple, pea+size lesions) on the fingertips or
toes and Banewa.<s lesions (flat, painless, small, red spots) on the palms and
soles
o >emorrhagic retinal lesions called ?oth(s spots
o 5 ne, or changing murmur in the aortic or mitral valve
o >@
=efinitive diagnosis of .* e)ists if t,o of the follo,ing ma#or criteria are present:
1+1"9
Key Points
positive lood cultures, ne, or changed cardiac murmur, or intracardiac mass or
vegetation noted on echocardiography&
Collaorative care consists of antiiotic prophyla)is for patients ,ith specific cardiac
conditions efore dental, respiratory tract, gastrointestinal (A.), and genitourinary (A4)
procedures and for high+ris' patients ,ho (1) are to undergo removal or drainage of
infected tissue, (") receive renal dialysis, or ($) have ventriculoatrial shunts for
management of hydrocephalus&
=rug therapy consists of long+term treatment ,ith .3 antiiotic therapy ,ith suse<uent
lood cultures to evaluate the effectiveness of antiiotic therapy&
*arly valve replacement follo,ed y prolonged (D ,ee's or longer) drug therapy is
recommended for patients ,ith fungal infection and prosthetic valve endocarditis&
@ever is treated ,ith aspirin, acetaminophen (Tylenol), iuprofen (:otrin), fluids, and
rest&
Complete ed rest is usually not indicated unless the temperature remains elevated or
there are signs of >@&
;verall goals for the patient ,ith .* include (1) normal or aseline cardiac function, (")
performance of activities of daily living (5=2s) ,ithout fatigue, and ($) 'no,ledge of
the therapeutic regimen to prevent recurrence of endocarditis&
Patients and families must e taught to recognize signs and symptoms of life+threatening
complications of .*, such as cereral emoli (e&g&, change in mental status), pulmonary
edema (e&g&, dyspnea), and >@ (e&g&, chest pain)&
o @ever (chronic or intermittent) is a common early sign that the drug therapy is
ineffective&
2aoratory data and lood cultures are monitored to determine the effectiveness of the
antiiotic therapy&
AC5, P-'CA-D','S
Pericarditis is caused y inflammation of the pericardial sac (the pericardium)&
5cute pericarditis most often is idiopathic ut can e caused y uremia, viral or acterial
infection, acute myocardial infarction (:.), tuerculosis, neoplasm, and trauma&
Pericarditis in the acute :. patient may e descried as t,o distinct syndromes: (1) acute
pericarditis (occurs ,ithin the initial %F to 9" hours after an :.), and (") =ressler
syndrome (late pericarditis ,hich appears % to D ,ee's after an :.)&
Clinical manifestations include the follo,ing:
1+1"F
Key Points
o Progressive, fre<uently severe chest pain that is sharp and pleuritic in nature and
,orse ,ith deep inspiration and ,hen lying supine& The pain is relieved y
sitting&
o Pain can e referred to the trapezius muscle (shoulder, upper ac')&
o The hallmar' finding in acute pericarditis is the "ericardial friction rub(
Complications include "ericardial effusion and cardiac tam"onade(
Collaorative care includes the follo,ing:
o 5ntiiotics
o Corticosteroids for pericarditis secondary to systemic lupus erythematosus,
patients already ta'ing corticosteroids for a rheumatologic or other immune
system condition, or patients ,ho do not respond to nonsteroidal
antiinflammatory drugs (NB5.=s)
o Pain and inflammation are usually treated ,ith NB5.=s or high+dose salicylates
(e&g&, aspirin)&
o Colchicine, an antiinflammatory agent used for gout, may e considered for
patients ,ho have recurrent pericarditis&
o Pericardiocentesis is usually performed for pericardial effusion ,ith acute
cardiac tamponade, purulent pericarditis, and a high suspicion of a neoplasm&
Complications from pericardiocentesis include dysrhythmias, further
cardiac tamponade, pneumomediastinum, pneumothora), myocardial
laceration, and coronary artery laceration&
The management of the patient(s pain and an)iety during acute pericarditis is a primary
nursing consideration&
*CA monitoring can aid in distinguishing ischemic pain from pericardial pain as
ischemia involves localized BT+segment changes, as compared to the diffuse BT+segment
changes present in acute pericarditis&
Pain relief measures include maintaining ed rest ,ith the head of the ed elevated to %C
degrees and providing an overed tale for support, and antiinflammatory medications&
C)-$N'C C$NS,-'C,'2 P-'CA-D','S
Chronic constricti!e "ericarditis results from scarring ,ith conse<uent loss of elasticity
of the pericardial sac and egins ,ith an initial episode of acute pericarditis follo,ed y
firous scarring, thic'ening of the pericardium from calcium deposition, and eventual
oliteration of the pericardial space&
The end result is that the firotic, thic'ened, and adherent pericardium impairs the aility
of the atria and ventricles to stretch ade<uately during diastole&
Clinical manifestations mimic >@ and cor pulmonale and include dyspnea on e)ertion,
peripheral edema, ascites, fatigue, anore)ia, and ,eight loss&
1+1"E
Key Points
The most prominent finding is #ugular venous distention&
5uscultation reveals a pericardial 'noc', ,hich is a loud early diastolic sound often heard
along the left sternal order&
Treatment of choice for chronic constrictive pericarditis is a pericardiectomy&
Pericardiectomy involves complete resection of the pericardium through a median
sternotomy ,ith the use of cardiopulmonary ypass&
M6$CA-D','S
M.ocarditis is a focal or diffuse inflammation of the myocardium caused y viruses,
acteria, fungi, radiation therapy, and pharmacologic and chemical factors&
:yocarditis is fre<uently associated ,ith acute pericarditis, particularly ,hen it is caused
y co)sac'ievirus 6 strains&
:yocarditis results in cardiac dysfunction and has een lin'ed to the development of
dilated cardiomyopathy&
Clinical manifestations include the follo,ing:
o @ever, fatigue, malaise, myalgias, pharyngitis, dyspnea, lymphadenopathy, and
nausea and vomiting are early systemic manifestations of the viral illness&
o *arly cardiac manifestations appear 9 to 18 days after viral infection and include
pleuritic chest pain ,ith a pericardial friction ru and effusion&
o 2ate cardiac signs relate to the development of >@ and may include an B
$
heart
sound, crac'les, #ugular venous distention, syncope, peripheral edema, and
angina&
Collaorative care includes the follo,ing:
o :anaging associated cardiac decompensation ,ith:
=igo)in (2ano)in) to treat ventricular failure
=iuretics to reduce fluid volume and decrease preload
Nitroprusside (Nitropress), inamrinone (.nocor), and milrinone (Primacor)
to reduce afterload and improve cardiac output
The use of anticoagulation therapy may e considered in patients ,ith a
lo, e#ection fraction ,ho are at ris' for thromus formation from lood
stasis in the cardiac chamers&
o .mmunosuppressive therapy to reduce myocardial inflammation and to prevent
irreversile myocardial damage&
o ;)ygen therapy, ed rest, and restricted activity&
o .ntraaortic alloon pump therapy and ventricular assist devices&
1+1$8
Key Points
Nursing interventions focus on assessment for the signs and symptoms of >@ and include
assessing the level of an)iety, instituting measures to decrease an)iety, and 'eeping the
patient and family informed aout therapeutic measures&
:ost patients ,ith myocarditis recover spontaneously, although some may develop
dilated cardiomyopathy& .f severe >@ occurs, the patient may re<uire heart
transplantation&
-)5MA,'C +2- AND )A-, D'SAS
-heumatic fe!er is an inflammatory disease of the heart potentially involving all layers
of the heart&
-heumatic heart disease is a chronic condition resulting from rheumatic fever that is
characterized y scarring and deformity of the heart valves&
Acute rheumatic fe!er (5?@) is a complication that occurs as a delayed se<uela of a
group 5 streptococcal pharyngitis and affects the heart, #oints, central nervous system
(CNB), and s'in&
5out %8K of 5?@ episodes are mar'ed y carditis, meaning that all layers of the heart
are involved, and this is referred to as rheumatic pancarditis&
o ?heumatic endocarditis is found primarily in the valves& 3egetation forms and
valve leaflets may fuse and ecome thic'ened or even calcified, resulting in
stenosis or regurgitation&
o :yocardial involvement is characterized y Aschoff<s bodies(
o ?heumatic pericarditis affects the pericardium, ,hich ecomes thic'ened and
covered ,ith a firinous e)udate, and often involves pericardial effusion&
o The lesions of rheumatic fever are systemic, especially involving the connective
tissue, as ,ell as the #oints, s'in, and CNB&
Clinical manifestations of 5?@ include the follo,ing:
o The presence of t,o ma#or criteria or one ma#or and t,o minor criteria plus
evidence of a preceding group 5 streptococcal infection&
:a#or criteria:
Carditis results in three signs: (1) murmurs of mitral or aortic
regurgitation, or mitral stenosis! (") cardiac enlargement and >@! ($)
pericarditis&
:ono+ or polyarthritis causes s,elling, heat, redness, tenderness, and
limitation of motion&
Chorea (Bydenham(s chorea) involves involuntary movements,
especially of the face and lims, muscle ,ea'ness, and disturances of
speech and gait&
*rythema marginatum lesions are right pin', nonpruritic, mapli'e
macular lesions that occur mainly on the trun' and pro)imal
e)tremities&
1+1$1
Key Points
Bucutaneous nodules are firm, small, hard, painless s,ellings
located over e)tensor surfaces of the #oints&
:inor criteria:
Clinical findings: fever, polyarthralgia
2aoratory findings: elevated *B?, elevated -6C, elevated C?P
Complications of 5?@ include chronic rheumatic carditis&
B'in should e assessed for sucutaneous nodules and erythema marginatum&
The overall goals for a patient ,ith rheumatic fever include (1) normal or aseline heart
function, (") resumption of daily activities ,ithout #oint pain, and ($) veralization of the
aility to manage the disease&
>ealth promotion emphasizes prevention of rheumatic fever y early detection and
treatment of group 5 streptococcal pharyngitis ,ith antiiotics, specifically penicillin&
o The success of treatment re<uires strict adherence to the full course of antiiotic
therapy&
o The primary goals of managing a patient ,ith 5?@ are to control and eradicate
the infecting organism! prevent cardiac complications! and relieve #oint pain,
fever, and other symptoms ,ith antiiotics! optimal rest! and antipyretics,
NB5.=s, and corticosteroids&
o Becondary prevention aims at preventing the recurrence of rheumatic fever ,ith
monthly in#ections of long+acting penicillin& 5dditional prophyla)is is necessary if
a patient ,ith 'no,n rheumatic heart disease has dental or surgical procedures
involving the upper respiratory, A. (e&g&, endoscopy), or A4 tract&
The e)pected outcomes for the patient ,ith rheumatic fever and heart disease include (1)
aility to perform 5=2s ,ith minimal fatigue and pain, (") adherence to treatment
regimen, and ($) e)pression of confidence in managing disease&
2AL25LA- )A-, D'SAS
3alvular stenosis refers to a constriction or narro,ing of the valve opening&
3alvular regurgitation (also called valvular incompetence or insufficiency) occurs ,ith
incomplete closure of the valve leaflets and results in the ac',ard flo, of lood&
Mitral 2al!e Stenosis
5dult mitral valve stenosis results from rheumatic heart disease& 2ess commonly, it
can occur congenitally, from rheumatoid arthritis and from systemic lupus
erythematosus&
Clinical manifestations of mitral stenosis include e)ertional dyspnea, fatigue, palpitations
from atrial firillation, and a loud first heart sound and a lo,+pitched, rumling diastolic
murmur&
1+1$"
Key Points
Mitral -egurgitation
:itral regurgitation (:?) is caused y :., chronic rheumatic heart disease, mitral valve
prolapse, ischemic papillary muscle dysfunction, and .*&
.n chronic :?, the additional volume load results in atrial enlargement, ventricular
dilation, and eventual ventricular hypertrophy&
.n acute :?, there is a sudden increase in pressure and volume that is transmitted to the
pulmonary ed, resulting in pulmonary edema and life+threatening shoc'&
Clinical manifestations of acute :? include thready, peripheral pulses and cool, clammy
e)tremities! and a ne, systolic murmur&
Patients ,ith asymptomatic :? should e monitored carefully, and surgery considered
efore significant left ventricular failure or pulmonary hypertension develops&
Mitral 2al!e Prola"se
Mitral !al!e "rola"se (:3P) is an anormality of the mitral valve leaflets and the
papillary muscles or chordae that allo,s the leaflets to prolapse, or uc'le, ac' into the
left atrium during systole& The etiology of :3P is un'no,n ut is related to diverse
pathogenic mechanisms of the mitral valve apparatus&
.n many patients :3P found y echocardiography is not accompanied y any other
clinical manifestations of cardiac disease, and the significance of the finding is unclear&
Clinical manifestations of :3P can include a murmur from regurgitation that gets more
intense through systole, chest pain, dyspnea, palpitations, and syncope&
Aortic 2al!e Stenosis
.n older patients, aortic stenosis is a result of rheumatic fever or senile firocalcific
degeneration that may have an etiology similar to coronary artery disease&
5ortic stenosis results in left ventricular hypertrophy and increased myocardial o)ygen
consumption, and eventually, reduced cardiac output leading to pulmonary hypertension
and >@&
Clinical manifestations include a systolic, crescendo+decrescendo murmur and the classic
triad of angina, syncope, and e)ertional dyspnea&
Aortic 2al!e -egurgitation
Acute aortic regurgitation (5?) is caused y .*, trauma, or aortic dissection&
Chronic 5? is generally the result of rheumatic heart disease, a congenital icuspid aortic
valve, syphilis, or chronic rheumatic conditions&
1+1$$
Key Points
Clinical manifestations of acute 5? include severe dyspnea, chest pain, and hypotension
indicating left ventricular failure and shoc' that constitute a medical emergency&
Clinical manifestations of chronic 5? include e)ertional dyspnea, orthopnea, and
paro)ysmal nocturnal dyspnea after considerale myocardial dysfunction has occurred&
,ricus"id and Pulmonic 2al!e Disease
=iseases of the tricuspid and pulmonic valves are uncommon, ,ith stenosis occurring
more fre<uently than regurgitation&
Tricuspid valve stenosis occurs almost e)clusively in patients ,ith rheumatic mitral
stenosis, in .3 drug ausers, or in patients treated ,ith a dopamine agonist&
Pulmonary stenosis is almost al,ays congenital&
Tricuspid and pulmonic stenosis oth result in the ac',ard flo, of lood to the right
atrium and right ventricle, respectively&
Tricuspid stenosis results in right atrial enlargement and elevated systemic venous
pressures& Pulmonic stenosis results in right ventricular hypertension and hypertrophy&
Collaborati!e Care of 2al!ular )eart Disease
Collaorative care of valvular heart disease includes the prevention of recurrent
rheumatic fever and .* and the prevention of e)acerations of >@, acute pulmonary
edema, and thromoemolism&
5nticoagulant therapy is used to prevent and treat systemic or pulmonary emolization
and is used prophylactically in patients ,ith atrial firillation&
5n alternative treatment for valvular heart disease is percutaneous transluminal alloon
valvuloplasty (PT63) to split open the fused commissures& .t is used for mitral, tricuspid,
and pulmonic stenosis, and less often for aortic stenosis&
Burgical intervention is ased on the clinical state of the patient and depends on the
valves involved, the valvular pathology, the severity of the disease, and the patient(s
clinical condition&
3alve repair (e&g&, mitral commissurotomy HvalvulotomyI, is typically the surgical
procedure of choice&
;pen surgical valvuloplasty involves repair of the valve y suturing the torn leaflets,
chordae tendineae, or papillary muscles and is used to treat mitral or tricuspid
regurgitation&
1+1$%
Key Points
5nnuloplasty entails reconstruction of the annulus, ,ith or ,ithout the aid of prosthetic
rings (e&g&, a Carpentier ring)&
Prosthetic mechanical valves are made from manmade materials&
Prosthetic iologic valves are constructed from ovine, porcine, and human cardiac tissue
and usually contain some human+made materials&
:echanical prosthetic valves are more durale and last longer than iologic valves ut
have an increased ris' of thromoemolism, necessitating long+term anticoagulation
therapy&
6iologic valves do not re<uire anticoagulation therapy due to their lo, thromogenicity&
>o,ever, they are less durale due to the tendency for early calcification, tissue
degeneration, and stiffening of the leaflets&
5uscultation of the heart should e performed to monitor the effectiveness of digo)in, +
adrenergic loc'ers, and antidysrhythmic drugs&
Prophylactic antiiotic therapy is necessary to prevent .* and, if the valve disease ,as
caused y rheumatic fever, ongoing prophyla)is is necessary&
Patients on anticoagulation therapy after valve replacement surgery must have the
international normalized ratio (.N?) chec'ed regularly (usually monthly) to assess the
ade<uacy of therapy& Therapeutic values are "&C to $&C&
The nurse must teach the patient to see' medical care if any manifestations of infection or
>@, any signs of leeding, and any planned invasive or dental procedures are planned&
Patients on anticoagulation therapy should e encouraged to ,ear a medical alert
racelet&
CA-D'$M6$PA,)6
Cardiom.o"ath. (C:P) constitutes a group of diseases that directly affect the structural
or functional aility of the myocardium&
C:P is classified as primary (refers to those conditions in ,hich the etiology of the heart
disease is un'no,n) or secondary (the cause of the myocardial disease is 'no,n and is
secondary to another disease process)&
Cardiomyopathies can lead to cardiomegaly and >@, and are the leading cause for heart
transplantation&
Dilated Cardiom.o"ath.
1+1$C
Key Points
Dilated cardiom.o"ath. is characterized y a diffuse inflammation and rapid
degeneration of myocardial fiers that results in ventricular dilation, impairment of
systolic function, atrial enlargement, and stasis of lood in the left ventricle&
Clinical manifestations develop acutely after an infectious process or insidiously over a
period of time&
o Bymptoms include decreased e)ercise capacity, fatigue, dyspnea at rest,
paro)ysmal nocturnal dyspnea, orthopnea, palpitations, adominal loating,
nausea, vomiting, and anore)ia&
o Bigns include an irregular heart rate ,ith an anormal B
$
and1or B
%
, tachycardia or
radycardia, pulmonary crac'les, edema, ,ea' peripheral pulses, pallor,
hepatomegaly, and #ugular venous distention&
o >eart murmurs and dysrhythmias are common&
.nterventions focus on controlling >@ y enhancing myocardial contractility and
decreasing afterload ,ith drug therapy&
Nutritional therapy and cardiac rehailitation may help alleviate symptoms of >@ and
improve C; and <uality of life&
=ilated C:P does not respond ,ell to therapy, and patients may enefit from a
ventricular assist device (35=) to allo, the heart to rest and recover from acute >@ or as
a ridge to heart transplantation&
Cardiac resynchronization therapy and an implantale cardioverter+defirillator may e
considered in appropriate patients& The patient(s family must learn cardiopulmonary
resuscitation (CP?) and ho, to access emergency care&
The goal of therapy is to 'eep the patient at an optimal level of function and out of the
hospital&
)."ertro"hic Cardiom.o"ath.
)."ertro"hic cardiom.o"ath. (>C:) is asymmetric left ventricular hypertrophy
,ithout ventricular dilation&
The four main characteristics of >C: are: (1) massive ventricular hypertrophy! (") rapid,
forceful contraction of the left ventricle! ($) impaired rela)ation (diastole)! and (%)
ostruction to aortic outflo, (not present in all patients)& The end result is impaired
ventricular filling as the ventricle ecomes noncompliant and unale to rela)&
>C: is the most common cause of BC= in other,ise healthy young people&
Patients ,ith >C: may e asymptomatic or may have e)ertional dyspnea, fatigue,
angina, syncope, and dysrhythmias&
1+1$D
Key Points
Aoals of intervention are to improve ventricular filling y reducing ventricular
contractility and relieving left ventricular outflo, ostruction&
=rug therapy for >C: includes +adrenergic loc'ers or calcium channel loc'ers&
=igitalis preparations are contraindicated unless they are used to treat atrial firillation,
and antidysrhythmics are used as needed&
@or patients at ris' for BC=, the implantation of a cardioverter+defirillator is
recommended&
5trioventricular pacing can e eneficial for patients ,ith >C: and outflo, ostruction&
Bome patients may e candidates for a surgical procedure called ventriculomyotomy and
myectomy, ,hich involves incision of the hypertrophied septal muscle and resection of
some of the hypertrophied ventricular muscle&
Nursing interventions for >C: focus on relieving symptoms, oserving for and
preventing complications, and providing emotional and psychologic support&
-estricti!e Cardiom.o"ath.
-estricti!e cardiom.o"ath., the least common C:P, impairs diastolic filling and
stretch though systolic function remains unaffected&
The specific etiology of restrictive C:P is un'no,n&
Clinical manifestations include fatigue, e)ercise intolerance, and dyspnea ecause the
heart cannot increase C; y increasing the heart rate ,ithout further compromising
ventricular filling&
Currently no specific treatment for restrictive C:P e)ists and interventions are aimed at
improving diastolic filling and the underlying disease process&
o Treatment includes conventional therapy for >@ and dysrhythmias&
o >eart transplant may also e a consideration&
o Nursing care is similar to the care of a patient ,ith >@&
th
edition
Key Points
Chapter $F: Nursing :anagement: 3ascular =isorders
P-'P)-AL A-,-'AL D'SAS
Peri"heral arterial disease (P5=) is a progressive narro,ing and degeneration of the
arteries of the nec', adomen, and e)tremities& .n most cases, it is a result of
1+1$9
Key Points
atherosclerosis&
P5= typically appears in the si)th to eighth decades of life& .t occurs at an earlier age in
persons ,ith diaetes mellitus and more fre<uently in 5frican 5mericans&
The four most significant ris' factors for P5= are cigarette smo'ing (most important),
hyperlipidemia, hypertension, and diaetes mellitus&
The most common locations for P5= are the coronary arteries, carotid arteries, aortic
ifurcation, iliac and common femoral arteries, profunda femoris artery, superficial
femoral artery, and distal popliteal artery&
AN5-6SMS
5ortic aneur.sms are outpouchings or dilations of the arterial ,all&
The primary causes of aortic aneurysms can e classified as degenerative, congenital,
mechanical, inflammatory, or infectious&
5ortic aneurysms may involve the aortic arch, thoracic aorta, and1or adominal aorta, ut
most are found in the adominal aorta elo, the level of the renal arteries&
Thoracic aorta aneurysms are often asymptomatic, ut the most common manifestations
are deep, diffuse chest pain that may e)tend to the interscapular area! hoarseness as a
result of pressure on the recurrent laryngeal nerve! and dysphagia from pressure on the
esophagus&
5dominal aortic aneurysms (555s) are often asymptomatic ut symptoms may mimic
pain associated ,ith adominal or ac' disorders&
The most serious complication related to an untreated aneurysm is rupture and leeding&
=iagnostic tests for 555s include chest )+ray, electrocardiogram (to rule out myocardial
infarction), echocardiography, CT scan, and magnetic resonance imaging scan&
The goal of management is to prevent the aneurysm from rupturing&
Burgical repair of 555 involves (1) incising the diseased segment of the aorta, (")
removing intraluminal thromus or pla<ue, ($) inserting a synthetic graft, and (%) suturing
the native aortic ,all around the graft&
:inimally invasive endovascular grafting is an alternative to conventional surgical repair
of 555 and involves the placement of a sutureless aortic graft into the adominal aorta
inside the aneurysm via a femoral artery cutdo,n&
Preoperatively, the patient is monitored for indications of aneurysm rupture&
1+1$F
Key Points
Preoperative teaching should include a rief e)planation of the disease process, the
planned surgical procedure(s), preoperative routines, and ,hat to e)pect immediately
after surgery&
The overall goals for a patient undergoing aortic surgery include (1) normal tissue
perfusion, (") intact motor and sensory function, and ($) no complications related to
surgical repair, such as thromosis or infection&
Postoperatively, the patient ,ill have an endotracheal tue for mechanical ventilation, an
arterial line, a central venous pressure or pulmonary artery catheter, peripheral
intravenous lines, an ind,elling urinary catheter, a nasogastric tue, and continuous *CA
and pulse o)imetry monitoring&
o :onitoring for graft patency and ade<uate renal perfusion are priorities!
maintenance of an ade<uate 6P is e)tremely important&
o 5ntiiotics are given to prevent infection&
o Peripheral pulses, s'in temperature and color, capillary refill time, and sensation
and movement of the e)tremities are assessed and recorded per hospital policy&
o >ourly urine outputs and daily ,eights are recorded&

;n discharge, the patient should e instructed to gradually increase activities ut to avoid
heavy lifting for at least % to D ,ee's&
*)pected outcomes for the patient ,ho undergoes aortic surgery include (1) patent
arterial graft ,ith ade<uate distal perfusion, (") ade<uate urine output, ($) normal ody
temperature, and (%) no signs of infection&
A$-,'C D'SSC,'$N
Aortic dissection occurs most commonly in the thoracic aorta and is the result of a tear
in the intimal (innermost) lining of the arterial ,all allo,ing lood to /trac'0 et,een the
intima and media and creates a false lumen of lood flo,&
The e)act cause of aortic dissection is uncertain, and most people ,ith dissection are
older and have chronic hypertension&
Clinical manifestations include a sudden, severe pain in the anterior part of the chest or
intrascapular pain radiating do,n the spine into the adomen or legs that is descried as
/tearing0 or /ripping&0
=iagnostic studies used to assess aortic dissection are similar to those performed for
555&
The initial goal of therapy for aortic dissection ,ithout complications is to lo,er the 6P
and myocardial contractility ,ith drug therapy&
1+1$E
Key Points
Burgery is indicated ,hen drug therapy is ineffective or ,hen complications of aortic
dissection are present&
P-'P)-AL A-,-'AL D'SAS $+ ,) L$7- 8,-M','S
P5= of the lo,er e)tremities affects the aortoiliac, femoral, popliteal, tiial, or peroneal
arteries&
The classic symptom of P5= of the lo,er e)tremities is intermittent claudication,
,hich is defined as ischemic muscle ache or pain that is precipitated y a consistent level
of e)ercise, resolves ,ithin 18 minutes or less ,ith rest, and is reproducile&
Paresthesia, manifested as numness or tingling in the toes or feet, may result from nerve
tissue ischemia& Aradually diminishing perfusion to neurons produces loss of oth
pressure and deep pain sensations&
Physical findings include thin, shiny, and taut s'in! loss of hair on the lo,er legs!
diminished or asent pedal, popliteal, or femoral pulses! pallor or lanching of the foot in
response to leg elevation (elevation pallor)! and reactive hyperemia (redness of the foot)
,hen the lim is in a dependent position (dependent ruor)&
?est pain most often occurs in the forefoot or toes, is aggravated y lim elevation, and
occurs ,hen there is insufficient lood flo, to maintain asic metaolic re<uirements of
the tissues and nerves of the distal e)tremity&
Complications of P5= include nonhealing ulcers over ony prominences on the toes,
feet, and lo,er leg, and gangrene& 5mputation may e re<uired if lood flo, is not
restored&
Tests used to diagnose P5= include =oppler ultrasound ,ith segmental lood pressures
at the thigh, elo, the 'nee, and at an'le level& 5 falloff in segmental 6P of more than $8
mm >g indicates P5=&
5ngiography is used to delineate the location and e)tent of the disease process&

The first treatment goal is to aggressively modify all cardiovascular ris' factors in all
patients ,ith P5=, ,ith smo'ing cessation a priority&
=rug therapy includes antiplatelet agents and 5C* inhiitors& T,o drugs are approved to
treat intermittent claudication, pento)ifylline (Trental) and cilostazol (Pletal)&
The primary nonpharmacologic treatment for claudication is a formal e)ercise+training
program ,ith ,al'ing eing the most effective e)ercise&
Ain'go iloa has een found to increase ,al'ing distance for patients ,ith intermittent
claudication&
1+1%8
Key Points
Critical limb ischemia is a chronic condition characterized y ischemic rest pain, arterial
leg ulcers, and1or gangrene of the leg due to advanced P5=&
.nterventional radiologic procedures for P5= include percutaneous transluminal alloon
angioplasty& There is a relatively high rate of restenosis after alloon angioplasty&
The most common surgical procedure for P5= is a peripheral arterial ypass operation
,ith autogenous vein or synthetic graft material to ypass or carry lood around the
lesion&
The overall goals for the patient ,ith lo,er e)tremity P5= include (1) ade<uate tissue
perfusion, (") relief of pain, ($) increased e)ercise tolerance, and (%) intact, healthy s'in
on e)tremities&
5fter surgical or radiologic intervention, the operative e)tremity should e chec'ed every
1C minutes initially and then hourly for s'in color and temperature, capillary refill,
presence of peripheral pulses, and sensation and movement of the e)tremity&
5ll patients ,ith P5= should e taught the importance of meticulous foot care to prevent
in#ury&
Acute arterial ischemia is a sudden interruption in the arterial lood supply to tissue, an
organ, or an e)tremity that, if left untreated, can result in tissue death&
Bigns and symptoms of an acute arterial ischemia usually have an arupt onset and
include the /si) Ps:0 pain, pallor, pulselessness, paresthesia, paralysis, and poi'ilothermia
(adaptation of the ischemic lim to its environmental temperature, most often cool)&
Treatment options include anticoagulation, thromolysis, emolectomy, surgical
revascularization, or amputation&
,)-$M/$AN4'','S $/L',-ANS %/5-4-<S D'SAS&
,hromboangiitis obliterans is a some,hat rare nonatherosclerotic, segmental, recurrent
inflammatory vaso+occlusive disorder of the small and medium+sized arteries, veins, and
nerves of the upper and lo,er e)tremities&
Patients may have intermittent claudication of the feet, hands, or arms&
5s the disease progresses, rest pain and ischemic ulcerations develop&
There are no laoratory or diagnostic tests specific to 6uerger(s disease&

Treatment includes complete cessation of toacco use in any form (including secondhand
smo'e)& ;ther therapies can e considered ut have had limited success&
1+1%1
Key Points
Burgical options include revascularization and sympathectomy, ,ith the most common
eing sympathectomy (transection of a nerve, ganglion, and1or ple)us of the sympathetic
nervous system)&
-A6NA5D<S P)N$MN$N
-a.naud<s "henomenon is an episodic vasospastic disorder of small cutaneous arteries,
most fre<uently involving the fingers and toes& The e)act etiology of ?aynaud(s
phenomenon remains un'no,n&
Clinical symptoms include vasospasm+induced color changes of the fingers, toes, ears,
and nose (,hite, lue, and red)& 5n episode usually lasts only minutes ut in severe cases
may persist for several hours&
Bymptoms usually are precipitated y e)posure to cold, emotional upsets, caffeine, and
toacco use&
There is no simple diagnostic test for ?aynaud(s phenomenon, and diagnosis is ased on
persistent symptoms for at least " years&
Patient teaching should e directed to,ard prevention of recurrent episodes: temperature
e)tremes and all toacco products should e avoided&
Calcium channel loc'ers are the first+line drug therapy&
2N$5S ,)-$M/$S'S
2enous thrombosis is the most common disorder of the veins and involves the formation
of a thromus (clot) in association ,ith inflammation of the vein&
Su"erficial thrombo"hlebitis occurs in aout DCK of all patients receiving .3 therapy
and is of minor significance&
Dee" !ein thrombosis (=3T) involves a thromus in a deep vein, most commonly the
iliac and femoral veins, and can result in emolization of thromi to the lungs&
Three important factors (called 2irchow<s triad) in the etiology of venous thromosis
are (1) venous stasis, (") damage of the endothelium, and ($) hypercoagulaility of the
lood&
Buperficial thromophleitis presents as a palpale, firm, sucutaneous cordli'e vein&
The area surrounding the vein may e tender to the touch, reddened, and ,arm& 5 mild
systemic temperature elevation and leu'ocytosis may e present&
o Treatment of superficial thromophleitis includes elevating the affected
e)tremity to promote venous return and decrease the edema and applying ,arm,
moist heat&
1+1%"
Key Points
o :ild oral analgesics such as acetaminophen or aspirin are used to relieve pain&
The patient ,ith =3T may or may not have unilateral leg edema, e)tremity pain, ,arm
s'in, erythema, and a systemic temperature greater than 188&% @ ($F C)&
The most serious complications of =3T are pulmonary emolism (P*) and chronic
venous insufficiency& Chronic venous insufficiency (C3.) results from valvular
destruction, allo,ing retrograde flo, of venous lood&
.nterventions for patients at ris' for =3T include early moilization of surgical patients&
Patients on ed rest need to e instructed to change position, dorsifle) their feet, and
rotate their an'les every " to % hours&
The usual treatment of =3T in hospitalized patients involves ed rest, elevation of the
e)tremity, and anticoagulation&
Patients ,ith hyperhomocysteinemia are treated ,ith vitamins 6
D
, 6
1"
, and folic acid to
reduce homocysteine levels&
The goal of anticoagulation therapy for =3T prophyla)is is to prevent =3T formation!
the goals in the treatment of =3T are to prevent propagation of the clot, development of
any ne, thromi, and emolization&
.ndirect thromin inhiitors include unfractionated heparin (4>) and lo,+molecular+
,eight heparin (2:->)&
o 4> affects oth the intrinsic and common path,ays of lood coagulation y ,ay
of the plasma cofactor antithromin&
o 2:-> is derived from heparin and also acts via antithromin, ut has an
increased affinity for inhiiting factor Ma&
=irect thromin inhiitors can e classified as hirudin derivatives or synthetic thromin
inhiitors& >irudin inds specifically ,ith thromin, therey directly inhiiting its
function ,ithout causing plasma protein and platelet interactions&
@actor Ma inhiitors inhiit factor Ma directly or indirectly, producing rapid
anticoagulation&
o @ondaparinu) (5ri)tra) is administered sucutaneously and is approved for =3T
prevention in orthopedic patients and treatment of =3T and P* in hospitalized
patients ,hen administered in con#unction ,ith ,arfarin&
o 6oth direct thromin inhiitors and factor Ma inhiitors have no antidote&
@or =3T prophyla)is, lo,+dose 4>, 2:->, fondaparinu), or ,arfarin can e
prescried&
o 2:-> has replaced heparin as the anticoagulant of choice to prevent =3T for
most surgical patients&
1+1%$
Key Points
o =3T prophyla)is typically lasts the duration of the hospitalization&
o Patients undergoing ma#or orthopedic surgery may e prescried prophyla)is for
up to 1 month postdischarge&
3ena cava interruption devices, such as the Areenfield filter, can e inserted
percutaneously through right femoral or right internal #ugular vein to filter clots ,ithout
interrupting lood flo,&
Nursing diagnoses and collaorative prolems for the patient ,ith venous thromosis can
include the follo,ing:
o 5cute pain related to venous congestion, impaired venous return, and
inflammation
o .neffective health maintenance related to lac' of 'no,ledge aout the disorder
and its treatment
o ?is' for impaired s'in integrity related to altered peripheral tissue perfusion
o Potential complication: leeding related to anticoagulant therapy
o Potential complication: pulmonary emolism related to emolization of thromus,
dehydration, and immoility
The overall goals for the patient ,ith venous thromosis include (1) relief of pain, (")
decreased edema, ($) no s'in ulceration, (%) no complications from anticoagulant therapy,
and (C) no evidence of pulmonary emoli&
o =epending on the anticoagulant prescried, 5CT, aPTT, .N?, hemogloin,
hematocrit, platelet levels, and1or liver enzymes are monitored&
o Platelet counts are monitored for patients receiving 4> or 2:-> to assess for
>.T&
o 4>, ,arfarin, and direct thromin inhiitors are titrated according to the results of
clotting studies&
o The nurse oserves for signs of leeding, including epista)is, gingival leeding,
hematuria, and melena&
=ischarge teaching should focus on elimination of modifiale ris' factors for =3T, the
importance of compression stoc'ings and monitoring of laoratory values, medication
instructions, and guidelines for follo,+up&
o The patient and family should e taught aout signs and symptoms of P* such as
sudden onset of dyspnea, tachypnea, and pleuritic chest pain&
o .f the patient is on anticoagulant therapy, the patient and family need information
on dosage, actions, and side effects, as ,ell as the importance of routine lood
tests and ,hat symptoms to report to the health care provider&
o >ome monitoring devices are no, availale for testing of PT1.N?&
o Patients on 2:-> ,ill need to learn ho, to self+administer the drug or have a
friend or family memer administer it&
o Patients on ,arfarin should e instructed to follo, a consistent diet of foods
containing vitamin K and to avoid any additional supplements that contain
vitamin K&
1+1%%
Key Points
o Proper hydration is recommended to prevent additional hypercoagulaility&
o *)ercise programs should e developed ,ith an emphasis on ,al'ing, s,imming,
and ,ading&
The e)pected outcomes for the patient ,ith venous thromosis include (1) minimal to no
pain, (") intact s'in, ($) no signs of hemorrhage or occult leeding, and (%) no signs of
respiratory distress&
2A-'C$S 2'NS
2aricose !eins, or varicosities, are dilated, tortuous sucutaneous veins most fre<uently
found in the saphenous system&
o Primary varicose veins are more common in ,omen and patients ,ith a strong
family history and are proaly caused y congenital ,ea'ness of the veins&
o Becondary varicose veins typically result from a previous =3T&
o Becondary varicose veins also may occur in the esophagus, in the anorectal area,
and as anormal arteriovenous connections&
o ?eticular veins are smaller varicose veins that appear flat, less tortuous, and lue+
green in color&
o Telangiectasias ('no,n as spider veins) are very small visile vessels that appear
luish+lac', purple, or red&
The etiology of varicose veins is un'no,n and ris' factors include congenital
,ea'ness of the vein structure, female gender, use of hormones (oral contraceptives
or >?T), increasing age, oesity, pregnancy, venous ostruction resulting from
thromosis or e)trinsic pressure y tumors, or occupations that re<uire prolonged
standing&
The most common symptom of varicose veins is an ache or pain after prolonged
standing, ,hich is relieved y ,al'ing or y elevating the lim& Nocturnal leg cramps
in the calf may occur&
Treatment usually is not indicated if varicose veins are only a cosmetic prolem&
Collaorative care involves rest ,ith the affected lim elevated, compression
stoc'ings, and e)ercise, such as ,al'ing&
5n heral therapy used for the treatment of varicose veins is horse chestnut seed
e)tract&
Bclerotherapy involves the in#ection of a sustance that oliterates venous
telangiectasias, reticular veins, and small, superficial varicose veins&
Ne,er, more costly, noninvasive options for the treatment of venous telangiectasias
include laser therapy and high+intensity pulsed+light therapy&
1+1%C
Key Points
Burgical intervention is indicated for recurrent thromophleitis or ,hen chronic
venous insufficiency cannot e controlled ,ith conservative therapy&
o Burgical intervention involves ligation of the entire vein (usually the greater
saphenous) and dissection and removal of its incompetent triutaries&
o 5n alternative techni<ue is amulatory phleectomy, ,hich involves pulling
the varicosity through a /sta0 incision, follo,ed y e)cision of the vein&
o Ne,er, less invasive procedures include endovenous occlusion using
radiofre<uency closure or laser, or transilluminated po,ered phleectomy&
Prevention is a 'ey factor related to varicose veins and the patient should avoid sitting
or standing for long periods of time, maintain ideal ody ,eight, ta'e precautions
against in#ury to the e)tremities, avoid ,earing constrictive clothing, and participate
in a daily ,al'ing program&
C)-$N'C 2N$5S 'NS5++'C'NC6 AND L4 5LC-S
Chronic !enous insufficienc. (C3.) is a condition in ,hich the valves in the veins are
damaged, ,hich results in retrograde venous lood flo,, pooling of lood in the legs, and
s,elling&
C3. often occurs as a result of previous episodes of =3T and can lead to venous leg
ulcers&
Causes of C3. include vein incompetence, deep vein ostruction, congenital venous
malformation, 53 fistula, and calf muscle failure&
o ;ver time, the s'in and sucutaneous tissue around the an'le are replaced y
firous tissue, resulting in thic', hardened, contracted s'in&
o The s'in of the lo,er leg is leathery, ,ith a characteristic ro,nish or /ra,ny0
appearance from the hemosiderin deposition&
o *dema and eczema, or /stasis dermatitis,0 are often present, and pruritus is a
common complaint&
3enous ulcers classically are located aove the medial malleolus&
o The ,ound margins are irregularly shaped, and the tissue is typically a ruddy
color&
o 4lcer drainage may e e)tensive, especially ,hen the leg is edematous&
o Pain is present and may e ,orse ,hen the leg is in a dependent position&
Compression is essential to the management of C3., venous ulcer healing, and
prevention of ulcer recurrence&
o ;ptions include elastic ,raps, custom+fitted compression stoc'ings, elastic
tuular support andages, a 3elcro ,rap, intermittent compression devices, a
paste andage ,ith an elastic ,rap, and multilayer (three or four) andage
systems&
o :oist environment dressings are the mainstay of ,ound care and include
transparent film dressings, hydrocolloids, hydrogels, foams, calcium alginates,
1+1%D
Key Points
impregnated gauze, gauze moistened ,ith saline, and comination dressings&
o Nutritional status and inta'e should e evaluated in a patient ,ith a venous leg
ulcer&
o ?outine prophylactic antiiotic therapy typically is not indicated&
o Clinical signs of infection in a venous ulcer include change in <uantity, color, or
odor of the drainage! presence of pus! erythema of the ,ound edges! change in
sensation around the ,ound! ,armth around the ,ound! increased local pain,
edema, or oth! dar'+colored granulation tissue! induration around the ,ound!
delayed healing! and cellulitis&
The usual treatment for infection is sharp deridement, ,ound e)cision,
and systemic antiiotics&
.f the ulcer fails to respond to conservative therapy, alternative treatments
may include use of a radiant heat andage, vacuum+assisted closure
therapy, and coverage ,ith a split+thic'ness s'in graft, cultured epithelial
autograft, allograft, or ioengineered s'in&
o 5n heral therapy used for the treatment of C3. is horse chestnut seed e)tract&
2ong+term management of venous leg ulcers should focus on teaching the patient aout
self+care measures ecause the incidence of recurrence is high&
o Proper foot and leg care is essential to avoid additional trauma to the s'in&
o The patient ,ith C3. ,ith or ,ithout a venous ulcer is instructed to avoid
standing or sitting ,ith the feet dependent for long periods&
o 3enous ulcer patients are instructed to elevate their legs aove the level of the
heart to reduce edema&
;nce an ulcer is healed, a daily ,al'ing program is encouraged&
Prescription compression stoc'ings should e ,orn daily and replaced
every % to D months to reduce the occurrence of C3.&
th
edition
Key Points
Chapter $E: Nursing 5ssessment: Aastrointestinal Bystem
The main function of the gastrointestinal (A.) system is to supply nutrients to ody cells&
The A. tract is innervated y the autonomic nervous system& The parasympathetic system
is mainly e)citatory, and the sympathetic system is mainly inhiitory&
1+1%9
Key Points
The t,o types of movement of the A. tract are mi)ing %segmentation& and propulsion
%peristalsis&#
The secretions of the A. system consist of enzymes and hormones for digestion, mucus
to provide protection and lurication, ,ater, and electrolytes&
:outh:
o The mouth consists of the lips and oral (uccal) cavity&
o The main function of saliva is to luricate and soften the food mass, thus
facilitating s,allo,ing&
Pharyn): a musculomemranous tue that is divided into the nasopharyn), oropharyn),
and laryngeal pharyn)&
*sophagus:
o 5 hollo,, muscular tue that receives food from the pharyn) and moves it to the
stomach y peristaltic contractions&
o 2o,er esophageal sphincter (2*B) at the distal end remains contracted e)cept
during s,allo,ing, elching, or vomiting&
Btomach:
o The functions are to store food, mi) the food ,ith gastric secretions, and empty
contents into the small intestine at a rate at ,hich digestion can occur&
o The secretion of >Cl acid ma'es gastric #uice acidic&
o .ntrinsic factor promotes coalamin asorption in the small intestine&
Bmall intestine: t,o primary functions are digestion and absor"tion(
2arge intestine:
o The four parts are (1) the cecum and appendi)! (") the colon (ascending,
transverse, descending, sigmoid colon)! ($) the rectum! and (%) the anus&
o The most important function of the large intestine is the asorption of ,ater and
electrolytes&
2iver:
o >epatocytes are the functional unit of the liver&
o .s essential for life& .t functions in the manufacture, storage, transformation, and
e)cretion of a numer of sustances involved in metaolism&
6iliary tract:
o Consists of the gallladder and the duct system&
o 6ile is produced in the liver and stored in the gallladder& 6ile consists of
bilirubin, ,ater, cholesterol, ile salts, electrolytes, and phospholipids&
1+1%F
Key Points
Pancreas:
o The e)ocrine function of the pancreas contriutes to digestion&
o The endocrine function occurs in the islets of 2angerhans, ,hose eta cells
secrete insulin! alpha cells secrete glucagon! and delta cells secrete somatostatin&
5ging causes changes in the functional aility of the A. system&
Merostomia (decreased saliva production) or dry mouth is common&
Taste uds decrease, the sense of smell diminishes, and salivary secretions diminish,
,hich can lead to a decrease in appetite&
5lthough constipation is a common complaint of elderly patients, age+related changes in
colonic secretion or motility have not een consistently sho,n&
The liver size decreases after C8 years of age, ut liver function tests remain ,ithin
normal ranges& There is decreased aility to metaolize drugs and hormones&
ASSSSMN,
Bu#ective data:
o .mportant health information: the patient is as'ed aout adominal pain, nausea
and vomiting, diarrhea, constipation, adominal distention, #aundice, anemia,
hearturn, dyspepsia, changes in appetite, hematemesis, food intolerance or
allergies, e)cessive gas, loating, melena, hemorrhoids, or rectal leeding&
o The patient is as'ed aout (1) history or e)istence of diseases such as gastritis,
hepatitis, colitis, gallladder disease, peptic ulcer, cancer, or hernias! (") ,eight
history! ($) past and current use of medications and prior hospitalizations for A.
prolems&
o :any chemicals and drugs are potentially hepatoto)ic and result in significant
patient harm unless monitored closely&
;#ective data:
o 5nthropometric measurements (height, ,eight, s'infold thic'ness) and lood
studies (e&g&, serum protein, alumin, hemogloin) may e performed&
o Physical e)amination
:outh& The lips are inspected for symmetry, color, and size& The lips,
tongue, and uccal mucosa are oserved for lesions, ulcers, fissures, and
pigmentation&
5domen& The s'in is assessed for changes (color, te)ture, scars, striae,
dilated veins, rashes, lesions), symmetry, contour, oservale masses, and
movement&
5uscultation of the four <uadrants of the adomen includes listening for
increased or decreased o,el sounds and vascular sounds&
1+1%E
Key Points
Percussion of the adomen is done to determine the presence of distention,
fluid, and masses& The nurse lightly percusses all four <uadrants of the
adomen&
2ight palpation is used to detect tenderness or cutaneous hypersensitivity,
muscular resistance, masses, and s,elling&
=eep palpation is used to delineate adominal organs and masses&
?eound tenderness indicates peritoneal inflammation&
=uring inspiration the liver edge should feel firm, sharp, and smooth& The
surface and contour and any tenderness are descried&
The spleen is normally not palpale& .f palpale, manual compression of
an enlarged spleen may cause it to rupture&
The perianal and anal areas should e inspected for color, te)ture, lumps,
rashes, scars, erythema, fissures, and e)ternal hemorrhoids&
D'A4N$S,'C S,5D'S
:any of the diagnostic procedures of the A. system re<uire measures to cleanse the A.
tract, as ,ell as the use of a contrast medium or a radiopa<ue tracer&
5n upper A. series ,ith small o,el follo,+through provides visualization of the
esophagus, stomach, and small intestine&
5 lo,er A. series (arium enema) )+ray e)amination is done to detect anormalities in
the colon&
4ltrasonography is used to sho, the size and configuration of organs&
3irtual colonoscopy comines computed tomography (CT) scanning or magnetic
resonance imaging (:?.)&
ndosco". refers to the direct visualization of a ody structure through a lighted
fieroptic instrument&
?etrograde cholangiopancreatography (*?CP) is an endoscopic procedure that visualizes
the pancreatic, hepatic, and common ile ducts&
*ndoscopy of the A. tract is often done ,ith iopsy and cytologic studies& 5 complication
of A. endoscopy is perforation&
Capsule endoscopy is a noninvasive approach to visualize the A. tract&
2iver iopsy is performed to otain tissue for diagnosis of firosis, cirrhosis, and
neoplasms&
2iver function tests reflect hepatic disease and function&
1+1C8
Key Points
th
edition
Key Points
Chapter %8: Nursing :anagement: Nutritional Prolems
Aood nutrition in the asence of any underlying disease process results from the
ingestion of a alanced diet&
The :yPyramid (formerly the @ood Auide Pyramid) consists of food groups that are
presented in proportions appropriate for a healthy diet, including grains, vegetales,
fruits, oils, mil', and meat and eans&
The National ?esearch Council recommends that at least half of the ody(s energy needs
should come from carohydrates, especially comple) carohydrates&
The =ietary Auidelines for 5mericans "88C from Healthy People '()( recommends that
people reduce their fat inta'e to "8K to $CK of their total daily caloric inta'e&
5n average adult re<uires an estimated "8 to $C calories per 'ilogram of ody ,eight per
day, leaning to,ard the higher end if the person is critically ill or very active and the
lo,er end if the person is sedentary&
The recommended daily protein inta'e is 8&F to 1 g1'g of ody ,eight&
3egetarians can have vitamin or protein deficiencies unless their diets are ,ell planned&
Culture, personal preferences, socioeconomic status, and religious preferences can
influence food choices&
The nurse should include cultural and ethnic considerations ,hen assessing the patient(s
diet history and implementing interventions that re<uire dietary changes&
MALN5,-','$N
Malnutrition is common in hospitalized patients&
-ith starvation, the ody initially uses carohydrates (glycogen) rather than fat and
protein to meet metaolic needs& ;nce carohydrate stores are depleted, protein egins to
e converted to glucose for energy&
1+1C1
Key Points
@actors that contriute to malnutrition include socioeconomic status, cultural influences,
psychologic disorders, medical conditions, and medical treatments&
?egardless of the cause of the illness, most sic' persons have increased nutritional needs&
*ach degree of temperature increase on the @ahrenheit scale raises the asal metaolic
rate (6:?) y aout 9K&
Prolonged illness, ma#or surgery, sepsis, draining ,ounds, urns, hemorrhage, fractures,
and immoilization can all contriute to malnutrition&
;n physical e)amination, the most ovious clinical signs of inade<uate protein and
calorie inta'e are apparent in the s'in, eyes, mouth, muscles, and the central nervous
system&
The malnourished person is more susceptile to all types of infection&
5cross all settings of care delivery, the nurse must e a,are of the nutritional status of
the patient&
The protein and calorie inta'e re<uired in the malnourished patient depends on the cause
of the malnutrition, the treatment eing employed, and other stressors affecting the
patient&
The older patient is at ris' for nutritional prolems due to the follo,ing factors:
o Changes in the oral cavity
o Changes in digestion and motility
o Changes in the endocrine system
o Changes in the musculos'eletal system
o =ecreases in vision and hearing
>igh+calorie oral supplements may e used in the patient ,hose nutritional inta'e is
deficient&
,5/ +D'N4S
,ube feeding (also 'no,n as enteral nutrition) may e ordered for the patient ,ho has a
functioning A. tract ut is unale to ta'e any or enough oral nourishment&
5 gastrostomy tue may e used for a patient ,ho re<uires tue feedings over an
e)tended time&
The most accurate assessment for correct tue placement is y )+ray visualization&
PA-N,-AL N5,-','$N
1+1C"
Key Points
Parenteral nutrition (PN) is used to meet the patient(s nutritional needs and to allo,
gro,th of ne, ody tissue&
5ll parenteral nutrition solutions should e prepared y a pharmacist or a trained
technician using strict aseptic techni<ues under a laminar flo, hood&
Complications of parenteral nutrition include infectious, metaolic, and mechanical
prolems&
&
th
edition
Key Points
C>5PT*? %1: N4?B.NA :5N5A*:*NT: ;6*B.TW
$/S',6
$besit. is the most common nutritional prolem, affecting almost one third of the
population&
5ppro)imately 1$K of 5mericans have a bod. mass inde1 (6:.) greater than $C 'g1m
"
&
;esity is the second leading cause of preventale disease in the 4nited Btates, after
smo'ing&
The cause of oesity involves significant genetic1iologic susceptiility factors that are
highly influenced y environmental and psychosocial factors&
The degree to ,hich a patient is classified as under,eight, healthy (normal) ,eight,
o!erweight, or obese is assessed y using a 6:. chart&
.ndividuals ,ith fat located primarily in the adominal area (apple+shaped ody) are at a
greater ris' for oesity+related complications than those ,hose fat is primarily located in
the upper legs (pear+shaped ody)&
Complications or ris' factors related to oesity include the follo,ing:
o Cardiovascular disease in oth men and ,omen
o Bevere oesity may e associated ,ith sleep apnea and oesity1hypoventilation
syndrome&
o Type " diaetes mellitus! as many as F8K of patients ,ith type " diaetes are
oese
1+1C$
Key Points
o ;steoarthritis, proaly ecause of the trauma to the ,eight+earing #oints and
gout
o Aastroesophageal reflu) disease (A*?=), gallstones, and nonalcoholic
steatohepatitis (N5B>)
o 6reast, endometrial, ovarian, and cervical cancer is increased in oese ,omen
-hen patients ,ho are oese have surgery, they are li'ely to suffer from other
comoridities, including diaetes, altered cardiorespiratory function, anormal metaolic
function, hemostasis, and atherosclerosis that place them at ris' for complications related
to surgery&
:easurements used ,ith the oese person may include s'infold thic'ness, height, ,eight,
and 6:.&
The overall goals for the oese patient include the follo,ing:
o :odifying eating patterns
o Participating in a regular physical activity program
o 5chieving ,eight loss to a specified level
o :aintaining ,eight loss at a specified level
o :inimizing or preventing health prolems related to oesity
;esity is considered a chronic condition that necessitates day+to+day attention to lose
,eight and maintain ,eight loss&
Persons on lo,+calorie and very+lo,+calorie diets need fre<uent professional monitoring
ecause the severe energy restriction places them at ris' for multiple nutrient
deficiencies&
?estricted food inta'e is a cornerstone for any ,eight loss or maintenance program&
:otivation is an essential ingredient for successful achievement of ,eight loss&
*)ercise is an important part of a ,eight control program& *)ercise should e done daily,
preferaly $8 minutes to an hour a day&
4seful asic techni<ues for ehavioral modification include self+monitoring, stimulus
control, and re,ards&
=rugs approved for ,eight loss can e classified into t,o categories, including those that
decrease the follo,ing:
o @ood inta'e y reducing appetite or increasing satiety (sense of feeling full after
eating)
o Nutrient asorption
1+1C%
Key Points
/ariatric surger. is currently the only treatment that has een found to have a successful
and lasting impact for sustained ,eight loss for severely oese individuals&
o -ound infection is one of the most common complications after surgery&
o *arly amulation follo,ing surgery is important for the oese patient&
o 2ate complications follo,ing ariatric surgery include anemia, vitamin
deficiencies, diarrhea, and psychiatric prolems&
;esity in older adults can e)acerate age+related declines in physical function and lead
to frailty and disaility&
M,A/$L'C S6ND-$M
Metabolic s.ndrome is a collection of ris' factors that increase an individual(s chance of
developing cardiovascular disease and diaetes mellitus&
2ifestyle therapies are the first+line interventions to reduce the ris' factors for metaolic
syndrome&
th
edition
Key Points
Chapter %": Nursing :anagement: 4pper Aastrointestinal Prolems
NA5SA AND 2$M','N4
Nausea and !omiting are found in a ,ide variety of gastrointestinal (A.) disorders&
They are also found in conditions that are unrelated to A. disease, including pregnancy,
infectious diseases, central nervous system (CNB) disorders (e&g&, meningitis),
cardiovascular prolems (e&g&, myocardial infarction), metaolic disorders (e&g&, diaetes
mellitus), side effects of drugs (e&g&, chemotherapy, opioids), and psychologic factors
(e&g&, fear)&
3omiting can occur ,hen the A. tract ecomes overly irritated, e)cited, or distended&
o .t can e a protective mechanism to rid the ody of spoiled or irritating foods and
li<uids&
o Pulmonary aspiration is a concern ,hen vomiting occurs in the patient ,ho is
elderly, is unconscious, or has other conditions that impair the gag refle)&
o The color of the emesis aids in identifying the presence and source of leeding&
=rugs that control nausea and vomiting include anticholinergics (e&g&, scopolamine),
antihistamines (e&g&, promethazine HPhenerganI), phenothiazines (e&g&, chlorpromazine
1+1CC
Key Points
HThorazineI, prochlorperazine HCompazineI), and utyrophenones (e&g&, droperidol
H.napsineI)&
The patient ,ith severe or prolonged vomiting is at ris' for dehydration and acid+ase
and electrolyte imalances& The patient may re<uire intravenous (.3) fluid therapy ,ith
electrolyte and glucose replacement until ale to tolerate oral inta'e&
5""er 4astrointestinal /leeding
The mortality rate for upper A. leeding remains at DK to 18K despite advances in
intensive care, hemodynamic monitoring, and endoscopy&
The severity of leeding depends on ,hether the origin is venous, capillary, or arterial&
6leeding ulcers account for C8K of the cases of upper A. leeding&
=rugs such as aspirin, nonsteroidal antiinflammatory agents, and corticosteroids are a
ma#or cause of upper A. leeding&
5lthough appro)imately F8K to FCK of patients ,ho have massive hemorrhage
spontaneously stop leeding, the cause must e identified and treatment initiated
immediately&
The immediate physical e)amination includes a systemic evaluation of the patient(s
condition ,ith emphasis on lood pressure, rate and character of pulse, peripheral
perfusion ,ith capillary refill, and oservation for the presence or asence of nec' vein
distention& 3ital signs are monitored every 1C to $8 minutes&
The goal of endoscopic hemostasis is to coagulate or thromose the leeding artery&
Beveral techni<ues are used including thermal (heat) proe, multipolar and ipolar
electrocoagulation proe, argon plasma coagulation, and neodymium:yttrium+aluminum+
garnet (Nd:W5A) laser&
The patient undergoing vasopressin therapy is closely monitored for its myocardial,
visceral, and peripheral ischemic side effects&
The nursing assessment for the patient ,ith upper A. leeding includes the patient(s level
of consciousness, vital signs, appearance of nec' veins, s'in color, and capillary refill&
The adomen is chec'ed for distention, guarding, and peristalsis&
The patient ,ho re<uires regular administration of ulcerogenic drugs, such as aspirin,
corticosteroids, or NB5.=s, needs instruction regarding the potential adverse effects
related to A. leeding&
=uring the acute leeding phase an accurate inta'e and output record is essential so that
the patient(s hydration status can e assessed&
1+1CD
Key Points
;nce fluid replacement has een initiated, the older adult or the patient ,ith a history of
cardiovascular prolems is oserved closely for signs of fluid overload&
The ma#ority of upper A. leeding episodes cease spontaneously, even ,ithout
intervention&
:onitoring the patient(s laoratory studies enales the nurse to estimate the effectiveness
of therapy&
The patient and family are taught ho, to avoid future leeding episodes& 4lcer disease,
drug or alcohol ause, and liver and respiratory diseases can all result in upper A.
leeding&
$ral 'nfections and 'nflammations
:ay e specific mouth diseases, or they may occur in the presence of systemic disorders
such as leu'emia or vitamin deficiency&
The patient ,ho is immunosuppressed (e&g&, patient ,ith ac<uired immunodeficiency
syndrome or receiving chemotherapy) is most susceptile to oral infections& The patient
on oral corticosteroid inhaler treatment for asthma is also at ris'&
:anagement of oral infections and inflammation is focused on identification of the
cause, elimination of infection, provision of comfort measures, and maintenance of
nutritional inta'e&
$ral %or $ro"har.ngeal& Cancer
:ay occur on the lips or any,here ,ithin the mouth (e&g&, tongue, floor of the mouth,
uccal mucosa, hard palate, soft palate, pharyngeal ,alls, tonsils)&
>ead and nec' s<uamous cell carcinoma is an umrella term for cancers of the oral
cavity, pharyn), and laryn)& 5ccounts for E8K of malignant oral tumors&
The overall goals are that the patient ,ith carcinoma of the oral cavity ,ill (1) have a
patent air,ay, (") e ale to communicate, ($) have ade<uate nutritional inta'e to
promote ,ound healing, and (%) have relief of pain and discomfort&
4AS,-$S$P)A4AL -+L58 D'SAS %4-D&
There is no one single cause of gastroeso"hageal reflu1 disease (A*?=)& .t can occur
,hen there is reflu) of acidic gastric contents into the esophagus&
Predisposing conditions include hiatal hernia, incompetent lo,er esophageal sphincter,
decreased esophageal clearance (aility to clear li<uids or food from the esophagus into
the stomach) resulting from impaired esophageal motility, and decreased gastric
emptying&
1+1C9
Key Points
5 complication of A*?= is /arrett<s eso"hagus (esophageal metaplasia), ,hich is
considered a precancerous lesion that increases the patient(s ris' for esophageal cancer&
:ost patients ,ith A*?= can e successfully managed y lifestyle modifications and
drug therapy&
=rug therapy for A*?= is focused on improving 2*B function, increasing esophageal
clearance, decreasing volume and acidity of reflu), and protecting the esophageal
mucosa&
6ecause of the lin' et,een A*?= and 6arrett(s esophagus, patients are instructed to see
their health care provider if symptoms persist&
)'A,AL )-N'A
The t,o most common types of hiatal hernia are sliding and paraesophageal (rolling)&
@actors that predispose to hiatal hernia development include increased intraadominal
pressure, including oesity, pregnancy, ascites, tumors, tight girdles, intense physical
e)ertion, and heavy lifting on a continual asis& ;ther factors are increased age, trauma,
poor nutrition, and a forced recument position (e&g&, prolonged ed rest)&
so"hageal Cancer
T,o important ris' factors for eso"hageal cancer are smo'ing and e)cessive alcohol
inta'e&
4astritis
4astritis occurs as the result of a rea'do,n in the normal gastric mucosal arrier&
=rugs such as aspirin, nonsteroidal antiinflammatory drugs (NB5.=s), digitalis, and
alendronate (@osama)) have direct irritating effects on the gastric mucosa& =ietary
indiscretions can also result in acute gastritis&
The symptoms of acute gastritis include anore)ia, nausea and vomiting, epigastric
tenderness, and a feeling of fullness&
Pe"tic 5lcer Disease
Aastric and duodenal ulcers, although defined as "e"tic ulcer disease (P4=), are
different in their etiology and incidence&
=uodenal ulcers are more common than gastric ulcers&
The organism Helicobacter pylori is found in the ma#ority of patients ,ith P4=&
1+1CF
Key Points
5lcohol, nicotine, and drugs such as aspirin and nonsteroidal antiinflammatory drugs
play a role in gastric ulcer development&
The three ma#or complications of chronic P4= are hemorrhage, perforation, and gastric
outlet ostruction& 5ll are considered emergency situations and are initially treated
conservatively&
*ndoscopy is the most commonly used procedure for diagnosis of P4=&
Treatment of P4= includes ade<uate rest, dietary modifications, drug therapy,
elimination of smo'ing, and long+term follo,+up care& The aim is to decrease gastric
acidity, enhance mucosal defense mechanisms, and minimize the harmful effects on the
mucosa&
The drugs most commonly used to treat P4= are histamine (>
"
)+receptor loc'ers,
proton pump inhiitors, and antacids& 5ntiiotics are employed to eradicate H# pylori
infection&
The immediate focus of management of a patient ,ith a perforation is to stop the spillage
of gastric or duodenal contents into the peritoneal cavity and restore lood volume&
The aim of therapy for gastric outlet ostruction is to decompress the stomach, correct
any e)isting fluid and electrolyte imalances, and improve the patient(s general state of
health&
;verall goals for the patient ,ith P4= include compliance ,ith the prescried
therapeutic regimen, reduction or asence of discomfort, no signs of A. complications,
healing of the ulcer, and appropriate lifestyle changes to prevent recurrence&
Burgical procedures for P4= include partial gastrectomy, vagotomy, and1or pyloroplasty&
S,$MAC) Cancer
Btomach (gastric) cancers often spread to ad#acent organs efore any distressing
symptoms occur&
The nursing role in the early detection of stomach cancer is focused on identification of
the patient at ris' ecause of specific disorders such as pernicious anemia and
achlorhydria&
-. coli $?C7:)7$?C7:)7
.t is the organism most commonly associated ,ith food+orne illness&
.t is found primarily in undercoo'ed meats, such as hamurger, roast eef, ham, and
tur'ey&
1+1CE
Key Points
th
edition
Key Points
Chapter %$: Nursing :anagement: 2o,er Aastrointestinal Prolems
Diarrhea
Diarrhea is most commonly defined as an increase in stool fre<uency or volume, and an increase in the
looseness of stool&
=iarrhea can result from alterations in gastrointestinal motility, increased secretion, and
decreased asorption&
5ll cases of acute diarrhea should e considered infectious until the cause is 'no,n&
Patients receiving antiiotics (e&g&, clindamycin HCleocinI, ampicillin, amo)icillin,
cephalosporin) are susceptile to Clostridium difficile %C# difficile&, ,hich is a serious
acterial infection&
+ecal 'ncontinence
+ecal incontinence, the involuntary passage of stool, occurs ,hen the normal structures
that maintain continence are disrupted&
?is' factors include constipation, diarrhea, ostetric trauma, and fecal impaction&
Prevention and treatment of fecal incontinence may e managed y implementing a
o,el training program&
C$NS,'PA,'$N
Consti"ation can e defined as a decrease in the fre<uency of o,el movements from
,hat is /normal0 for the individual! hard, difficult+to+pass stools! a decrease in stool
volume! and1or retention of feces in the rectum&
The overall goals are that the patient ,ith constipation is to increase dietary inta'e of
fier and fluids! increase physical activity! have the passage of soft, formed stools! and
not have any complications, such as leeding hemorrhoids&
5n important role of the nurse is teaching the patient the importance of dietary measures
to prevent constipation&
1+1D8
Key Points
Abdominal Pain, ,rauma, and 'nflammator. Disorders
5cute adominal pain is a symptom of many different types of tissue in#ury and can arise
from damage to adominal or pelvic organs and lood vessels&
Pain is the most common symptom of an acute adominal prolem&
The goal of management of the patient ,ith acute adominal pain is to identify and treat
the cause and monitor and treat complications, especially shoc'&
6o,el sounds that are diminished or asent in a <uadrant may indicate a complete o,el
ostruction, acute peritonitis, or paralytic ileus&
*)pected outcomes for the patient ,ith acute adominal pain include resolution of the
cause of the acute adominal pain! relief of adominal pain and discomfort! freedom
from complications (especially hypovolemic shoc' and septicemia)! and normal fluid,
electrolyte, and nutritional status&
Common causes of chronic adominal pain include irritable bowel s.ndrome (.6B),
diverticulitis, peptic ulcer disease, chronic pancreatitis, hepatitis, cholecystitis, pelvic
inflammatory disease, and vascular insufficiency&
The adominal pain or discomfort associated ,ith .6B is most li'ely due to increased
visceral sensitivity&
Abdominal ,rauma
6lunt trauma commonly occurs ,ith motor vehicle accidents and falls and may not e
ovious ecause it does not leave an open ,ound&
Common in#uries of the adomen include lacerated liver, ruptured spleen, pancreatic
trauma, mesenteric artery tears, diaphragm rupture, urinary ladder rupture, great vessel
tears, renal in#ury, and stomach or intestine rupture&
A""endicitis
A""endicitis results in distention, venous engorgement, and the accumulation of mucus
and acteria, ,hich can lead to gangrene and perforation&
5ppendicitis typically egins ,ith periumilical pain, follo,ed y anore)ia, nausea, and
vomiting& The pain is persistent and continuous, eventually shifting to the right lo,er
<uadrant and localizing at :c6urney(s point&
4ntil a health care provider sees the patient, nothing should e ta'en y mouth (NP;) to
ensure that the stomach is empty in the event that surgery is needed&
1+1D1
Key Points
Peritonitis
Peritonitis results from a localized or generalized inflammatory process of the
peritoneum&
5ssessment of the patient(s adominal pain, including the location, is important and may
help in determining the cause of peritonitis&
4astroenteritis
4astroenteritis is an inflammation of the mucosa of the stomach and small intestine&
Clinical manifestations include nausea, vomiting, diarrhea, adominal cramping, and distention& :ost cases
are self+limiting and do not re<uire hospitalization&
.f the causative agent is identified, appropriate antiiotic and antimicroial drugs are given&
Bymptomatic nursing care is given for nausea, vomiting, and diarrhea&
'nflammator. /owel Disease
Crohn<s disease and ulcerati!e colitis are immunologically related disorders that are
referred to as inflammator. bowel disease (.6=)&
.6= is characterized y mild to severe acute e)acerations that occur at unpredictale intervals over many
years&
4lcerative colitis usually starts in the rectum and moves in a continual fashion to,ard the
cecum& 5lthough there is sometimes mild inflammation in the terminal ileum, ulcerative
colitis is a disease of the colon and rectum&
Crohn(s disease can occur any,here in the A. tract from the mouth to the anus, ut
occurs most commonly in the terminal ileum and colon& The inflammation involves all
layers of the o,el ,all ,ith segments of normal o,el occurring et,een diseased
portions, the so+called /s'ip lesions&0
-ith Crohn(s disease, diarrhea and colic'y adominal pain are common symptoms& .f the small intestine is
involved, ,eight loss occurs due to malasorption& .n addition, patients may have systemic symptoms such
as fever& The primary symptoms of ulcerative colitis are loody diarrhea and adominal pain&
The goals of treatment for .6= include rest the o,el, control the inflammation, comat infection, correct
malnutrition, alleviate stress, provide symptomatic relief, and improve <uality of life&
Nutritional prolems are especially common ,ith Crohn(s disease ,hen the terminal
ileum is involved&
1+1D"
Key Points
The follo,ing five ma#or classes of medications are used to treat .6=:
o 5minosalicylates
o 5ntimicroials
o Corticosteroids
o .mmunosuppressants
o 6iologic therapy
Burgery is indicated if the patient ,ith .6= fails to respond to treatment! e)acerations
are fre<uent and deilitating! massive leeding, perforation, strictures, and1or ostruction
occur! tissue changes suggest that dysplasia is occurring! or carcinoma develops&
=uring an acute e)aceration of .6=, nursing care is focused on hemodynamic staility,
pain control, fluid and electrolyte alance, and nutritional support&
Nurses and other team memers can assist patients to accept the chronicity of .6= and
learn strategies to cope ,ith its recurrent, unpredictale nature&
'ntestinal $bstruction
The causes of intestinal obstruction can e classified as mechanical or nonmechanical&
.ntestinal ostruction can e a life+threatening prolem&
Cancer is the most common cause of large o,el ostruction, follo,ed y volvulus and
diverticular disease&
*mergency surgery is performed if the o,el is strangulated, ut many o,el
ostructions resolve ,ith conservative treatment&
-ith a o,el ostruction, there is retention of fluid in the intestine and peritoneal cavity,
,hich can result in a severe reduction in circulating lood volume and lead to
hypotension and hypovolemic shoc'&
Pol."s
5denomatous polyps are characterized y neoplastic changes in the epithelium and are
closely lin'ed to colorectal adenocarcinoma&
@amilial adenomatous polyposis (@5P) is the most common hereditary polyp disease&
Colorectal Cancer
Colorectal cancer is the third most common form of cancer and the second leading cause
of cancer+related deaths in the 4nited Btates&
:ost people ,ith colorectal cancer have hematochezia (passage of lood through rectum)
or melena (lac', tarry stools), adominal pain, and1or changes in o,el haits&
1+1D$
Key Points
The 5merican Cancer Bociety recommends that a person ,ho has no estalished ris'
factors should have a fecal occult lood test (@;6T) or a fecal immunochemical test
(@.T) yearly, a doule+contrast enema every C years, a sigmoidoscopy every C years, or a
colonoscopy every 18 years starting at age C8&
Colonoscopy is the gold standard for colorectal cancer screening&
Burgery for a rectal cancer may include an adominal+perineal resection& Potential
complications of adominal+perineal resection include delayed ,ound healing,
hemorrhage, persistent perineal sinus tracts, infections, and urinary tract and se)ual
dysfunctions&
Chemotherapy is used oth as an ad#uvant therapy follo,ing colon resection and as
primary treatment for nonresectale colorectal cancer&
The goals for the patient ,ith colorectal cancer include normal o,el elimination
patterns, <uality of life appropriate to disease progression, relief of pain, and feelings of
comfort and ,ell+eing&
Psychologic support for the patient ,ith colorectal cancer and family is important& The
recovery period is long, and the cancer could return&
5n ostom. is used ,hen the normal elimination route is no longer possile&
The t,o ma#or aspects of nursing care for the patient undergoing ostomy surgery are (1)
emotional support as the patient copes ,ith a radical change in ody image, and (")
patient teaching aout the many aspects of stoma care and the ostomy&
6o,el preparations are used to empty the intestines efore surgery to decrease the chance
of a postoperative infection caused y acteria in the feces&
Postoperative nursing care includes assessment of the stoma and provision of an
appropriate pouching system that protects the s'in and contains drainage and odor&
The patient should e ale to perform a pouch change, provide appropriate s'in care,
control odor, care for the stoma, and identify signs and symptoms of complications&
Colostomy irrigations are used to stimulate emptying of the colon in order to achieve a
regular o,el pattern& .f control is achieved, there should e little or no spillage et,een
irrigations&
The patient ,ith an ileostom. should e oserved for signs and symptoms of fluid and
electrolyte imalance, particularly potassium, sodium, and fluid deficits&
1+1D%
Key Points
6o,el surgery can disrupt nerve and vascular supply to the genitals& ?adiation therapy,
chemotherapy, and medications can also alter se)ual function&
Concerns of people ,ith stomas include the aility to resume se)ual activity, altering
clothing styles, the effect on daily activities, sleeping ,hile ,earing a pouch, passing gas,
the presence of odor, cleanliness, and deciding ,hen or if to tell others aout the stoma&
Di!erticular Disease
=iverticular disease covers a spectrum from asymptomatic, uncomplicated diverticulosis
to diverticulitis ,ith complications such as perforation, ascess, fistula, and leeding&
=iverticular disease is a common disorder that affects CK of the 4&B& population y age
%8 years and C8K y age F8 years&
The ma#ority of patients ,ith diverticular disease are asymptomatic&
Bymptomatic diverticular disease can e further ro'en do,n into the follo,ing:
o Painful diverticular disease
o =iverticulitis (inflammation of the diverticuli)
Complications of diverticulitis include perforation ,ith peritonitis&
5 high+fier diet, mainly from fruits and vegetales, and decreased inta'e of fat and red
meat are recommended for preventing diverticular disease&
)-N'A
5 hernia is a protrusion of a viscus through an anormal opening or a ,ea'ened area in
the ,all of the cavity in ,hich it is normally contained&
.f the hernia ecomes strangulated, the patient ,ill e)perience severe pain and symptoms
of a o,el ostruction, such as vomiting, cramping adominal pain, and distention&
MALA/S$-P,'$N S6ND-$M
:alasorption results from impaired asorption of fats, carohydrates, proteins, minerals,
and vitamins&
Causes of malasorption include the follo,ing:
o 6iochemical or enzyme deficiencies
o 6acterial proliferation
o =isruption of small intestine mucosa
o =istured lymphatic and vascular circulation
o Burface area loss
1+1DC
Key Points
Celiac Disease
Three factors necessary for the development of celiac disease (gluten intolerance) are
genetic predisposition, gluten ingestion, and an immune+mediated response&
*arly diagnosis and treatment of celiac disease can prevent complications such as cancer
(e&g&, intestinal lymphoma), osteoporosis, and possily other autoimmune diseases&
Celiac disease is treated ,ith lifelong avoidance of dietary gluten& -heat, arley, oats,
and rye products must e avoided&
LAC,AS D+'C'NC6
The symptoms of lactose intolerance include loating, flatulence, cramping adominal
pain, and diarrhea& They usually occur ,ithin $8 minutes to several hours after drin'ing a
glass of mil' or ingesting a mil' product&
Treatment consists of eliminating lactose from the diet y avoiding mil' and mil'
products and1or replacement of lactase ,ith commercially availale preparations&
$ther Lower 4' Disorders
Short bowel s.ndrome (B6B) results from surgical resection, congenital defect, or disease+related loss of
asorption&
o B6B is characterized y failure to maintain protein+energy, fluid, electrolyte and micronutrient
alances on a standard diet&
o The length and portions of small o,el resected are associated ,ith the numer and severity
of symptoms& Bhort o,el syndrome is characterized y failure to maintain protein+energy,
fluid, electrolyte, and micronutrient alances on a standard diet&
)emorrhoids are dilated hemorrhoidal veins& They may e internal (occurring aove the
internal sphincter) or e"ternal (occurring outside the e)ternal sphincter)& Nursing
management for the patient ,ith hemorrhoids includes teaching measures to prevent
constipation, avoidance of prolonged standing or sitting, proper use of over+the+counter
(;TC) drugs, and the need to see' medical care for severe symptoms of hemorrhoids
(e&g&, e)cessive pain and leeding, prolapsed hemorrhoids) ,hen necessary&
5n anal fissure is a s'in ulcer or a crac' in the lining of the anal ,all that is caused y
trauma, local infection, or inflammation&
5 "ilonidal sinus is a small tract under the s'in et,een the uttoc's in the
sacrococcygeal area& Nursing care for the patient ,ith a pilonidal cyst or ascess includes
,arm, moist heat applications&
1+1DD
Key Points
th
edition
Key Points
Chapter %%: Nursing :anagement: 2iver, Pancreas, and 6iliary Tract Prolems
BA5ND'C
Baundice, a yello,ish discoloration of ody tissues, results from an alteration in normal
iliruin metaolism or flo, of ile into the hepatic or iliary duct systems&
The three types of #aundice are hemolytic, hepatocellular, and ostructive&
o >emolytic (prehepatic) #aundice is due to an increased rea'do,n of red lood
cells (?6Cs), ,hich produces an increased amount of uncon#ugated iliruin in
the lood&
o >epatocellular (hepatic) #aundice results from the liver(s altered aility to ta'e up
iliruin from the lood or to con#ugate or e)crete it&
o ;structive (posthepatic) #aundice is due to decreased or ostructed flo, of ile
through the liver or iliary duct system&
)PA,','S
)e"atitis is an inflammation of the liver& 3iral hepatitis is the most common cause of
hepatitis& The types of viral hepatitis are 5, 6, C, =, *, and A&
Hepatitis A
o >53 is an ?N5 virus that is transmitted through the fecal+oral route&
o The mode of transmission of >53 is mainly transmitted y ingestion of food or
li<uid infected ,ith the virus and rarely parenteral&
Hepatitis B
o >63 is a =N5 virus that is transmitted perinatally y mothers infected ,ith
>63! percutaneously (e&g&, .3 drug use)! or horizontally y mucosal e)posure to
infectious lood, lood products, or other ody fluids&
o >63 is a comple) structure ,ith three distinct antigens: the surface antigen
(>6s5g), the core antigen (>6c5g), and the e antigen (>6e5g)&
o 5ppro)imately DK of those infected ,hen older than age C develop chronic >63&
Hepatitis "
o >C3 is an ?N5 virus that is primarily transmitted percutaneously&
o The most common mode of >C3 transmission is the sharing of contaminated
needles and paraphernalia among .3 drug users&
o There are D genotypes and more than C8 sutypes of >C3&
Hepatitis D, -, /
1+1D9
Key Points
o >epatitis = virus (>=3) is an ?N5 virus that cannot survive on its o,n& .t
re<uires >63 to replicate&
o >epatitis * virus (>*3) is an ?N5 virus that is transmitted y the fecal+oral
route&
o >epatitis A virus (>A3) is a se)ually transmitted virus& >A3 coe)ists ,ith other
viral infections, including >63, >C3, and >.3&
Clinical manifestations:
o :any patients ,ith hepatitis have no symptoms&
o Bymptoms of the acute phase include malaise, anore)ia, fatigue, nausea,
occasional vomiting, and adominal (right upper <uadrant) discomfort& Physical
e)amination may reveal hepatomegaly, lymphadenopathy, and sometimes
splenomegaly&
:any >63 infections and the ma#ority of >C3 infections result in chronic (lifelong)
viral infection&
:ost patients ,ith acute viral hepatitis recover completely ,ith no complications&
5ppro)imately 9CK to FCK of patients ,ho ac<uire >C3 ,ill go on to develop chronic
infection&
@ulminant viral hepatitis results in severe impairment or necrosis of liver cells and
potential liver failure&
There is no specific treatment or therapy for acute viral hepatitis&
=rug therapy for chronic >63 and >6C is focused on decreasing the viral load, aspartate
aminotransferase (5BT) and aspartate aminotransferase (52T) levels, and the rate of
disease progression&
o Chronic >63 drugs include interferon, lamivudine (*pivir), adefovir (>epsera),
entecavir (6araclude), and telivudine (Tyze'a)&
o Treatment for >C3 includes pegylated +interferon (Peg+.ntron, Pegasys) given
,ith riavirin (?eetol, Copegus)&
6oth hepatitis 5 vaccine and immune gloulin (.A) are used for prevention of hepatitis 5&
.mmunization ,ith >63 vaccine is the most effective method of preventing >63
infection& @or poste)posure prophyla)is, the vaccine and hepatitis 6 immune gloulin
(>6.A) are used&
Currently there is no vaccine to prevent >C3&
1+1DF
Key Points
:ost patients ,ith viral hepatitis ,ill e cared for at home, so the nurse must assess the
patient(s 'no,ledge of nutrition and provide the necessary dietary teaching&
A5,$'MM5N )PA,','S
5utoimmune hepatitis is a chronic inflammatory disorder of un'no,n cause& .t is
characterized y the presence of autoantiodies, high levels of serum immunogloulins,
and fre<uent association ,ith other autoimmune diseases&
5utoimmune hepatitis (in ,hich there is evidence of necrosis and cirrhosis) is treated
,ith corticosteroids or other immunosuppressive agents&
7'LS$N<S D'SAS
7ilson<s disease is a progressive, familial, terminal neurologic disease accompanied y
chronic liver disease leading to cirrhosis&
.t is associated ,ith increased storage of copper&
P-'MA-6 /'L'A-6 C'--)$S'S
Primary iliary cirrhosis (P6C) is characterized y generalized pruritus, hepatomegaly,
and hyperpigmentation of the s'in&
N$NALC$)$L'C +A,,6 L'2- D'SAS
Nonalcoholic fatt. li!er disease (N5@2=) is a group of disorders that is characterized
y hepatic steatosis (accumulation of fat in the liver) that is not associated ,ith other
causes such as hepatitis, autoimmune disease, or alcohol&
The ris' for developing N5@2= is a ma#or complication of oesity& N5@2= can progress
to liver cirrhosis&
N5@2= should e considered in patients ,ith ris' factors such as oesity, diaetes,
hypertriglyceridemia, severe ,eight loss (especially in those ,hose ,eight loss ,as
recent), and syndromes associated ,ith insulin resistance&
C'--)$S'S
Cirrhosis is a chronic progressive disease characterized y e)tensive degeneration and
destruction of the liver parenchymal cells&
Common causes of cirrhosis include alcohol, malnutrition, hepatitis, iliary ostruction,
and right+sided heart failure& *)cessive alcohol ingestion is the single most common
cause of cirrhosis follo,ed y chronic hepatitis (6 and C)&
:anifestations of cirrhosis include #aundice, s'in lesions (s"ider angiomas),
hematologic prolems (thromocytopenia, leucopenia, anemia, coagulation disorders),
endocrine prolems, and peripheral neuropathy&
1+1DE
Key Points
:a#or complications of cirrhosis include "ortal h."ertension, eso"hageal and gastric
!arices, peripheral edema and ascites, hepatic encephalopathy, and he"atorenal
s.ndrome(
o )e"atic ence"halo"ath. is a neuropsychiatric manifestation of liver damage& .t
is considered a terminal complication in liver disease&
o 5 characteristic symptom of hepatic encephalopathy is asteri1is (flapping
tremors)&
=iagnostic tests for cirrhosis include elevations in liver enzymes, decreased total protein,
fat metaolism anormalities, and liver iopsy&
There is no specific therapy for cirrhosis& :anagement of ascites is focused on sodium
restriction, diuretics, and fluid removal&
o Peritoneovenous shunt is a surgical procedure that provides continuous reinfusion
of ascitic fluid into the venous system&
o The main therapeutic goal for esophageal and gastric varices is avoidance of
leeding and hemorrhage&
o Trans#ugular intrahepatic portosystemic shunt (T.PB) is a nonsurgical procedure
in ,hich a tract (shunt) et,een the systemic and portal venous systems is created
to redirect portal lood flo,&
o :anagement of hepatic encephalopathy is focused on reducing ammonia
formation and treating precipitating causes&
5n important nursing focus is the prevention and early treatment of cirrhosis&
.f the patient has esophageal and1or gastric varices in addition to cirrhosis, the nurse
oserves for any signs of leeding from the varices (e&g&, hematemesis, melena)&
The focus of nursing care of the patient ,ith hepatic encephalopathy is on maintaining a
safe environment, sustaining life, and assisting ,ith measures to reduce the formation of
ammonia&
+ulminant he"atic failure, or acute liver failure, is a clinical syndrome characterized y
severe impairment of liver function associated ,ith hepatic encephalopathy&
L'2- ,-ANSPLAN,A,'$N
.ndications for liver transplant include chronic viral hepatitis, congenital iliary
anormalities (iliary atresia), inorn errors of metaolism, hepatic malignancy (confined
to the liver), sclerosing cholangitis, fulminant hepatic failure, and chronic end+stage liver
disease&
Postoperative complications of liver transplant include re#ection and infection&
The patient ,ho has had a liver transplant re<uires highly s'illed nursing care&
1+198
Key Points
AC5, PANC-A,','S
Acute "ancreatitis is an acute inflammatory process of the pancreas& The primary
etiologic factors are iliary tract disease (most common cause in ,omen) and alcoholism
(most common cause in men)&
5dominal pain usually located in the left upper <uadrant is the predominant symptom of
acute pancreatitis& ;ther manifestations include nausea, vomiting, hypotension,
tachycardia, and #aundice&
T,o significant local complications of acute pancreatitis are pseudocyst and ascess& 5
pancreatic "seudoc.st is a cavity continuous ,ith or surrounding the outside of the
pancreas&
The primary diagnostic tests for acute pancreatitis are serum amylase and lipase&
;#ectives of collaorative care for acute pancreatitis include relief of pain! prevention or
alleviation of shoc'! reduction of pancreatic secretions! control of fluid and electrolyte
imalances! prevention or treatment of infections! and removal of the precipitating cause&
6ecause hypocalcemia can also occur, the nurse must oserve for symptoms of tetany,
such as #er'ing, irritaility, and muscular t,itching&
C)-$N'C PANC-A,','S
Chronic "ancreatitis is a continuous, prolonged, inflammatory, and firosing process of
the pancreas& The pancreas ecomes progressively destroyed as it is replaced ,ith firotic
tissue& Btrictures and calcifications may also occur in the pancreas&
Clinical manifestations of chronic pancreatitis include adominal pain, symptoms of
pancreatic insufficiency, including malasorption ,ith ,eight loss, constipation, mild
#aundice ,ith dar' urine, steatorrhea, and diaetes mellitus&
:easures used to control the pancreatic insufficiency include diet, pancreatic enzyme
replacement, and control of the diaetes&
PANC-A,'C CANC-
The ma#ority of pancreatic cancers have metastasized at the time of diagnosis& The signs
and symptoms of pancreatic cancer are often similar to those of chronic pancreatitis&
Transadominal ultrasound and CT scan are the most commonly used diagnostic imaging
techni<ues for pancreatic diseases, including cancer&
Burgery provides the most effective treatment of cancer of the pancreas! ho,ever, only
1CK to "8K of patients have resectale tumors&
4ALL/LADD- D'S$-D-S
1+191
Key Points
The most common disorder of the iliary system is cholelithiasis (stones in the
gallladder)& Cholec.stitis (inflammation of the gallladder) is usually associated ,ith
cholelithiasis&
4ltrasonography is commonly used to diagnose gallstones&
:edical dissolution therapy is recommended for patients ,ith small radiolucent stones
,ho are mildly symptomatic and are poor surgical ris's&
Cholelithiasis develops ,hen the alance that 'eeps cholesterol, ile salts, and calcium in
solution is altered and precipitation occurs& 4ltrasonography is commonly used to
diagnose gallstones&
.nitial symptoms of acute cholecystitis include indigestion and pain and tenderness in the
right upper <uadrant&
Complications of cholecystitis include gangrenous cholecystitis, suphrenic ascess,
pancreatitis, cholangitis (inflammation of iliary ducts), iliary cirrhosis, fistulas, and
rupture of the gallladder, ,hich can produce ile peritonitis&
Postoperative nursing care follo,ing a laparoscopic cholecystectomy includes monitoring
for complications such as leeding, ma'ing the patient comfortale, and preparing the
patient for discharge&
The nurse should assume responsiility for recognition of predisposing factors of
gallladder disease in general health screening&
th
edition
Key Points
Chapter %C: Nursing 5ssessment: 4rinary Bystem
The urinary system consists of t,o 'idneys, t,o ureters, a urinary ladder, and a urethra&
The ladder provides storage, and the ureters and urethra are the drainage channels for
the urine after it is formed y the 'idneys&
9idne.s
The primary functions of the 'idneys are (1) to regulate the volume and composition of
e)tracellular fluid (*C@), and (") to e)crete ,aste products from the ody&
1+19"
Key Points
The 'idneys function to control lood pressure, produce erythropoietin, activate vitamin
=, and regulate acid+ase alance&
The outer layer of the 'idney is termed the corte", and the inner layer is called the
medulla#
The ne"hron is the functional unit of the 'idney& *ach 'idney contains F88,888 to 1&"
million nephrons&
5 nephron is composed of a glomerulus, 6o,man(s capsule, and a tuular system& The
tuular system consists of the pro)imal convoluted tuule, the loop of >enle, the distal
convoluted tuule, and a collecting tuule&
The 'idneys receive "8K to "CK of cardiac output&
The primary function of the 'idneys is to filter the lood and maintain the ody(s internal
homeostasis&
4rine formation is the result of a multistep process of filtration, reasorption, secretion,
and e)cretion of ,ater, electrolytes, and metaolic ,aste products&
/lomerular )unction
6lood is filtered in the glomerulus(
The hydrostatic pressure of the lood ,ithin the glomerular capillaries causes a portion of
lood to e filtered across the semipermeale memrane into 6o,man(s capsule&
The ultrafiltrate is similar in composition to lood e)cept that it lac's lood cells,
platelets, and large plasma proteins&
The amount of lood filtered y the glomeruli in a given time is termed the glomerular
filtration rate (A@?)& The normal A@? is aout 1"C ml1min&
Tu%ular )unction
The functions of the tuules and collecting ducts include reasorption and secretion&
!eabsorption is the passage of a sustance from the lumen of the tuules through the
tuule cells and into the capillaries& *ubular secretion is the passage of a sustance from
the capillaries through the tuular cells into the lumen of the tuule&
o The loop of >enle is important in conserving ,ater and thus concentrating the
filtrate& .n the loop of >enle, reasorption continues&
o T,o important functions of the distal convoluted tuules are final regulation of
,ater alance and acid+ase alance&
5ntidiuretic hormone (5=>) is re<uired for ,ater reasorption in the
'idney&
1+19$
Key Points
5ldosterone acts on the distal tuule to cause reasorption of sodium ions
(Na
O
) and ,ater& .n e)change for Na
O
, potassium ions (K
O
) are e)creted&
o 5cid+ase regulation involves reasoring and conserving most of the icaronate
(>C;
$
) and secreting e)cess >

O
&
o 5trial natriuretic peptide (5NP) acts on the 'idneys to increase sodium e)cretion&
o Parathyroid hormone (PT>) acts on renal tuules to increase reasorption of
calcium&
0ther )unctions of the 1iney
The 'idneys produce erythropoietin in response to hypo)ia and decreased renal lood
flo,& *rythropoietin stimulates the production of red lood cells (?6Cs) in the one
marro,&
3itamin = is activated in 'idneys& 3itamin = is important for calcium alance and one
health&
?enin, ,hich is produced and secreted y #u)taglomerular cells, is important in the
regulation of lood pressure&
Prostaglandin (PA) synthesis (primarily PA*
"
and PA.
"
) occurs in the 'idney, primarily
in the medulla& These PAs have a vasodilating action, thus increasing renal lood flo,
and promoting Na
O
e)cretion&
5reters
The ureters are tues that carry urine from the renal pelvis to the ladder&
Circular and longitudinal smooth muscle fiers, arranged in a meshli'e outer layer,
contract to promote the peristaltic one+,ay flo, of urine&
/ladder
The urinary ladder is a distensile organ positioned ehind the symphysis puis and
anterior to the vagina and rectum&
.ts primary functions are to serve as a reservoir for urine and to help the ody eliminate
,aste products&
Normal adult urine output is appro)imately 1C88 ml1day, ,hich varies ,ith food and
fluid inta'e&
;n the average, "88 to "C8 ml of urine in the ladder causes moderate distention and the
urge to urinate&
5rethra
The urethra is a small muscular tue that leads from the ladder nec' to the e)ternal
meatus&
1+19%
Key Points
The primary function of the urethra is to serve as a conduit for urine from the ladder
nec' to outside the ody during voiding&
The female urethra is significantly shorter than that of the male&
5rethro!esical 5nit
Together, the ladder, urethra, and pelvic floor muscles form the urethrovesical unit& .t
receives neuronal input from the autonomic nervous system&
Normal voluntary control of this unit is defined as continence#
5ny disease or trauma that affects function of the rain, spinal cord, or nerves that
directly innervate the ladder, ladder nec', e)ternal sphincter, or pelvic floor can affect
ladder function&
ffects of Aging on the 5rinar. S.stem
6y the seventh decade of life, $8K to C8K of glomeruli have lost their function&
5therosclerosis has een found to accelerate the decrease of renal size ,ith age&

;lder individuals maintain ody fluid homeostasis unless they encounter diseases or
other physiologic stressors&
ASSSSMN,
Bu#ective data:
Past health history
The patient is as'ed aout the presence or history of diseases that are related to
renal or urologic prolems& =iseases include hypertension, diaetes mellitus, gout
and other metaolic prolems, connective tissue disorders (e&g&, systemic lupus
erythematosus), s'in or upper respiratory infections of streptococcal origin,
tuerculosis, hepatitis, congenital disorders, neurologic conditions (e&g&, stro'e),
or trauma&
:edications: an assessment of the patient(s current and past use of medications is
important& This should include over+the+counter drugs, prescription medications,
and hers& :any drugs are 'no,n to e nephroto)ic&
Burgery or other treatments: the patient is as'ed aout any previous
hospitalizations related to renal or urologic diseases and all urinary prolems
during past pregnancies& Past surgeries, particularly pelvic surgeries, or urinary
tract instrumentation is documented&
;#ective data:
Physical e)amination
1+19C
Key Points
.nspection: the nurse should assess for changes in the follo,ing:
Skin: pallor, yellow-gray cast, excoriations, changes in turgor, bruises,
texture (e.g., rough, dry skin)
Mouth: stomatitis, ammonia breath odor
ace and extremities: generali!ed edema, peripheral edema, bladder
distention, masses, enlarged kidneys
"bdomen: striae, abdominal contour #or midline mass in lower abdomen
(may indicate urinary retention) or unilateral mass (occasionally seen in
adult, indicating enlargement o# one or both kidneys #rom large tumor or
polycystic kidney)
$eight: weight gain secondary to edema% weight loss and muscle wasting
in renal #ailure
&eneral state o# health: #atigue, lethargy, and diminished alertness
Palpation: 5 landmar' useful in locating the 'idneys is the costo!ertebral angle
(C35) formed y the ri cage and the verteral column&
The normal+size 'idney is usually not palpale&
.f the 'idney is palpale, its size, contour, and tenderness should e noted&
Kidney enlargement is suggestive of neoplasm or other serious renal
pathologic condition&
The urinary ladder is normally not palpale unless it is distended ,ith
urine&
Percussion: Tenderness in the flan' area may e detected y fist percussion
('idney punch)&
Normally a firm lo, in the flan' area should not elicit pain&
Normally a ladder is not percussile until it contains 1C8 ml of urine& .f
the ladder is full, dullness is heard aove the symphysis puis& 5
distended ladder may e percussed as high as the umilicus&
5uscultation: -ith a stethoscope the adominal aorta and renal arteries are
auscultated for a bruit (an anormal murmur), ,hich indicates impaired lood
flo, to the 'idneys&
D'A4N$S,'C S,5D'S
4rine studies:
o 5rinal.sis( This test may provide information aout possile anormalities,
indicate ,hat further studies need to e done, and supply information on the
progression of a diagnosed disorder&
o Creatinine clearance& 6ecause almost all creatinine in the lood is normally
e)creted y the 'idneys, creatinine clearance is the most accurate indicator of
renal function& The result of a creatinine clearance test closely appro)imates that
of the A@?&
o 4rodynamic tests study the storage of urine ,ithin the ladder and the flo, of
urine through the urinary tract to the outside of the ody&
1+19D
Key Points
th
edition
Key Points
Chapter %D: Nursing :anagement: ?enal and 4rologic Prolems
5-'NA-6 ,-AC, 'N+C,'$NS
4rinary tract infections (4T.s) are the second most common acterial disease, and the
most common acterial infection in ,omen&
4T.s include cystitis, pyelonephritis, and urethritis&
?is' factors for 4T.s include pregnancy, menopause, instrumentation, and se)ual
intercourse& +scherichia coli %+# coli) is the most common pathogen causing a 4T.&
4T.s that are hospital+ac<uired are called nosocomial infections&
4T. symptoms include dysuria, fre<uent urination (more than every " hours), urgency,
and suprapuic discomfort or pressure& @lan' pain, chills, and the presence of a fever
indicate an infection involving the upper urinary tract (pyelonephritis)&
4T.s are diagnosed y dipstic' urinalysis to identify the presence of nitrites (indicating
acteriuria), -6Cs, and leu'ocyte esterase (an enzyme present in -6Cs indicating
pyuria)& 5 voided midstream techni<ue yielding a clean+catch urine sample is preferred&
Trimethoprim+sulfametho)azole (T:P+B:M) or nitrofurantoin (:acrodantin) is often
used to empirically treat uncomplicated or initial 4T.s& 5dditional drugs may e used to
relieve discomfort&
>ealth promotion activities include teaching preventive measures such as (1) emptying
the ladder regularly and completely, (") evacuating the o,el regularly, ($) ,iping the
perineal area from front to ac' after urination and defecation, and (%) drin'ing an
ade<uate amount of li<uid each day&
P6L$NP)-','S
P.elone"hritis is an inflammation of the renal parenchyma and collecting system
(including the renal pelvis)& The most common cause is acterial infection ,hich egins
in the lo,er urinary tract& ?ecurring infection can result in chronic pyelonephritis#
Clinical manifestations vary from mild fatigue to the sudden onset of chills, fever,
vomiting, malaise, flan' pain, and the lo,er 4T. characteristics&
1+199
Key Points
.nterventions include teaching aout the disease process ,ith emphasis on (1) the need to
continue drugs as prescried, (") the need for a follo,+up urine culture to ensure proper
management, and ($) identification of ris' for recurrence or relapse&
'N,-S,','AL C6S,','S
'nterstitial c.stitis (.C) is a chronic, painful inflammatory disease of the ladder
characterized y symptoms of urgency1fre<uency and pain in the ladder and1or pelvis&
'MM5N$L$4'C D'S$-D-S $+ ,) 9'DN6
4lomerulone"hritis
.mmunologic processes involving the urinary tract predominantly affect the renal
glomerulus (glomerulone"hritis)&
Clinical manifestations of glomerulonephritis include varying degrees of hematuria
(ranging from microscopic to gross) and urinary e)cretion of various formed elements,
including ?6Cs, -6Cs, proteins, and casts&
,cute poststreptococcal glomerulonephritis (5PBAN) develops C to "1 days after an
infection of the tonsils, pharyn), or s'in (e&g&, streptococcal sore throat, impetigo) y
nephroto)ic strains of group 5 +hemolytic streptococci& :anifestations include
generalized ody edema, hypertension, oliguria, hematuria ,ith a smo'y or rusty
appearance, and proteinuria&
5PBAN management focuses on symptomatic relief& This includes rest, edema and
hypertension management, and dietary protein restriction ,hen an increase in
nitrogenous ,astes (e&g&, elevated 64N value) is present&
;ne of the most important ,ays to prevent the development of 5PBAN is to encourage
early diagnosis and treatment of sore throats and s'in lesions&
4ood"asture s.ndrome is a rare autoimmune disease characterized y the presence of
circulating antiodies against glomerular and alveolar asement memrane&
!apidly progressive glomerulonephritis (?PAN) is glomerular disease associated ,ith
acute renal failure ,here there is rapid, progressive loss of renal function over days to
,ee's&
Chronic glomerulonephritis is a syndrome that reflects the end stage of glomerular
inflammatory disease& .t is characterized y proteinuria, hematuria, and development of
uremia& Treatment is supportive and symptomatic&
Ne"hrotic s.ndrome results ,hen the glomerulus is e)cessively permeale to plasma
protein, causing proteinuria that leads to lo, plasma alumin and tissue edema&
1+19F
Key Points
o Nephrotic syndrome is associated ,ith systemic illness such as diaetes or systemic
lupus erythematosus&
o Treatment is focused on symptom management&
o The ma#or nursing interventions for a patient ,ith nephrotic syndrome are related to
edema& *dema is assessed y ,eighing the patient daily, accurately recording inta'e
and output, and measuring adominal girth or e)tremity size&
$/S,-5C,'2 5-$PA,)'S
5rinar. Stones
@actors involved in the development of urinary stones include metaolic, dietary, genetic,
climatic, lifestyle, and occupational influences& ;ther factors are ostruction ,ith urinary
stasis and urinary tract infection&
The five ma#or categories of stones (lithiasis) are (1) calcium phosphate, (") calcium
o)alate, ($) uric acid, (%) cystine, and (C) struvite&
4rinary stones cause clinical manifestations ,hen they ostruct urinary flo,& Common
sites of complete ostruction are at the 4P\ (the point ,here the ureter crosses the iliac
vessels) and at the ureterovesical #unction (43\)&
:anagement of a patient ,ith renal lithiasis consists of treating the symptoms of pain,
infection, or ostruction&
Lithotri"s. is used to eliminate calculi from the urinary tract& ;utcome for lithotripsy is
ased on stone size, stone location, and stone composition&
The goals are that the patient ,ith urinary tract calculi ,ill have (1) relief of pain, (") no
urinary tract ostruction, and ($) an understanding of measures to prevent further
recurrence of stones&
To prevent stone recurrence, the patient should consume an ade<uate fluid inta'e to
produce a urine output of appro)imately " 21day& 5dditional preventive measures focus
on reducing metaolic or secondary ris' factors&
5rethral Stricture
5 stricture is a narro,ing of the lumen of the ureter or urethra& 4reteral strictures can
affect the entire length of the ureter&
5 urethral stricture is the result of firosis or inflammation of the urethral lumen&
o Causes of urethral strictures include trauma, urethritis, iatrogenic, or a congenital
defect&
o Clinical manifestations associated ,ith a urethral stricture include a diminished
force of the urinary stream, straining to void, sprayed stream, postvoid driling,
or a split urine stream&
1+19E
Key Points
-NAL 2ASC5LA- P-$/LMS
3ascular prolems involving the 'idney include (1) nephrosclerosis, (") renal artery
stenosis, and ($) renal vein thromosis&
-enal arter. stenosis is a partial occlusion of one or oth renal arteries and their ma#or
ranches due to atherosclerotic narro,ing& The goals of therapy are control of 6P and
restoration of perfusion to the 'idney&
)-D',A-6 -NAL D'SASS
Pol.c.stic 0idne. disease (PK=) is the most common life+threatening genetic disease& .t
is characterized y cysts that enlarge and destroy surrounding tissue y compression&
=iagnosis is ased on clinical manifestations, family history, .3P, ultrasound (est
screening measure), or CT scan&
-NAL 'N2$L2MN, 'N M,A/$L'C AND C$NNC,'2 ,'SS5 D'SASS
=iaetic nephropathy is the primary cause of end+stage renal failure in the 4nited Btates&
=iaetes mellitus affects the 'idneys y causing microangiopathic changes&
Bystemic sclerosis (scleroderma) is a disease of un'no,n etiology characterized y
,idespread alterations of connective tissue and y vascular lesions in many organs&
Aout, a syndrome of acute attac's of arthritis caused y hyperuricemia, can also result in
significant renal disease&
Bystemic lupus erythematosus is a connective tissue disorder characterized y the
involvement of several tissues and organs, particularly the #oints, s'in, and 'idneys& .t
results in clinical manifestations similar to glomerulonephritis&
5-'NA-6 ,-AC, ,5M$-S
9idne. cancer:
o There are no early symptoms of 'idney cancer& :any patients ,ith 'idney cancer go
undetected&
o =iagnostic tests include .3P ,ith nephrotomography, ultrasound, percutaneous
needle aspiration, CT, and :?.&
/ladder cancer:
o ?is' factors for ladder cancer include cigarette smo'ing, e)posure to dyes used in
the ruer and cale industries, chronic ause of phenacetin+containing analgesics,
and chronic, recurrent renal calculi
o :icroscopic or gross, painless hematuria (chronic or intermittent) is the most
common clinical finding ,ith ladder cancer&
o Burgical therapies for ladder cancer include transurethral resection ,ith fulguration,
laser photocoagulation, and open loop resection&
1+1F8
Key Points
o Postoperative management follo,ing ladder cancer surgery includes instructions to
drin' a large volume of fluid each day for the first ,ee' follo,ing the procedure and
to avoid inta'e of alcoholic everages&
o .ntravesical therapy is chemotherapy that is locally instilled& Chemotherapeutic or
immune+stimulating agents can e delivered directly into the ladder y a urethral
catheter& 6CA is the treatment of choice for carcinoma in situ&
5-'NA-6 'NC$N,'NNC AND -,N,'$N
5rinar. incontinence (4.) is an uncontrolled lea'age of urine& The prevalence of
incontinence is higher among older ,omen and older men, ut it is not a natural
conse<uence of aging&
Causes of 4. include confusion or depression, infection, atrophic vaginitis, urinary
retention, restricted moility, fecal impaction, or drugs&
5rinar. retention is the inaility to empty the ladder despite micturition or the
accumulation of urine in the ladder ecause of an inaility to urinate&
4rinary retention is caused y t,o different dysfunctions of the urinary system: ladder
outlet ostruction and deficient detrusor (ladder muscle) contraction strength&
*valuation for 4. and urinary retention includes a focused history, physical assessment,
and a ladder log or voiding record ,henever possile&
:anagement strategies for 4. include lifestyle interventions such as an ade<uate volume
of fluids and reduction or elimination of ladder irritants from the diet& 6ehavioral
treatments include scheduled voiding regimens (timed voiding, hait training, and
prompted voiding), ladder retraining, and pelvic floor muscle training&
,cute urinary retention is a medical emergency that re<uires prompt recognition and
ladder drainage&
Bhort+term urinary catheterization may e performed to otain a urine specimen for
laoratory analysis& Complications from long+term use (U$8 days) of ind,elling catheters
include ladder spasms, periurethral ascess, pain, and urosepsis&
-hile the patient has a catheter in place, nursing actions should include maintaining
patency of the catheter, managing fluid inta'e, providing for the comfort and safety of the
patient, and preventing infection&
The ureteral catheter is placed through the ureters into the renal pelvis& The catheter is
inserted either (1) y eing threaded up the urethra and ladder to the ureters under
cystoscopic oservation, or (") y surgical insertion through the adominal ,all into the
ureters&
1+1F1
Key Points
The suprapuic catheter is used in temporary situations such as ladder, prostate, and
urethral surgery& The suprapuic catheter is also used long term in selected patients&
S5-4-6 $+ ,) 5-'NA-6 ,-AC,
Common indications for nephrectomy include a renal tumor, polycystic 'idney disease
(PK=) that is leeding or severely infected, massive traumatic in#ury to the 'idney, and
the elective removal of a 'idney from a donor& 5 'idney can e removed y laparoscopic
nephrectomy&
.n the immediate postoperative period follo,ing renal surgery, urine output should e
determined at least every 1 to " hours&
Numerous urinary diversion techni<ues and ladder sustitutes are possile, including an
incontinent urinary diversion, a continent urinary diversion catheterized y the patient, or
an orthotopic ladder so that the patient voids urethrally&
Common peristomal s'in prolems associated ,ith an ileal conduit include dermatitis,
yeast infections, product allergies, and shearing+effect e)coriations&
=ischarge planning after an ileal conduit includes teaching the patient symptoms of
ostruction or infection and care of the ostomy&
th
edition
Key Points
Chapter %9: Nursing :anagement: 5cute ?enal @ailure and Chronic Kidney
=isease
!enal failure is the partial or complete impairment of 'idney function resulting in an
inaility to e)crete metaolic ,aste products and ,ater&
?enal failure causes functional disturances of all ody systems&
?enal failure is classified as acute or chronic&
AC5, -NAL +A'L5- %A-+&
Acute renal failure (5?@) usually develops over hours or days ,ith progressive
elevations of lood urea nitrogen (64N), creatinine, and potassium ,ith or ,ithout
oliguria( .t is a clinical syndrome characterized y a rapid loss of renal function ,ith
progressive a#otemia(
1+1F"
Key Points
5?@ is often associated ,ith oliguria (a decrease in urinary output to ]%88 ml1day)&
The causes of 5?@ are multiple and comple)& They are categorized according to similar
pathogenesis into prerenal (most common), intrarenal (or intrinsic), and postrenal causes&
o Prerenal causes are factors e)ternal to the 'idneys (e&g&, hypovolemia) that reduce
renal lood flo, and lead to decreased glomerular perfusion and filtration&
o -ntrarenal causes include conditions that cause direct damage to the renal tissue,
resulting in impaired nephron function& Causes include prolonged ischemia,
nephroto)ins, hemogloin released from hemolyzed ?6Cs, or myogloin released
from necrotic muscle cells& Acute tubular necrosis (5TN) is an intrarenal
condition caused y ischemia, nephroto)ins, or pigments& 5TN is potentially
reversile if the asement memrane is not destroyed and the tuular epithelium
regenerates&
o Postrenal causes involve mechanical ostruction of urinary outflo,& Common
causes are enign prostatic hyperplasia, prostate cancer, calculi, trauma, and
e)trarenal tumors&
Clinically, 5?@ may progress through four phases: initiating, oliguric, diuretic, and
recovery& .n some situations, the patient does not recover from 5?@ and chronic 'idney
disease (CK=) results, eventually re<uiring dialysis or a 'idney transplant&
$liguric Phase
@luid and electrolyte anormalities and uremia occur during the oliguric phase& The
'idneys cannot synthesize ammonia or e)crete acid products of metaolism, resulting in
acidosis&
=amaged tuules cannot conserve sodium resulting in normal or elo,+normal levels of
serum sodium& 4ncontrolled hyponatremia or ,ater e)cess can lead to cereral edema&
@luid inta'e must e closely monitored&
>yper'alemia is a serious complication of 5?@& The serum potassium levels increase
ecause the aility of the 'idneys to e)crete potassium is impaired& 5cidosis ,orsens
hyper'alemia as hydrogen ions enter the cells and potassium is driven out of the cells&
-hen potassium levels e)ceed D m*<12 (D mmol12) or dysrhythmias are identified,
treatment must e initiated immediately&
>ematologic disorders associated ,ith 5?@ include anemia due to impaired
erythropoietin production and platelet anormalities leading to leeding from multiple
sources&
5 lo, serum calcium level results from the inaility of the 'idneys to activate vitamin =&
-hen hypocalcemia occurs, the parathyroid gland secretes parathyroid hormone, ,hich
stimulates one demineralization, therey releasing calcium from the ones& Phosphate is
also released, leading to elevated serum phosphate levels&
1+1F$
Key Points
The t,o most common causes of death in patients ,ith 5?@ are infection and
cardiorespiratory complications&
The est serum indicator of renal failure is creatinine ecause it is not significantly
altered y other factors&
Neurologic changes can occur as the nitrogenous ,aste products increase& Bymptoms can
include fatigue and difficulty concentrating, later escalating to seizures, stupor, and coma&
Diuretic Phase
The diuretic phase egins ,ith a gradual increase in daily urine output of 1 to $ 21day,
ut may reach $ to C 2 or more& The nephrons are still not fully functional& The uremia
may still e severe, as reflected y lo, creatinine clearances, elevated serum creatinine
and 64N levels, and persistent signs and symptoms&
-eco!er. Phase
The recovery phase egins ,hen the A@? increases, allo,ing the 64N and serum
creatinine levels to plateau and then decrease& ?enal function may ta'e up to 1" months
to stailize&
Collaborati!e Management
6ecause 5?@ is potentially reversile, the primary goals of treatment are to eliminate
the cause, manage the signs and symptoms, and prevent complications ,hile the
'idneys recover&
Common indications for dialysis in 5?@ are (1) volume overload! (") elevated
potassium level ,ith *CA changes! ($) metaolic acidosis! (%) significant change in
mental status! and (C) pericarditis, pericardial effusion, or cardiac tamponade&
)emodial.sis (>=) is used ,hen rapid changes are re<uired in a short period of time&
Peritoneal dial.sis (P=) is simpler than >=, ut it carries the ris' of peritonitis, is less
efficient in the cataolic patient, and re<uires longer treatment times& Continuous
renal re"lacement thera". (C??T) may also e used in the treatment of 5?@,
particularly in those ,ho are hemodynamically unstale&
Prevention of 5?@ is primarily directed to,ard identifying and monitoring high+ris'
populations, controlling e)posure to nephroto)ic drugs and industrial chemicals, and
preventing prolonged episodes of hypotension and hypovolemia&
The patient ,ith 5?@ is critically ill and suffers not only from the effects of renal
disease ut also from the effects of comorid diseases or conditions (e&g&, diaetes,
cardiovascular disease)&
1+1F%
Key Points
The nurse has an important role in managing fluid and electrolyte alance during the
oliguric and diuretic phases& ;serving and recording accurate inta'e and output and
ody ,eight are essential&
6ecause infection is the leading cause of death in 5?@, meticulous aseptic techni<ue is
critical& The nurse should e alert for local manifestations of infection (e&g&, s,elling,
redness, pain) as ,ell as systemic manifestations (e&g&, malaise, leu'ocytosis) ecause
an elevated temperature may not e present&
?espiratory complications, especially pneumonitis, can e prevented& >umidified
o)ygen! incentive spirometry! coughing, turning, and deep reathing! and amulation
are measures to help maintain ade<uate respiratory ventilation&
B'in care and measures to prevent pressure ulcers should e performed ecause of
edema and decreased muscle tone& :outh care is important to prevent stomatitis&
?ecovery from 5?@ is highly variale and depends on the underlying illness, the
general condition and age of the patient, the length of the oliguric phase, and the
severity of nephron damage& Aood nutrition, rest, and activity are necessary& Protein
and potassium inta'e should e regulated in accordance ,ith renal function&
The long+term convalescence of $ to 1" months may cause psychosocial and financial
hardships for the family, and appropriate counseling, social ,or', and psychiatrist1
psychologist referrals are made as needed& .f the 'idneys do not recover, the patient
,ill eventually need dialysis or transplantation&
4erontologic Considerations
The older adult is more susceptile than the younger adult to 5?@ as the numer of
functioning nephrons decreases ,ith age&
Causes of 5?@ include dehydration, hypotension, diuretic therapy, aminoglycoside
therapy, prostatic hyperplasia, surgery, infection, and radiocontrast agents&
C)-$N'C 9'DN6 D'SAS
Chronic 0idne. disease (CK=) involves progressive, irreversile loss of 'idney
function&
CK= usually develops slo,ly over months to years and necessitates the initiation of
dialysis or transplantation for long+term survival& The prognosis of CK= is variale
depending on the etiology, patient(s condition and age, and ade<uacy of follo,+up&

4remia is a syndrome that incorporates all the signs and symptoms seen in the various
systems throughout the ody in CK=&
1+1FC
Key Points
.n the early stage of renal insufficiency, polyuria results from the inaility to
concentrate urine& 5s the A@? decreases, the 64N and serum creatinine levels
increase&
Clinical manifestations of uremia develop& @atigue, lethargy, and pruritus are often the
early symptoms& >ypertension and proteinuria are often the first signs& >yperglycemia,
hyperinsulinemia, and anormal glucose tolerance tests may e seen&
:any patients ,ith uremia develop hyperlipidemia, ,ith elevated very+lo,+density
lipoproteins (32=2s), normal or decreased lo,+density lipoproteins (2=2s), and
decreased high+density lipoproteins (>=2s)&
>yper'alemia results from the decreased e)cretion y the 'idneys, the rea'do,n of
cellular protein, leeding, and metaolic acidosis& Potassium may also come from the
food consumed, dietary supplements, drugs, and .3 infusions&
6ecause of impaired sodium e)cretion, sodium along ,ith ,ater is retained resulting in
dilutional hyponatremia& Bodium retention can contriute to edema, hypertension, and
heart failure&
:etaolic acidosis results from the impaired aility to e)crete the acid load (primarily
ammonia) and from defective reasorption and regeneration of icaronate&
Normocytic or normochromic anemia is due to decreased production of erythropoietin&
The most common cause of leeding is a <ualitative defect in platelet function&
.nfectious complications are common in CK=& Clinical findings include lymphopenia,
lymphoid tissue atrophy, decreased antiody production, and suppression of the
delayed hypersensitivity response&
The most common cardiovascular anormality is hypertension, ,hich is usually
present pre+*B?= and is aggravated y sodium retention and increased e)tracellular
fluid volume& =iaetes mellitus is an additional ris' factor&
Cardiac dysrhythmias may result from hyper'alemia, hypocalcemia, and decreased
coronary artery perfusion&
?espiratory changes include Kussmaul respiration, dyspnea from fluid overload,
pulmonary edema, uremic pleuritis (pleurisy), pleural effusion, and a predisposition to
respiratory infections&
Neurologic changes are due to increased nitrogenous ,aste products, electrolyte
imalances, metaolic acidosis, a)onal atrophy, and demyelination& =epression of the
CNB results in lethargy, apathy, decreased aility to concentrate, fatigue, irritaility,
and altered mental aility&
1+1FD
Key Points
Peripheral neuropathy may result in restless legs syndrome, paresthesias, ilateral
footdrop, muscular ,ea'ness and atrophy, and loss of deep tendon refle)es&
The treatment for neurologic prolems is dialysis or transplantation& 5ltered mental
status is often the signal that dialysis must e initiated&
-enal osteod.stro"h. is a syndrome of s'eletal changes that is a result of alterations
in calcium and phosphate metaolism& .steomalacia is demineralization resulting
from slo, one turnover and defective mineralization of ne,ly formed one& .steitis
fibrosa cystica results from decalcification of the one and replacement of one tissue
,ith firous tissue&
Pruritus results from a comination of the dry s'in, calcium+phosphate deposition in
the s'in, and sensory neuropathy&
6oth se)es e)perience infertility and a decreased liido& Be)ual dysfunction may also
e caused y anemia, peripheral neuropathy, and psychologic prolems, physical
stress, and side effects of drugs&
Personality and ehavioral changes, emotional laility, ,ithdra,al, depression, fatigue,
and lethargy are commonly oserved& Changes in ody image caused y edema,
integumentary disturances, and access devices lead to further an)iety and depression&
5dverse outcomes of CK= can often e prevented or delayed through early detection
and treatment& @irst, conservative therapy is attempted efore maintenance dialysis
egins& *fforts are made to detect and treat potentially reversile causes of renal
failure& The progression of CK= can e delayed y controlling hypertension&
Btrategies to reduce serum calcium levels include .3 glucose and insulin, .3 18K
calcium gluconate, and sodium polystyrene sulfonate (Kaye)alate)&
The antihypertensive drugs most commonly used are diuretics (e&g&, furosemide
H2asi)I), +adrenergic loc'ers (e&g&, metoprolol H2opressorI), calcium channel
loc'ers (e&g&, nifedipine HProcardiaI), angiotensin+converting enzyme inhiitors (e&g&,
captopril HCapotenI), and angiotensin receptor loc'er agents (e&g&, losartan HCozaarI)&
*rythropoietin is used for the treatment of anemia& .t can e administered .3 or
sucutaneously& Btatins (>:A+Co5 reductase inhiitors) are the most effective drugs
for lo,ering 2=2 cholesterol levels&
=rug doses and fre<uency of administration must e ad#usted ased on the severity of
the 'idney disease&
1+1F9
Key Points
=ietary protein is restricted ecause urea nitrogen and creatinine are end products of
protein metaolism& ;nce the patient starts dialysis, protein inta'e can e increased&
Bufficient calories from carohydrates and fat are needed to minimize cataolism of
ody protein and to maintain ody ,eight&
-ater inta'e depends on the daily urine output& Aenerally, D88 ml (from insensile
loss) plus an amount e<ual to the previous day(s urine output is allo,ed for a patient
,ho is not receiving dialysis& Phosphate should e limited to appro)imately 1888
mg1day&
The overall goals are that a patient ,ith CK= ,ill (1) demonstrate 'no,ledge and
aility to comply ,ith treatment, (") participate in decision+ma'ing, ($) demonstrate
effective coping strategies, and (%) continue ,ith activities of daily living ,ithin
limitations&
People at ris' for CK= include those ,ith a history (or a family history) of renal
disease, hypertension, diaetes mellitus, and repeated urinary tract infection& These
individuals should have regular chec'ups including serum creatinine, 64N, and
urinalysis and e advised that any changes in urine appearance, fre<uency, or volume
must e reported to the health care provider&
Dial.sis
Dial.sis is a techni<ue in ,hich sustances move from the lood through a
semipermeale memrane and into a dialysis solution (dialysate)&
The t,o methods of dialysis are "eritoneal dial.sis (P=) and hemodial.sis (>=)&
Peritoneal Dialysis
T,o types of P= are automated "eritoneal dial.sis (5P=) and continuous
ambulator. "eritoneal dial.sis (C5P=)&
o P= is indicated ,hen there are vascular access prolems& The three phases of
the P= cycle (called an e)change) are inflow (fill), dwell (e<uiliration), and
drain#
o The patient dialyzing at home ,ill receive aout four e)changes per day&
Contraindications for P= are history of multiple adominal surgeries, recurrent
adominal ,all or inguinal hernias, e)cessive oesity ,ith large fat deposits,
pree)isting verteral disease, and severe ostructive pulmonary disease&
=ialysis solutions have an electrolyte composition similar to that of plasma& 4sing dry
heat, the dialysis solution is ,armed to ody temperature to increase peritoneal
clearance, prevent hypothermia, and enhance comfort&
C5P= is carried out manually y e)changing 1&C to $ 2 (usually " 2) of peritoneal
dialysate at least % times daily, ,ith d,ell times of % to 18 hours& P= is associated ,ith
a short training program, independence, and ease of traveling&
1+1FF
Key Points
.nfection of the peritoneal catheter e)it site is most commonly caused y
Staphylococcus aureus or S# epidermidis (from s'in flora)& Peritonitis results from
contamination of the dialysate or tuing or from progression of an e)it site infection&
Pain is a common complication of P=& 5 change in the position of the catheter should
correct this prolem& 5 decrease in infusion rate may also help& 5dditional
complications include hernias, lo,er ac' pain, protein loss, encapsulating sclerosing
peritonitis, and leeding& 5telectasis, pneumonia, and ronchitis may occur from
repeated up,ard displacement of the diaphragm&
Hemoialysis
The types of vascular access include arteriovenous fistulas (53@s) and grafts (53As),
temporary and semipermanent catheters, sucutaneous ports, and shunts&
Bhunts are not fre<uently used e)cept for the patient ,ith continuous renal replacement
therapy (C??T) ecause of the numerous complications (e&g&, infection, thromosis)&
5n 53@ is created most commonly in the forearm ,ith an anastomosis et,een an
artery (usually radial or ulnar) and a vein (usually cephalic)& Native fistulas have the
est overall patency rates and least numer of complications&
Arterio!enous grafts (53As) are made of synthetic materials and form a /ridge0
et,een the arterial and venous lood supplies& Arafts are placed under the s'in and
are surgically anastomosed et,een an artery (usually rachial) and a vein (usually
antecuital)&
6P measurements, insertion of .3s, and venipuncture should never e performed on
the affected e)tremity&
-hen immediate vascular access is re<uired, percutaneous cannulation of the internal
#ugular or femoral vein may e performed&
6efore eginning treatment, the nurse must complete an assessment that includes fluid
status (,eight, 6P, peripheral edema, lung and heart sounds), condition of vascular
access, temperature, and general s'in condition&
>ypotension that occurs during >= results from rapid removal of vascular volume,
decreased cardiac output, and decreased systemic intravascular resistance& Treatment
includes decreasing the volume of fluid eing removed and infusion of 8&EK saline
solution (188 to $88 ml)&
Painful muscle cramps due to rapid removal of sodium and ,ater are a common
prolem& Treatment includes reducing the ultrafiltration rate and infusing hypertonic
saline or a normal saline olus&
1+1FE
Key Points
The causes of hepatitis 6 and C (most common) in dialysis patients include lood
transfusions or the lac' of adherence to precautions used to prevent the spread of
infection&
Dise/uilibrium syndrome develops as a result of very rapid changes in the composition
of the e)tracellular fluid& :anifestations include nausea, vomiting, confusion,
restlessness, headaches, t,itching and #er'ing, and seizures&
.ndividual adaptation to maintenance >= varies consideraly& The primary nursing
goals are to help the patient regain or maintain positive self+esteem and control of his
or her life and to continue to e productive in society&
Continuous -enal -e"lacement ,hera".
Continuous renal re"lacement thera". (C??T) is an alternative or ad#unctive
treatment&
4remic to)ins and fluids are removed, ,hile acid+ase status and electrolytes are
ad#usted slo,ly and continuously from a hemodynamically unstale patient&

3ascular access is achieved through the use of a doule+lumen catheter placed in the
femoral, #ugular, or suclavian vein& 5nticoagulation is used to prevent lood clotting
during C??T&
9idne. ,rans"lantation
;ne+year graft survival rates for 'idney transplantation are E8K for deceased donor
transplants and ECK for live donor transplants&
Contraindications to transplantation include disseminated malignancies, refractory or
untreated cardiac disease, chronic respiratory failure, e)tensive vascular disease,
chronic infection, and unresolved psychosocial disorders&
Kidneys for transplantation may e otained from compatile+lood+type deceased
donors, lood relatives, emotionally related living donors, and altruistic living donors&
2ive donors must undergo an e)tensive evaluation to e certain that they are in good
health and have no history of disease that ,ould place them at ris' for developing
'idney failure or operative complications&
=eceased (cadaver) 'idney donors are relatively healthy individuals ,ho have suffered
an irreversile rain in#ury& Permission from the donor(s legal ne)t of 'in is re<uired
after rain death is determined even if the donor carried a signed donor card&
@or a live donor transplant, the donor nephrectomy is performed either through an
open incision or laparoscopically& The short cold ischemic time is the primary reason
for the success of living donor transplants&
1+1E8
Key Points
The transplanted 'idney is usually placed e)traperitoneally in the right iliac fossa to
facilitate anastomoses and minimize the occurrence of ileus& Nursing care of the
patient in the preoperative phase includes emotional and physical preparation for
surgery&
The usual postoperative care for the living donor is similar to that follo,ing
conventional or laparoscopic nephrectomy&
@or the 'idney transplant recipient the first priority during this period is maintenance
of fluid and electrolyte alance& 3ery large volumes of urine may e produced soon
after the lood supply to the transplanted 'idney is reestalished& This is due to (1) the
ne, 'idney(s aility to filter 64N, ,hich acts as an osmotic diuretic! (") the
aundance of fluids administered during the operation! and ($) initial renal tuular
dysfunction, ,hich inhiits the 'idney from concentrating urine normally&
Postoperative teaching should include the prevention and treatment of re#ection,
infection, and complications of surgery and the purpose and side effects of
immunosuppression&
?e#ection, a ma#or prolem follo,ing 'idney transplantation, can e hyperacute, acute,
or chronic& .mmunosuppressive therapy is used to prevent re#ection ,hile maintaining
sufficient immunity to prevent over,helming infection&
.nfection is a significant cause of moridity and mortality after 'idney transplantation&
Transplant recipients usually receive prophylactic antifungal drugs& 3iral infections
can e primary or reactivation of e)isting disease& C:3 is one of the most common
viral infections&
Cardiovascular disease is the leading cause of death after renal transplantation&
>ypertension, hyperlipidemia, diaetes mellitus, smo'ing, re#ection, infections, and
increased homocysteine levels can all contriute to cardiovascular disease&
The overall incidence of malignancies in 'idney transplant recipients is 188 times
greater than in the general population& The primary cause is the immunosuppressive
therapy&
5septic necrosis of the hips, 'nees, and other #oints can result from chronic
corticosteroid therapy and renal osteodystrophy&
5ppro)imately $CK to DCK of patients ,ho have CK= are DC or older& Physiologic
changes in the older CK= patient include diminished cardiopulmonary function, one
loss, immunodeficiency, altered protein synthesis, impaired cognition, and altered drug
metaolism&
1+1E1
Key Points
:ost elderly *B?= patients select home dialysis& >o,ever, estalishing vascular access
for >= may e challenging due to atherosclerotic changes&
The most common cause of death in the elderly *B?= patient is cardiovascular disease
(:., stro'e), follo,ed y ,ithdra,al from dialysis&
th
edition
Key Points
Chapter %F: Nursing 5ssessment: *ndocrine Bystem
)ormones e)ert their effects on target tissue&
The specificity of hormoneNtarget cell interaction is determined y receptors in a /loc'+
and+'ey0 type of mechanism&
The regulation of hormone levels in the lood depends on a highly specialized
mechanism called feedac'&
-ith negati!e feedbac0, the gland responds y increasing or decreasing the secretion of
a hormone ased on feedac' from various factors&
The hypothalamus and pituitary gland integrate communication et,een the nervous and
endocrine systems&
Anterior Pituitar.
Beveral hormones secreted y the anterior pituitary are referred to as tro"ic hormones
ecause they control the secretion of hormones y other glands&
o *hyroid$stimulating hormone (TB>) stimulates the thyroid gland to secrete thyroid
hormones&
o ,drenocorticotropic hormone (5CT>) stimulates the adrenal corte) to secrete
corticosteroids&
o 0ollicle$stimulating hormone (@B>) stimulates secretion of estrogen and the
development of ova in the female and sperm development in the male&
o 1uteini2ing hormone (2>) stimulates ovulation in the female and secretion of se)
hormones in oth the male and female&
4rowth hormone (A>) has effects on all ody tissues&
1+1E"
Key Points
Antidiuretic hormone (5=>) regulates fluid volume y stimulating reasorption of
,ater in the 'idneys&
$1.tocin stimulates e#ection of mil' into mammary ducts and contraction of uterine
smooth muscle&
,h.roid 4land
The ma#or function of the thyroid gland is the production, storage, and release of the
thyroid hormones, th.ro1ine (T
%
) and triiodoth.ronine (T
$
)&
o .odine is necessary for the synthesis of thyroid hormones&
o T
%
and T
$
affect metaolic rate, carohydrate and lipid metaolism, gro,th and
development, and nervous system activities&
Calcitonin is a hormone produced y C cells (parafollicular cells) of the thyroid gland in
response to high circulating calcium levels&
Parath.roid 4land
The parathyroid glands are four small, oval structures usually arranged in pairs ehind
each thyroid loe& They secrete "arath.roid hormone (PT>), ,hich regulates the lood
level of calcium&
Adrenal 4land
The adrenal glands are small, paired, highly vascularized glands located on the upper
portion of each 'idney&
o The adrenal medulla secretes the catecholamines epinephrine (the ma#or hormone
H9CKI), norepinephrine ("CK), and dopamine&
o The adrenal corte) secretes cortisol, ,hich is the most aundant and potent
glucocorticoid& Cortisol is necessary to maintain life& .ts functions include
regulation of lood glucose concentration, inhiition of inflammatory action, and
support in response to stress&
o Aldosterone is a potent mineralocorticoid that maintains e)tracellular fluid volume&
o The adrenal corte) secretes small amounts of androgens& 5drenal androgens
stimulate puic and a)illary hair gro,th and se) drive in females&
Pancreas
The pancreas secretes several hormones, including glucagon and insulin&
o 4lucagon increases lood glucose y stimulating glycogenolysis, gluconeogenesis,
and 'etogenesis&
o 'nsulin is the principal regulator of the metaolism and storage of ingested
carohydrates, fats, and proteins&
1+1E$
Key Points
Normal aging results in decreased hormone production and secretion, altered hormone
metaolism and iologic activity, decreased responsiveness of target tissues to hormones,
and alterations in circadian rhythms&
Butle changes of aging often mimic manifestations of endocrine disorders&
ASSSSMN,
>ormones affect every ody tissue and system, causing great diversity in the signs and
symptoms of endocrine dysfunction&
*ndocrine dysfunction may result from deficient or e)cessive hormone secretion,
transport anormalities, an inaility of the target tissue to respond to a hormone, or
inappropriate stimulation of the target+tissue receptor&
Bu#ective data:
o The nurse should in<uire aout use of hormone replacements, previous
hospitalizations, surgery, chemotherapy, and radiation therapy (especially of the
nec')&
;#ective data:
o :ost endocrine glands are inaccessile to direct e)amination&
Physical e)amination:
o Clinical manifestations of endocrine function vary significantly, depending on the
gland involved&
o 5ssessment includes a history of gro,th and development, ,eight distriution and
changes, and comparisons of these factors ,ith normal findings&
o =isorders can commonly cause changes in mental and emotional status&
o The nurse should note the color and te)ture of the s'in, hair, and nails& The s'in
should e palpated for s'in te)ture and presence of moisture&
o -hen inspecting the thyroid gland, oservation should e made first in the normal
position (preferaly ,ith side lighting), then in slight e)tension, and then as the
patient s,allo,s some ,ater&
o The thyroid is palpated for its size, shape, symmetry, and tenderness and for any
nodules&
o The size, shape, symmetry, and general proportion of hand and feet size should e
assessed&
o The hair distriution pattern of the genitalia should e inspected&
D'A4N$S,'C S,5D'S
2aoratory tests usually involve lood and urine testing&
4ltrasound may e used as a screening tool to localize endocrine gro,ths such as thyroid
nodules&
1+1E%
Key Points
2aoratory studies may include direct measurement of the hormone level, or involve an
indirect indication of gland function y evaluating lood or urine components affected y
the hormone (e&g&, electrolytes)&
Notation of sample time on the laoratory slip and sample is important for hormones ,ith
circadian or sleep+related secretion&
The studies used to assess function of the anterior pituitary hormones relate to A>,
prolactin, @B>, 2>, TB>, and 5CT>&
Tests to assess anormal thyroid function include TB> (most common), total T
%
, free T
%
,
and total T
$
&
th
edition
Key Points
Chapter %E: Nursing :anagement: =iaetes :ellitus
Diabetes mellitus is a chronic multisystem disorder of glucose metaolism related to
asent or insufficient insulin supplies and1or poor utilization of the insulin that is
availale&
The t,o most common types of diaetes are classified as type 1 or type " diaetes
mellitus& Aestational diaetes, prediaetes, and secondary diaetes are other
classifications of diaetes commonly seen in clinical practice&
,6P ? D'A/,S
*ype ) diabetes mellitus most often occurs in people ,ho are under $8 years of age, ,ith
a pea' onset et,een ages 11 and 1$, ut can occur at any age&
Type 1 diaetes is the end result of a long+standing process ,here the ody(s o,n T cells
attac' and destroy pancreatic eta cells, ,hich are the source of the ody(s insulin&
6ecause the onset of type 1 diaetes is rapid, the initial manifestations are usually acute&
The classic symptoms are polyuria, polydipsia, and polyphagia#
The individual ,ith type 1 diaetes re<uires a supply of insulin from an outside source
%e"ogenous insulin&, such as an in#ection, in order to sustain life& -ithout insulin, the
1+1EC
Key Points
patient ,ill develop diaetic 'etoacidosis (=K5), a life+threatening condition resulting in
metaolic acidosis&
PREDIABETES
Prediabetes is a condition ,here lood glucose levels are higher than normal ut not
high enough for a diagnosis of diaetes& :ost people ,ith prediaetes are at increased
ris' for developing type " diaetes and if no preventive measures are ta'en, they ,ill
usually develop it ,ithin 18 years&
2ong+term damage to the ody, especially the heart and lood vessels, may already e
occurring in patients ,ith prediaetes&
TYPE 2 DIABETES
*ype ' diabetes mellitus is, y far, the most prevalent type of diaetes, accounting for
over E8K of patients ,ith diaetes&
.n type " diaetes, the pancreas usually continues to produce some endogenous (self+
made) insulin& >o,ever, the insulin that is produced is either insufficient for the needs of
the ody and1or is poorly used y the tissues&
The most important ris' factors for developing type " diaetes are elieved to e oesity,
specifically adominal and visceral adiposity& 5lso, individuals ,ith metaolic syndrome
are at an increased ris' for the development of type " diaetes&
Bome of the more common manifestations associated ,ith type " diaetes include
fatigue, recurrent infections, recurrent vaginal yeast or monilia infections, prolonged
,ound healing, and visual changes&
GESTATIONAL DIABETES
3estational diabetes develops during pregnancy and is detected at "% to "F ,ee's of
gestation, usually follo,ing an oral glucose tolerance test&
5lthough most ,omen ,ith gestational diaetes ,ill have normal glucose levels ,ithin D
,ee's postpartum, their ris' for developing type " diaetes in C to 18 years is increased&
5 diagnosis of diaetes is ased on one of three methods: (1) fasting plasma glucose
level, (") random plasma glucose measurement, or ($) "+hour oral glucose tolerance test&
The goals of diaetes management are to reduce symptoms, promote ,ell+eing, prevent
acute complications of hyperglycemia, and prevent or delay the onset and progression of
1+1ED
Key Points
long+term complications& These goals are most li'ely to e met ,hen the patient is ale to
maintain lood glucose levels as near to normal as possile&
'NS5L'N ,)-AP6
*)ogenous (in#ected) insulin is needed ,hen a patient has inade<uate insulin to meet
specific metaolic needs&
.nsulin is divided into t,o main categories: short+acting (olus) and long+acting (asal)
insulin& 6asal insulin is used to maintain a ac'ground level of insulin throughout the day
and olus insulin is used at mealtime&
5 variety of insulin regimens are recommended for patients depending on the needs of
the patient and their preference&
?outine administration of insulin is most commonly done y means of sucutaneous
in#ection, although intravenous administration of regular insulin can e done ,hen
immediate onset of action is desired&
The techni<ue for insulin in#ections should e taught to ne, insulin users and revie,ed
periodically ,ith long+term users&
The speed ,ith ,hich pea' serum concentrations are reached varies ,ith the anatomic
site for in#ection& The fastest asorption is from the adomen&
Continuous sucutaneous insulin infusion can e administered using an insulin "um", a
small attery+operated device that resemles a standard paging device in size and
appearance& The device is programmed to deliver a continuous infusion of rapid+acting or
short+acting insulin "% hours a day and at mealtime, the user programs the pump to
deliver a olus infusion of insulin&
5n alternative to in#ectale insulin is inhaled insulin& *)uera is a rapid+acting, dry
po,der form of insulin that is inhaled through the mouth into the lungs prior to eating via
a specially designed inhaler&
>ypoglycemia, allergic reactions, lipodystrophy, and the Bomogyi effect are prolems
associated ,ith insulin therapy&
o Li"od.stro"h. (atrophy of sucutaneous tissue) may occur if the same in#ection
sites are used fre<uently&
o The Somog.i effect is a reound effect in ,hich an overdose of insulin induces
hypoglycemia& 4sually occurring during the hours of sleep, the Bomogyi effect
produces a decline in lood glucose level in response to too much insulin&
o The dawn "henomenon is characterized y hyperglycemia that is present on
a,a'ening in the morning due to the release of counterregulatory hormones in the
preda,n hours&
1+1E9
Key Points
$-AL A4N,S
;ral agents (;5s) are not insulin, ut they ,or' to improve the mechanisms y ,hich
insulin and glucose are produced and used y the ody& ;5s ,or' on the three defects of
type " diaetes, including (1) insulin resistance, (") decreased insulin production, and
($) increased hepatic glucose production&
Bulfonylureas are fre<uently the drugs of choice in treating type " diaetes due to the
decreased chance of prolonged hypoglycemia& The primary action of the sulfonylureas is
to increase insulin production from the pancreas&
2i'e the sulfonylureas, meglitinides increase insulin production from the pancreas& 6ut
ecause they are more rapidly asored and eliminated, they offer a reduced potential for
hypoglycemia&
:etformin (Alucophage) is a iguanide glucose+lo,ering agent& The primary action of
metformin is to reduce glucose production y the liver&
T+Alucosidase inhiitors, also 'no,n as /starch loc'ers,0 these drugs ,or' y slo,ing
do,n the asorption of carohydrate in the small intestine&
Bometimes referred to as /insulin sensitizers,0 thiazolidinediones are most effective for
people ,ho have insulin resistance& They improve insulin sensitivity, transport, and
utilization at target tissues&
$,)- D-54 ,)-AP'S
Pramlintide (Bymlin) is a synthetic analog of human amylin, a hormone secreted y the 4
cells of the pancreas& -hen ta'en concurrently ,ith insulin, it provides for etter glucose
control&
*)anatide (6yetta) is a synthetic peptide that stimulates the release of insulin from the
pancreatic V cells& *)anatide is administered using a sucutaneous in#ection&
N5,-','$NAL ,)-AP6 AND 8-C'S
The overall goal of nutritional therapy is to assist people ,ith diaetes in ma'ing healthy
nutritional choices, eating a varied diet, and maintaining e)ercise haits that ,ill lead to
improved metaolic control&
@or those ,ith type 1 diaetes, day+to+day consistency in timing and amount of food
eaten is important for those individuals using conventional, fi)ed insulin regimens&
Patients using rapid+acting insulin can ma'e ad#ustments in dosage efore the meal ased
on the current lood glucose level and the carohydrate content of the meal&
The emphasis for nutritional therapy in type " diaetes should e placed on achieving
glucose, lipid, and lood pressure goals&
1+1EF
Key Points
The nutritional energy inta'e should e constantly alanced ,ith the energy output of the
individual, ta'ing into account e)ercise and metaolic ody ,or'&
.n a general diaetic meal plan, carohydrates and monounsaturated fat should provide
%CK to DCK of the total energy inta'e each day& @ats should compose no more than "CK
to $8K of the meal plan(s total calories, ,ith less than 9K of calories from saturated fats,
and protein should contriute less than 18K of the total energy consumed&
5lcohol is high in calories, has no nutritive value, and promotes hypertriglyceridemia&
Patients should e cautioned to honestly discuss the use of alcohol ,ith their health care
providers ecause its use can ma'e lood glucose more difficult to control&
?egular, consistent e)ercise is considered an essential part of diaetes and prediaetes
management& *)ercise increases insulin receptor sites in the tissue and can have a direct
effect on lo,ering the lood glucose levels&
M$N',$-'N4 /L$$D 4L5C$S
Self-monitoring of blood glucose (B:6A) is a cornerstone of diaetes management& 6y
providing a current lood glucose reading, B:6A enales the patient to ma'e self+
management decisions regarding diet, e)ercise, and medication&
The fre<uency of monitoring depends on several factors, including the patient(s glycemic
goals, the type of diaetes that the patient has, the patient(s aility to perform the test
independently, and the patient(s ,illingness to test&
PANC-AS ,-ANSPLAN,A,'$N
Pancreas transplantation can e used as a treatment option for patients ,ith type 1
diaetes mellitus& :ost commonly it is done for patients ,ho have end+stage renal
disease and ,ho have had or plan to have a 'idney transplant&
Kidney and pancreas transplants are often performed together, or a pancreas may e
transplanted follo,ing a 'idney transplant& Pancreas transplants alone are rare&
N5-S'N4 MANA4MN,
Nursing responsiilities for the patient receiving insulin include proper administration,
assessment of the patient(s response to insulin therapy, and education of the patient
regarding administration, ad#ustment to, and side effects of insulin&
Proper administration, assessment of the patient(s use of and response to the ;5, and
education of the patient and the family aout ;5s are all part of the nurse(s function&
The goals of diaetes self+management education are to enale the patient to ecome the
most active participant in his or her care, ,hile matching the level of self+management to
the aility of the individual patient&
1+1EE
Key Points
AC5, C$MPL'CA,'$NS $+ D'A/,S MLL',5S
Diabetic 0etoacidosis (=K5), also referred to as diabetic acidosis and diabetic coma, is
caused y a profound deficiency of insulin and is characterized y hyperglycemia,
'etosis, acidosis, and dehydration& .t is most li'ely to occur in people ,ith type 1
diaetes&
o =K5 is a serious condition that proceeds rapidly and must e treated promptly&
o 6ecause fluid imalance is potentially life threatening, the initial goal of therapy
is to estalish intravenous access and egin fluid and electrolyte replacement&
)."erosmolar h."ergl.cemic s.ndrome (>>B) is a life+threatening syndrome that can
occur in the patient ,ith diaetes ,ho is ale to produce enough insulin to prevent =K5
ut not enough to prevent severe hyperglycemia, osmotic diuresis, and e)tracellular fluid
depletion(
>ypoglycemia, or lo, lood glucose, occurs ,hen there is too much insulin in proportion
to availale glucose in the lood& Causes of hypoglycemia are often related to a mismatch
in the timing of food inta'e and the pea' action of insulin or oral hypoglycemic agents
that increase endogenous insulin secretion&
C)-$N'C C$MPL'CA,'$NS $+ D'A/,S MLL',5S
Chronic complications of diaetes are primarily those of end+organ disease from damage
to lood vessels secondary to chronic hyperglycemia& These chronic lood vessel
dysfunctions are divided into t,o categories: macrovascular complications and
microvascular complications&
o Macrovascular complications are diseases of the large and medium+sized lood
vessels that occur ,ith greater fre<uency and ,ith an earlier onset in people ,ith
diaetes&
o Microvascular complications result from thic'ening of the vessel memranes in
the capillaries and arterioles in response to conditions of chronic hyperglycemia&
Diabetic retino"ath. refers to the process of microvascular damage to the retina as a
result of chronic hyperglycemia in patients ,ith diaetes&
Diabetic ne"hro"ath. is a microvascular complication associated ,ith damage to the
small lood vessels that supply the glomeruli of the 'idney&
Diabetic neuro"ath. is nerve damage that occurs ecause of the metaolic
derangements associated ,ith diaetes mellitus& The t,o ma#or categories of diaetic
neuropathy are sensory neuropathy, ,hich affects the peripheral nervous system, and
autonomic neuropathy&
o The most common form of sensory neuropathy is distal symmetric neuropathy,
,hich affects the hands and1or feet ilaterally& This is sometimes referred to as
/stoc'ing+glove neuropathy&0
1+"88
Key Points
o ,utonomic neuropathy can affect nearly all ody systems and lead to
hypoglycemic una,areness, o,el incontinence and diarrhea, and urinary
retention&
C$MPL'CA,'$NS $+ ,) +, AND L$7- 8,-M','S
@oot complications are the most common cause of hospitalization in the person ,ith
diaetes&
Bensory neuropathy is a ma#or ris' factor for lo,er e)tremity amputation in the person
,ith diaetes& 2oss of protective sensation often prevents the patient from ecoming
a,are that a foot in#ury has occurred&
Proper care of a diaetic foot ulcer is critical to prevention of infections&
th
edition
Key Points
Chapter C8: Nursing :anagement: *ndocrine Prolems
AC-$M4AL6
Acromegal. results from e)cess secretion of gro,th hormone (A>)&
.t is a rare condition of one and soft tissue overgro,th&
6ones increase in thic'ness and ,idth ut not length&
:anifestations include enlargement of hands and feet, thic'ening and enlargement of
face and head ony and soft tissue, sleep apnea, signs of diaetes mellitus, cardiomegaly,
and hypertension&
Treatment focuses on returning A> levels to normal through surgery, radiation, and drug
therapy& The prognosis depends on age at onset, age ,hen treatment is initiated, and
tumor size&
Nursing care for surgical patients postoperatively includes avoidance of vigorous
coughing, sneezing, and straining at stool to prevent cererospinal fluid lea'age from
,here the sella turcica ,as entered&
1+"81
Key Points
5fter surgery ,ith a transsphenoidal approach, the head of the ed is elevated to a $8+
degree angle at all times, and neurologic status is monitored& :ild analgesia is used for
headaches, and toothrushing is avoided for at least 18 days&
.f hypophysectomy is done or the pituitary is damaged, antidiuretic hormone (5=>),
cortisol, and thyroid hormone replacement must e ta'en for life& Patient teaching is
essential ,ith hormone replacement therapy&
)6P$P',5',A-'SM
)."o"ituitarism is rare, and involves a decrease in one or more of the pituitary
hormones:
o The anterior pituitary gland secretes adrenocorticotrophic hormone (5CT>),
thyroid+stimulating hormone (TB>), follicle+stimulating hormone (@B>),
luteinizing hormone (2>), A>, and prolactin&
o The posterior pituitary gland secretes 5=> and o)ytocin&
:ost deficiencies associated ,ith hypopituitarism involve A> and gonadotropins (e&g&,
2>, @B>) due to a pituitary tumor&
S6ND-$M $+ 'NAPP-$P-'A, AN,'D'5-,'C )$-M$N
S.ndrome of ina""ro"riate antidiuretic hormone (B.5=>) results from an
overproduction or oversecretion of 5=>&
B.5=> results from anormal production or sustained secretion of 5=> and is
characterized y fluid retention, serum hypoosmolality, dilutional hyponatremia,
hypochloremia, concentrated urine in presence of normal or increased intravascular
volume, and normal renal function&
The most common cause is lung cancer&
Treatment is directed at underlying cause, ,ith a goal to restore normal fluid volume and
osmolality& @luid restriction results in gradual, daily ,eight reductions, progressive rise in
serum sodium concentration and osmolality, and symptomatic improvement& -ith
chronic B.5=>, the patient must learn self+management&
D'A/,S 'NS'P'D5S
Diabetes insi"idus (=.) is associated ,ith deficiency of production or secretion of 5=>
or decreased renal response to 5=>&
=ecreases in 5=> cause fluid and electrolyte imalances due to increased urinary output
and increased plasma osmolality&
=epending on the cause, =. may e transient or chronic lifelong condition&
Types of =. include:
1+"8"
Key Points
o Central D- (or neurogenic D-) occurs ,hen an organic lesion of the
hypothalamus, infundiular stem, or posterior pituitary interferes ,ith 5=>
synthesis, transport, or release&
o 5ephrogenic D- occurs ,hen there is ade<uate 5=>, ut a decreased 'idney
response to 5=>& 2ithium is a common cause of drug+induced nephrogenic =.&
>ypo'alemia and hypercalcemia may also lead to nephrogenic =.&
o Psychogenic D- is associated ,ith e)cessive ,ater inta'e, caused y lesion in
thirst center or y psychosis&
=. is characterized y polydipsia and polyuria&
.f oral fluid inta'e cannot 'eep up ,ith urinary losses, severe fluid volume deficit results
as manifested y ,eight loss, constipation, poor tissue turgor, hypotension, and shoc'&
Bevere dehydration and hypovolemic shoc' may occur&
Treating the primary cause is central to management& Therapeutic goal is maintenance of
fluid and electrolyte alance&
Nursing care includes early detection, maintenance of ade<uate hydration, and patient
teaching for long+term management&
4$',-
4oiter is thyroid gland hypertrophy and enlargement caused y e)cess TB> stimulation,
,hich can e caused y inade<uate circulating thyroid hormones&
Aoiter is also found in Araves( disease&
TB> and T% levels are measured to determine if goiter is associated ,ith
hyperthyroidism, hypothyroidism, or normal thyroid function&
Thyroid antiodies are measured to assess for thyroiditis&
Treatment ,ith thyroid hormone may prevent further thyroid enlargement&
Burgery to remove large goiters may e done&
,)6-$'D N$D5LS
5 th.roid nodule, a palpale deformity of the thyroid gland, may e enign or
malignant&
6enign nodules are usually not dangerous, ut can cause tracheal compression if they
ecome too large&
:alignant tumors of thyroid gland are rare&
1+"8$
Key Points
5 ma#or sign of thyroid cancer is presence of hard, painless nodule or nodules on
enlarged thyroid gland&
Burgical tumor removal is usually indicated ,ith cancer&
Procedures include unilateral total loectomy ,ith removal of isthmus to total
thyroidectomy ,ith ilateral loectomy&
?adiation therapy may also e indicated&
Nursing care for thyroid tumors is similar to care for patient ,ho has undergone
thyroidectomy&
,)6-$'D','S
,h.roiditis is an inflammatory process in the thyroid gland&
Buacute and acute forms of thyroiditis have arupt onset, and the thyroid gland is
painful&
Chronic autoimmune thyroiditis (>ashimoto(s thyroiditis) can lead to hypothyroidism&
Hashimoto6s thyroiditis is a chronic autoimmune disease in ,hich thyroid tissue is
replaced y lymphocytes and firous tissue& .t is most common cause of goiterous
hypothyroidism&
?ecovery may e complete in ,ee's or months ,ithout treatment&
)6P-,)6-$'D'SM
)."erth.roidism is thyroid gland hyperactivity ,ith sustained increase in synthesis and
release of thyroid hormones&
,h.roto1icosis refers to physiologic effects or clinical syndrome of hypermetaolism
resulting from e)cess circulating levels of T%, T$, or oth&
>yperthyroidism and thyroto)icosis usually occur together as in Araves( disease&
The most common form of hyperthyroidism is Araves( disease&
;ther causes include to)ic nodular goiter, thyroiditis, e)ogenous iodine e)cess, pituitary
tumors, and thyroid cancer&
4ra!es< Disease
4ra!es< disease is an autoimmune disease mar'ed y diffuse thyroid enlargement and
e)cessive thyroid hormone secretion&
1+"8%
Key Points
@actors such as insufficient iodine supply, infection, and stressful life events may interact
,ith genetic factors to cause Araves( disease&
:anifestations relate to the effect of thyroid hormone e)cess&
-hen thyroid gland is large, a goiter may e noted, and auscultation of thyroid gland may
reveal ruits&
5 classic finding is e1o"hthalmos, a protrusion of eyealls from the orits&
Treatment options are antithyroid medications, radioactive iodine therapy, and sutotal
thyroidectomy&
,h.roto1ic Crisis
,h.roto1ic crisis, also 'no,n as thyroid storm, is an acute, rare condition in ,hich all
hyperthyroid manifestations are heightened&
5lthough it is a life+threatening emergency, death is rare ,hen treatment is vigorous and
initiated early&
:anifestations include severe tachycardia, shoc', hyperthermia, seizures, adominal
pain, diarrhea, delirium, and coma&
Treatment focuses on reducing circulating thyroid hormone levels y drug therapy&
)6P$,)6-$'D'SM
)."oth.roidism is one of most common medical disorders&
.t results from insufficient circulating thyroid hormone&
This condition may e primary (related to destruction of thyroid tissue or defective
hormone synthesis), or secondary (related to pituitary disease ,ith decreased TB>
secretion or hypothalamic dysfunction ,ith decreased thyrotropin+releasing hormone
HT?>I secretion)&
>ypothyroidism also can e transient and related to thyroiditis or from a discontinuation
of thyroid hormone therapy&
.odine deficiency is the most common cause ,orld,ide(
.n areas ,ith ade<uate iodine inta'e, the most common cause is thyroid gland atrophy
(end result of >ashimoto(s thyroiditis and Araves( disease)&
1+"8C
Key Points
:anifestations include fatigue, lethargy, personality and mental changes, decreased
cardiac output, anemia, and constipation&
Patients ,ith severe long+standing hypothyroidism may display m.1edema, an
accumulation of hydrophilic mucopolysaccharides in dermis and other tissues& This
mucinous edema causes characteristic facies of hypothyroidism (i&e&, puffiness,
periorital edema, and mas'li'e affect)&
5 my)edema coma can e precipitated y infection, drugs (especially opioids,
tran<uilizers, and ariturates), e)posure to cold, and trauma& This condition is
characterized y sunormal temperature, hypotension, and hypoventilation& To survive,
vital functions are supported and .3 thyroid hormone replacement administered&
The overall treatment in hypothyroidism is restoration of euthyroid state as safely and
rapidly as possile ,ith hormone replacement therapy&
2evothyro)ine (Bynthroid) is the drug of choice&
Patient teaching is imperative, and the need for lifelong drug therapy is stressed&
)6P-PA-A,)6-$'D'SM
)."er"arath.roidism involves increased secretion of parathyroid hormone (PT>)&
*)cess PT> leads to hypercalcemia and hypophosphatemia&
:anifestations include ,ea'ness, loss of appetite, constipation, emotional disorders, and
shortened attention span&
:a#or signs include osteoporosis, fractures, and 'idney stones&
Neuromuscular anormalities are muscle ,ea'ness in pro)imal muscles of lo,er
e)tremities&
Parathyroidectomy leads to a reduction in chronically high calcium levels&
Continued amulation, avoidance of immoility, a high fluid inta'e and moderate
calcium inta'e are important&
Beveral drugs are helpful in lo,ering calcium levels: isphosphonates (e&g&, alendronate
H@osama)I) estrogen or progestin therapy, oral phosphate, diuretics, and calcimimetic
agents (e&g&, cinacalcet HBensiparI)&
)6P$PA-A,)6-$'D'SM
)."o"arath.roidism is rare, and results from inade<uate circulating PT>&
1+"8D
Key Points
.t is characterized y hypocalcemia resulting from a lac' of PT> to maintain serum
calcium levels&
The most common cause is iatrogenic, due to accidental removal of parathyroid glands or
damage to these glands during nec' surgery&
Budden decreases in serum calcium cause tetany, ,hich is characterized y tingling of
lips, fingertips, and increased muscle tension ,ith paresthesias and stiffness&
Painful tonic spasms of smooth and s'eletal muscles (e)tremities and face), and
laryngospasms and a positive Chvoste' sign and Trousseau sign are usually present&
@ocus of patient care is to treat tetany, maintain normal serum calcium levels, and prevent
long+term complications& *mergency treatment of tetany re<uires .3 calcium&
.nstruction aout lifelong treatment and follo,+up care includes monitoring of calcium
levels&
C5S)'N4 S6ND-$M
Cushing s.ndrome is a spectrum of clinical anormalities caused y e)cessive
corticosteroids, particularly glucocorticoids&
The most common cause is iatrogenic administration of e)ogenous corticosteroids (e&g&,
prednisone)&
:ost cases of endogenous Cushing syndrome are due to adrenocorticotrophic hormone
(5CT>) secreting pituitary tumor (Cushing(s disease)&
Key signs include centripedal or generalized oesity, /moon facies0 (fullness of face),
purplish red striae elo, the s'in surface, hirsutism in ,omen, hypertension, and
une)plained hypo'alemia&
Treatment is dependent on the underlying cause, and includes surgery and drug therapy to
normalize hormone levels&
=ischarge instructions are ased on patient(s lac' of endogenous corticosteroids and
resulting inaility to react to stressors physiologically&
2ifetime replacement therapy is re<uired y many patients&
ADD'S$N<S D'SAS
.n the patient ,ith Addison<s disease, all three classes of adrenal corticosteroids
(glucocorticoids, mineralocorticoids, and androgens) are reduced&
The etiology is mostly autoimmune ,here adrenal corte) is destroyed y autoantiodies&
1+"89
Key Points
:anifestations have a slo, onset and include ,ea'ness, ,eight loss, and anore)ia&
B'in hyperpigmentation is seen in sun+e)posed areas of ody, at pressure points, over
#oints, and in palmar creases&
The treatment is replacement therapy& >ydrocortisone, the most commonly used form of
replacement therapy, has oth glucocorticoid and mineralocorticoid properties& =uring
times of stress, glucocorticoid dosage is increased to prevent addisonian crisis&
:ineralocorticoid replacement ,ith fludrocortisone acetate (@lorinef) is given daily ,ith
increased dietary salt& Patient teaching covers medications, techni<ues for stress
management, and that patient must al,ays ,ear an identification racelet (:edic 5lert)&
Addisonian Crisis
Patients ,ith 5ddison(s disease are at ris' for an acute adrenal insufficiency (addisonian
crisis), a life+threatening emergency caused y insufficient or sudden decrease in
adrenocortical hormones&
5ddisonian crisis is triggered y stress (e&g&, surgery, trauma, hemorrhage, or psychologic
distress)! sudden ,ithdra,al of corticosteroid hormone replacement therapy! and post+
adrenal surgery&
:anifestations include postural hypotension, tachycardia, dehydration, hyponatremia,
hyper'alemia, hypoglycemia, fever, ,ea'ness, and confusion&
Treatment is shoc' management and high+dose hydrocortisone replacement& 2arge
volumes of 8&EK saline solution and CK de)trose are given to reverse hypotension and
electrolyte imalances until lood pressure normalizes&
L$N4-,-M ADM'N'S,-A,'$N $+ C$-,'C$S,-$'DS
The use of long+term corticosteroids in therapeutic doses often leads to serious
complications and side effects&
Therapy is reserved for diseases in ,hich there is a ris' of death or permanent loss of
function, and conditions in ,hich short+term therapy is li'ely to produce remission or
recovery&
The potential treatment enefits must al,ays e ,eighed against ris's&
The danger of arupt cessation of corticosteroid therapy must e emphasized to patients
and significant others&
Corticosteroids ta'en longer than 1 ,ee' ,ill suppress adrenal production and oral
corticosteroids should e tapered&
1+"8F
Key Points
Nurses must ensure that increased doses of corticosteroids are prescried in acute care or
home care situations ,ith increased physical or emotional stress&
)6P-ALD$S,-$N'SM
)."eraldosteronism is characterized y e)cessive aldosterone secretion commonly
caused y small solitary adrenocortical adenoma&
The main effects are sodium retention and potassium and hydrogen ion e)cretion&
5 'ey sign of this disease is hypertension ,ith hypo'alemic al'alosis&
The preferred treatment is surgical removal of adenoma (adrenalectomy)&
Patients ,ith ilateral adrenal hyperplasia are treated ,ith drugs& Calcium channel
loc'ers may e used to control 6P&
Patients are taught to monitor o,n 6P and need for monitoring&
P)$C)-$M$C6,$MA
Pheochromoc.toma is a rare condition characterized y an adrenal medulla tumor that
produces e)cessive catecholamines (epinephrine, norepinephrine)&
The tumor is enign in most cases&
The secretion of e)cessive catecholamines results in severe hypertension&
.f undiagnosed and untreated, pheochromocytoma may lead to diaetes mellitus,
cardiomyopathy, and death&
:anifestations include severe, episodic hypertension accompanied y classic triad of (1)
severe, pounding headache, (") tachycardia ,ith palpitations and profuse s,eating, and
($) une)plained adominal or chest pain&
5ttac's may e provo'ed y many medications, including antihypertensives, opioids,
radiologic contrast media, and tricyclic antidepressants&
The treatment consists of surgical removal of tumor&
th
edition
1+"8E
Key Points
Key Points
Chapter C1: Nursing 5ssessment: ?eproductive Bystem
The primary roles of male reproductive system are production and transportation of
sperm, deposition of sperm in female reproductive tract, and secretion of hormones&
o The primary male reproductive organs are the testes&
The primary roles of female reproductive system are production of ova, secretion of
hormones, and protection and facilitation of the development of the fetus in a pregnant
female&
o The primary female reproductive organs are the ovaries&
The hypothalamus, pituitary gland, and gonads secrete numerous hormones that regulate
the processes of ovulation, spermatogenesis, fertilization, and formation and function of
secondary se) characteristics&
.n ,omen, follicle+stimulating hormone (@B>) production y anterior pituitary stimulates
gro,th and maturity of ovarian follicles&
o :ature follicle produces estrogen, ,hich in turn suppresses the release of
@B>& .n men, @B> stimulates seminiferous tuules to produce sperm&
*strogen and progesterone are produced y the ovaries&
o *strogen is essential to development and maintenance of secondary se)
characteristics, proliferative phase of menstrual cycle immediately after
menstruation, and pregnancy uterine changes&
o Progesterone is also involved in ody changes of pregnancy&
The ma#or gonadal hormone of men is testosterone, ,hich is produced y the testes&
Testosterone is responsile for development and maintenance of secondary se)
characteristics and s"ermatogenesis(
Menarche is the first episode of menstrual leeding, indicating that a female has reached
puerty&
o This usually occurs at 1" to 1$ years of age&
o The length of the menstrual c.cle generally ranges from "8 to %8 days&
The ma#or functions of ovaries are ovulation and secretion of hormones& These functions
are accomplished during the menstrual cycle&
.f fertilization occurs, high levels of estrogen and progesterone continue to e secreted
due to continued activity of corpus luteum from stimulation y human chorionic
gonadotropin (hCA)&
1+"18
Key Points
o .f fertilization does not ta'e place, menstruation occurs ecause of a decrease
in estrogen production and progesterone&
Meno"ause is the physiologic cessation of menses associated ,ith declining ovarian
function& .t is usually considered complete after 1 year of amenorrhea(
The se)ual response is a comple) interplay of psychologic and physiologic phenomena
influenced y a numer of variales, including daily stress, illness, and crisis&
o Changes that occur during se)ual e)citement are similar for men and ,omen&
o Be)ual response can e descried in terms of the e)citement, plateau,
orgasmic, and resolution phases&
.n ,omen, many changes relate to the altered estrogen production of menopause&
5 reduction in circulating estrogen along ,ith an increase in androgens in
postmenopausal ,omen is associated ,ith reast and genital atrophy, reduction in one
mass, and increased rate of atherosclerosis&
Changes in aging men include an increase in prostate size, decreased testosterone level
and sperm production, decreased scrotum muscle tone and size and firmness of the
testicles& *rectile dysfunction and se)ual dysfunction can occur as result of these
changes&
ASSSSMN,
Nurses have an important role in providing accurate and uniased information aout
se)uality and age& Nurses should emphasize normalcy of se)ual activity in older adults&
?eproduction and se)ual issues are often considered e)tremely personal and private&
o 5 professional demeanor is important ,hen ta'ing a reproductive or se)ual
history&
o The nurse needs to e sensitive, as' gender+neutral <uestions, and maintain
a,areness of patient(s culture and eliefs&
o .t is helpful if the nurse egins ,ith least sensitive information (e&g&,
menstrual history) efore as'ing <uestions aout more sensitive issues such as
se)ual practices or se)ually transmitted diseases&
-omen should have a complete menstrual and gynecologic history ta'en, including oral
contraceptive use&
o The nurse should <uestion the patient regarding current health status and
presence of any acute or chronic health prolems as prolems in other ody
systems often relate to prolems ,ith reproductive system&
Physical e)amination:
1+"11
Key Points
o Male e"ternal genitalia inspection and palpation of puis, penis, scrotum and
testes, inguinal region and spermatic cord, anus and prostate&
o 0emale egins ,ith inspection and palpation of reasts and then proceeds to
adomen and e)ternal genitalia including mons "ubis, laia ma#ora, laia
minora, perineum, and anal region&
o Pelvic and imanual e)aminations are considered advanced s'ills&
D'A4N$S,'C S,5D'S
Berum hormone test, hCA, is used to identify pregnancy&
Prolactin assay is used for patient ,ith amenorrhea&
Berum progesterone and estradiol can also help in ovarian function assessment,
particularly for amenorrhea&
>ormonal lood studies are essential for a fertility ,or'up&
th
edition
Key Points
Chapter C": Nursing :anagement: 6reast =isorders
Bcreening guidelines for early detection of reast cancer are yearly mammograms starting
at age %8, and clinical reast e)aminations every $ years for ,omen et,een ages "8 and
$8 and every year for ,omen eginning at age %8&
-omen should report any reast changes promptly to their health care provider&
6reast self+e)amination is an option for ,omen&
-omen at increased reast cancer ris' (family history, genetic tendency, past reast
cancer) should tal' ,ith their health care provider aout enefits and limitations of
starting mammography screening earlier, having additional tests (reast ultrasound), or
having more fre<uent e)aminations&
:ammography is used to visualize internal structures of the reast using )+rays& This
procedure can detect tumors and cysts not felt y palpation&
4ltrasound is another procedure used to differentiate a enign tumor from a malignant
tumor& .t is useful for ,omen ,ith firocystic changes ,hose reasts are very dense&
1+"1"
Key Points
=efinitive diagnosis of reast cancer is made y histologic e)amination of iopsied
tissue& 6iopsy techni<ues include fine+needle aspiration (@N5) iopsy, stereotactic or
handheld core iopsy, and open surgical iopsy&
:astalgia (reast pain):
o Mastalgia is the most common reast+related enign complaint in ,omen&
o .t is descried as diffuse reast tenderness or heaviness&
o 6reast pain may last " to $ days or most of month&
o Bymptoms often decrease ,ith menopause&
o Bome relief may occur ,ith caffeine and dietary fat reduction! hormonal therapy,
ta'ing vitamins, and gamma+linolenic acid (evening primrose oil)! and ,earing of
support ra&
:astitis:
o Mastitis is a reast inflammatory condition that occurs most fre<uently in
lactating ,omen&
o 1actational mastitis manifests as a localized area that is erythematous, painful,
and tender to palpation&
o @ever is usually present& .nfection develops ,hen organisms, usually
staphylococci, gain access to reast through crac'ed nipple&
o .n its early stages, mastitis can e cured ,ith antiiotics&
@irocystic changes in reast:
o +ibroc.stic changes is a common enign condition characterized y changes in
reast tissue including development of e)cess firous tissue, hyperplasia of
epithelial lining of mammary ducts, proliferation of mammary ducts, and cyst
formation&
o These changes produce pain y nerve irritation from edema in connective tissue
and y firosis from nerve pinching&
o Types of treatment that might help firocystic reast disease include use of good
support ra, dietary therapy (lo,+salt diet, restriction of methyl)anthines such as
coffee and chocolate), vitamin * therapy, analgesics, danazol, diuretics, hormone
therapy, and antiestrogen therapy&
o +ibroadenoma is a common cause of enign reast lumps in young ,omen& 5
possile cause may e increased estrogen sensitivity in localized area of reast&
Treatment includes surgical e)cision or cryoablation#
o 4.necomastia is a transient, noninflammatory enlargement of one or oth reasts
and is the most common enign reast prolem in men&
/-AS, CANC-
6reast cancer is the most common malignancy in 5merican ,omen e)cept for s'in
cancer&
5lthough the etiology of reast cancer is not completely understood, a numer of factors
1+"1$
Key Points
are thought to relate to reast cancer including a family history, environmental factors,
genetics, early menarche and late menopause, and age D8 or over& >o,ever, most ,omen
,ho develop reast cancer have no identifiale ris' factors&
Noninvasive reast cancers include ductal carcinoma in situ (=C.B) and lobular
carcinoma in situ (2C.B)&
o =C.B tends to e unilateral and most li'ely ,ould progress to invasive reast
cancer if left untreated&
o 2C.B is a ris' factor for developing reast cancer, ut it is not 'no,n to e a
premalignant lesion& No treatment is necessary for 2C.B& Tamo)ifen may e given
as a chemoprevention&
Paget(s disease:
o Paget<s disease is a rare reast malignancy characterized y a persistent lesion of
the nipple and areola ,ith or ,ithout a palpale mass&
o Treatment is a simple or modified radical mastectomy&
.nflammatory reast cancer:
o -nflammatory breast cancer is the most malignant form of all reast cancers&
o The s'in of the reast loo's red, feels ,arm, ,ith a thic'ened appearance
descried as resemling an orange peel (peau d(orange)&
o :etastases occur early and ,idely& ?adiation, chemotherapy, and hormone
therapy are more li'ely to e used for treatment than surgery&
6reast cancer is detected as a lump or mammographic anormality in the reast& .t occurs
most often in upper, outer <uadrant of reast&
.f palpale, reast cancer is usually hard, and may e irregularly shaped, poorly
delineated, nonmoile, and nontender& Nipple discharge may also e present&
.n addition to earlier listed tests, other tests useful in predicting ris' of recurrence or
metastatic reast disease include a)illary lymph node status, tumor size, estrogen and
progesterone receptor status, and cell proliferative indices&
Patients ,ith reast cancer should discuss all treatment options ,ith their health care
provider, including local e)cision, mastectom. ,ith reast reconstruction, reast+
conserving treatment (lumpectomy), radiation therapy, and1or tamo)ifen&
Common options for resectale reast cancer include reast conservation surgery ,ith
radiation therapy and modified radical mastectomy ,ith or ,ithout reconstruction&
6reast conservation surgery (lum"ectom.) involves removal of entire tumor along ,ith a
margin of normal tissue& :odified radical mastectomy includes removal of reast and
a)illary lymph nodes, ut it preserves pectoralis ma#or muscle&
1+"1%
Key Points
L.m"hedema can occur due to surgical e)cision or radiation of lymph nodes& Bymptoms
are heaviness, pain, impaired motor function in the arm, and numness and paresthesia of
the fingers as a result of lymphedema&
@ollo,ing surgery, radiation therapy is delivered to the entire reast, ending ,ith a oost
to the tumor ed& .f there is evidence of systemic disease, then chemotherapy may e
given efore radiation therapy&
?adiation therapy may e used for reast cancer as a primary treatment to prevent local
reast recurrences after reast conservation surgery, ad#uvant treatment follo,ing
mastectomy to prevent local and nodal recurrences, and palliative treatment for pain
caused y local recurrence and metastases&
6reast cancer is one of the solid tumors most responsive to chemotherapy ,ith the use of
cominations of drugs, ,hich is clearly superior to use of single drug therapy&
>ormonal therapy removes or loc's the source of estrogen, thus promoting tumor
regression&
Nursing interventions at time of reast cancer diagnosis include e)ploring ,oman(s usual
decision+ma'ing patterns, helping the ,oman accurately evaluate advantages and
disadvantages of options, and providing information and support relevant to treatment
decisions&
The ,oman ,ith reast conservation surgery usually has an uneventful postoperative
course ,ith only a moderate amount of pain& .f an a)illary lymph node dissection or
mastectomy is done, drains are often left in place&
Postoperative discomfort is minimized y administering analgesics $8 minutes efore
initiating e)ercises& -ith sho,ering, the flo, of ,arm ,ater over the involved shoulder
often has a soothing effect and reduces #oint stiffness&
:ammoplasty:
o Mammo"last. is a surgical change in size or shape of the reast&
o .t may e done electively for cosmetic purposes to either augment or reduce the
size of reasts or to reconstruct the reast after mastectomy&
o .n augmentation, an implant is placed in a surgically created poc'et et,een the
capsule of the reast and the pectoral fascia&
o ?eduction mammoplasty is performed y resecting ,edges of tissue from upper
and lo,er <uadrants of reast&
6reast reconstructive surgery may e done simultaneously ,ith mastectomy or some time
after,ard to achieve symmetry and to restore or preserve ody image&
1+"1C
Key Points
th
edition
Key Points
Chapter C$: Nursing :anagement: Be)ually Transmitted =iseases
Se1uall. transmitted diseases (BT=s) are infectious diseases transmitted most
commonly through se)ual contact&
Types of BT= infections include acterial (gonorrhea, chlamydia, syphilis) and viral
(genital herpes, genital ,arts)&
:ost infections start as lesions on the genitalia and other se)ually e)posed mucous
memranes& -ide dissemination to other ody areas can then occur&
5 latent, or suclinical, phase is present ,ith all BT=s& This can lead to a long+term
persistent infection and transmission of disease from asymptomatic (ut infected) person
to another contact&
=ifferent BT=s can coe)ist ,ithin one person&
4$N$--)A
4onorrhea is the second most fre<uently reported BT= in 4nited Btates&
.t is caused y 5eisseria gonorrhoeae, a gram+negative diplococcus&
Aonorrhea is spread y direct physical contact ,ith an infected host, usually during
se)ual activity (vaginal, oral, or anal)&
The initial site of gonorrhea infection in men is usually the urethra&
Bymptoms of urethritis consist of dysuria and profuse, purulent urethral discharge
developing " to C days after infection&
-omen ,ith gonorrhea are often asymptomatic or have minor symptoms that are often
overloo'ed& 5 fe, ,omen may complain of vaginal discharge, dysuria, or fre<uency of
urination&
Complications of gonorrhea in men are prostatitis, urethral strictures, and sterility from
orchitis or epididymitis&
1+"1D
Key Points
6ecause ,omen ,ith gonorrhea ,ho are asymptomatic seldom see' treatment,
complications are more common and include pelvic inflammatory disease (P.=),
6artholin(s ascess, ectopic pregnancy, and infertility&
Typical clinical manifestations of gonorrhea, comined ,ith a positive finding in a Aram+
stained smear of the purulent discharge from the penis, gives an almost certain diagnosis
in men& 5 culture must e performed to confirm the diagnosis in ,omen&
The most common treatment for gonorrhea is a single .: dose of ceftria)one (?ocephin)&
Patients ,ith coe)isting syphilis are li'ely to e cured y same drugs used for gonorrhea&
5ll se)ual contacts of patients ,ith gonorrhea must e evaluated and treated to prevent
reinfection after resumption of se)ual relations&
S6P)'L'S
The cause of s."hilis is *reponema pallidum, a spirochete ,hich enters the ody through
very small rea's in s'in or mucous memranes&
.n addition to se)ual contact, syphilis may e spread through contact ,ith infectious
lesions and sharing of needles among .3 drug users&
.f syphilis is not treated, specific stages are characteristic of disease progression&
.n the primary stage, chancres appear& =uring this time, draining of microorganisms into
lymph nodes causes regional lymphadenopathy& Aenital ulcers may also e present&
-ithout treatment, syphilis progresses to a secondary (systemic) stage# :anifestations
include flu+li'e symptoms of fever, sore throat, headaches, fatigue, and generalized
adenopathy&
The third stage is most severe stage& :anifestations include gummas, aneurysms, heart
valve insufficiency, and heart failure, and general paresis&
Byphilis is commonly diagnosed y a serologic test& 6enzathine penicillin A (6icillin) or
a<ueous procaine penicillin A remains the treatment for all stages of syphilis&
C)LAM6D'AL 'N+C,'$NS
Chlam.dial infections are the most commonly reported BT= in the 4nited Btates&
They are caused y Chlamydia trachomatis, a gram+negative acterium that is
transmitted during vaginal, anal, or oral se)&
Chlamydial infections are associated ,ith gonococcal infections, ,hich ma'es clinical
differentiation difficult& .n men, urethritis, epididymitis, and proctitis may occur in oth
diseases& .n ,omen, artholinitis, cervicitis, and salpingitis (inflammation of the fallopian
1+"19
Key Points
tue) can occur in oth diseases& Therefore, oth Chlamydia and gonorrhea are usually
treated concurrently even ,ithout diagnostic evidence&
Complications from chlamydial infections in men result in epididymitis ,ith possile
infertility and reactive arthritis&
Complications from chlamydial infections in ,omen may result in P.=, ,hich can lead to
chronic pelvic pain and infertility&
=N5 amplification tests are the most sensitive diagnostic methods availale to detect
chlamydial infections&
Chlamydial infections respond to treatment ,ith do)ycycline (3iramycin) or
azithromycin (Jithroma))&
4N',AL )-PS
4enital her"es is caused y herpes simple) virus type " (>B3+")&
The virus enters through mucous memranes or rea's in s'in during contact ,ith
infected person&
.n general, >B3 type 1 (>B3+1) causes infection aove ,aist, involving gingivae,
dermis, upper respiratory tract, and CNB&
>B3 type " (>B3+") most fre<uently infects the genital tract and perineum (locations
elo, ,aist)&
.n a primary episode of genital herpes the patient may complain of urning or tingling at
the site of inoculation& :ultiple small, vesicular lesions may appear on penis, scrotum,
vulva, perineum, perianal region, vagina, or cervi)&
!ecurrent genital herpes occurs in C8K to F8K of individuals during the year follo,ing
the primary episode& Btress, fatigue, sunurn, and menses are noted triggers& Bymptoms
of recurrent episodes are less severe, and lesions usually heal ,ithin F to 1" days&
The diagnosis of genital herpes is confirmed through isolation of the virus from active
lesions y means of tissue culture&
Three antiviral agents are availale for treatment: acyclovir (Jovira)), valacyclovir
(3altre)), and famciclovir (@amvir)& These drugs inhiit herpetic viral replication and are
prescried for primary and recurrent infections&
4N',AL 7A-,S
Aenital ,arts are caused y the human papillomavirus (>P3)& There are over 188 types
of papillomaviruses, and aout %8 of these affect the genital tract&
1+"1F
Key Points
:ost individuals ,ho have >P3 infection do not 'no, they are infected ecause
symptoms are often not present&
Bome >P3 types appear to e harmless and self+limiting, ,hereas others are lin'ed to
cervical and vulvar cancer in ,omen and anorectal and s<uamous cell carcinoma of the
penis in men&
Aenital ,arts are discrete single or multiple papillary gro,ths that are ,hite to gray and
pin'+flesh colored& They may gro, and coalesce to form large, cauliflo,er+li'e masses&
.n men, ,arts may occur on the penis and scrotum, around the anus, or in the urethra& .n
,omen, ,arts may e located on the vulva, vagina, or cervi) and in the perianal area&
=iagnosis of genital ,arts can e made on the asis of gross appearance of lesions&
Aenital ,arts are difficult to treat and often re<uire multiple office visits ,ith a variety of
treatments&
Treatment consists of chemical or alative (removal ,ith laser or electocautery) methods&
6ecause treatment does not destroy the virus, recurrences and reinfection are possile,
and careful long+term follo,+up is advised&
5 vaccine is no, availale to prevent precancerous genital lesions and genital ,arts due
to human >P3 (types D, 11, 1D, and 1F)&
N5-S'N4 MANA4MN,
Nurses should e prepared to discuss decreasing e)posure to BT=s ,ith all patients, not
only those ,ho are perceived to e at ris'&
/Bafe0 se) practices include astinence, monogamy ,ith the uninfected partner,
avoidance of certain high+ris' se)ual practices, and use of condoms and other arriers to
limit contact ,ith potentially infectious ody fluids or lesions&
Nurses can actively encourage communities to provide etter education aout BT=s for
their citizens& Teenagers have a high incidence of infection and should e a prime target
for such educational programs&
5n BT= may e met ,ith many emotions, such as shame, guilt, anger, and a desire for
vengeance& The nurse should provide counseling and try to help patient veralize feelings
related to the BT=&
1+"1E
Key Points
th
edition
Key Points
Chapter C%: Nursing :anagement: @emale ?eproductive Prolems
'N+-,'L',6
'nfertilit. is the inaility to achieve a pregnancy after at least 1 year of regular
intercourse ,ithout contraception&
=iagnostic studies include ovulatory studies, tual patency studies, and postcoital studies&
:anagement depends on the cause and can include supplemental hormone therapy and
antiiotic therapy&
A/$-,'$N
Abortion is the loss or termination of a pregnancy efore the fetus has developed to a
state of viaility&
5ortions are classified as spontaneous (those occurring naturally) or induced (those
occurring as a result of mechanical or medical intervention)&
Nursing management includes the use of comfort measures to provide needed physical
and mental rest& The support of the patient and her family is essential&
P-MNS,-5AL S6ND-$M
Premenstrual s.ndrome (P:B) is a common disorder of physical and psychologic
symptoms during the last fe, days of the menstrual cycle and efore onset of
menstruation&
P:B is thought to have a iologic trigger ,ith compounding psychosocial factors&
Physical symptoms include reast discomfort, adominal loating, sensation of ,eight
gain, episodes of inge eating, and headache& 5n)iety, depression, irritaility, and mood
s,ings are some of the emotional symptoms&
No single treatment is availale to relieve symptoms& The goal is to reduce symptom
severity&
D6SMN$--)A
D.smenorrhea is adominal cramping pain or discomfort associated ,ith
menstrual flo,&
o Primary dysmenorrhea is caused y an e)cess of prostaglandin @
"
T (PA@
"
T)
and1or an increased sensitivity to it&
o Secondary dysmenorrhea is ac<uired after adolescence! pelvic causes include
1+""8
Key Points
endometriosis, chronic pelvic inflammatory disease, and uterine firoids&
Treatment for primary dysmenorrhea includes heat, e)ercise, and drug therapy& @or
secondary dysmenorrhea, it depends on the cause&
5normal vaginal or uterine leeding is a common gynecologic concern and is caused y
dysfunction of hypothalamic+pituitary+ovarian a)is, infection, and stressful changes in
lifestyle& Treatment varies depending on the cause ut can include drug therapy and
surgery&
C,$P'C P-4NANC6
5n ecto"ic "regnanc. is the implantation of the fertilized ovum any,here outside the
uterine cavity&
5ny loc'age of the tue or reduction of tual peristalsis that impedes or delays the
zygote passing to the uterine cavity can result in tual implantation&
?is' factors include a history of pelvic inflammatory disease, prior ectopic pregnancy,
current progestin+releasing intrauterine device (.4=), progestin+only irth control failure,
and prior pelvic or tual surgery&
*ventually the tue ruptures ,ith acute peritoneal symptoms of adominal1 pelvic pain,
missed menses, and irregular vaginal leeding& 2ess acute symptoms egin D to F ,ee's
after last normal menstrual period&
Burgery is usually the treatment&
MN$PA5S
Meno"ause is the physiologic cessation of menses associated ,ith declining ovarian
function& .t is usually considered complete after 1 year of amenorrhea&
;varian changes start the cascade of events that result in menopause&
Premenopausal symptoms include hot flashes, irregular vaginal leeding, fat
redistriution, and a tendency to gain ,eight&
Treatment might include hormone replacement, drug therapy, and alternative therapies&

'N+C,'$N AND 'N+LAMMA,'$N $+ 2A4'NA, C-2'8, AND 25L2A
.nfection and inflammation of vagina, cervi), and vulva commonly occur ,hen natural
defenses of the acid vaginal secretions (maintained y sufficient estrogen levels) and
presence of 1actobacillus are disrupted&
5normal vaginal discharge and reddened vulvar lesions are often noted ,ith itching and
dysuria&
1+""1
Key Points
Treatment includes antiiotics and antifungal preparations&
PL2'C 'N+LAMMA,$-6 D'SAS
Pel!ic inflammator. disease (P.=) is an infectious condition of pelvic cavity that may
involve infection of fallopian tues (salpingitis), ovaries (oophoritis), and pelvic
peritoneum (peritonitis)&
P.= is often the result of untreated cervicitis&
The main symptom is constant lo,er adominal pain&
2ong+term complications include ectopic pregnancy, infertility, and chronic pelvic pain&
P.= is usually treated ,ith antiiotics&
ND$M,-'$S'S
ndometriosis is the presence of normal endometrial tissue in sites outside endometrial
cavity&
;ne cause is retrograde menstrual flo, through the fallopian tues carrying viale
endometrial tissues into the pelvis&
Bymptoms are secondary dysmenorrhea, infertility, pelvic pain, dyspareunia, and
irregular leeding&
=rug therapy reduces symptoms ,ith surgery for a potential cure&
L'$M6$MAS
Leiom.omas (uterine firoids) are enign smooth+muscle tumors that occur ,ithin the
uterus&
Bymptoms may include anormal uterine leeding, and pain&
Treatment depends on size of tumor and may include surgery&
C-2'CAL CANC-
There is a strong relationship et,een se)ual e)posure of papillomavirus (>P3) and
dysplasia&
2ater signs are leu'orrhea, intermenstrual leeding, and pain&
The finding of an anormal Pap test indicates need for follo,+up&
.nvasive disease is treated ,ith surgery, radiation, and chemotherapy&
1+"""
Key Points
5 ne, vaccine can protect against most types of cervical cancer&
ND$M,-'AL CANC-
The ma#or ris' factor of endometrial cancer is unopposed estrogen&
.t has lo, mortality rate, as most cases are diagnosed early&
The first sign of endometrial cancer is anormal uterine leeding&
Treatment is total hysterectomy and ilateral salpingo+oophorectomy ,ith lymph node
iopsies& ?adiation and chemotherapy may also e given&
$2A-'AN CANC-
The etiology of ovarian cancer is generally not 'no,n&
:ost ,omen ,ith ovarian cancer have advanced disease at diagnosis&
The greatest ris' factor is family history&
.n the early stages, manifestations are vague and may consist of adominal discomfort
(gas, indigestion, pressure, loating, cramps) and change in o,el haits&
Wearly imanual pelvic e)aminations should e performed to identify an ovarian mass&
Treatment includes surgery, chemotherapy, and radiation&
Nurses can teach ,omen importance of routine screening for cancers of the reproductive
system&
5,-'N P-$LAPS
5terine "rola"se is the do,n,ard displacement of uterus into the vaginal canal&
Bymptoms are dyspareunia, dragging or heavy pelvic feeling, ac'ache, and o,el or
ladder prolems if c.stocele or rectocele is also present&
Therapy depends on degree of prolapse and can include strengthening e)ercises, and a
pessary&
S85AL ASSA5L,
Se1ual assault is the forcile perpetration of a se)ual act on a person ,ithout his or her
consent& .t can include sodomy, forced vaginal or anal intercourse, oral copulation, and
assault ,ith a foreign o#ect&
Physical in#uries may include ruising and lacerations to perineum, hymen, vulva,
1+""$
Key Points
vagina, cervi), and anus&
@eelings of humiliation, degradation, emarrassment, anger, self+lame, and fear of
another assault are commonly e)pressed&
*nsuring the ,oman(s emotional and physical safety is the highest priority&
@ollo,+up physical and psychologic care is essential&
th
edition
Key Points
Chapter CC: Nursing :anagement: :ale ?eproductive Prolems
/N'4N P-$S,A,'C )6P-PLAS'A %/P)&
/enign "rostatic h."er"lasia (6P>) is prostate gland enlargement due to increased
epithelial cells and stromal tissue&
6P> results from endocrine changes associated ,ith the aging process&
The compression of the urethra leads to clinical symptoms including decrease in calier
and force of the urinary stream, difficulty in initiating voiding, intermittency and
driling&
Conservative and initial treatment is /,atchful ,aiting0 ,hen there are no symptoms or
only mild ones& =rug therapy may also e used&
.nvasive treatment of symptomatic 6P> involves prostate resection or alation&
P-$S,A, CANC-
Prostate cancer is the most common cancer among men, e)cluding s'in cancer&
?is' factors include family history, age, and ethnicity&
Bymptoms of prostate cancer are similar to those for 6P>, including dysuria, hesitancy,
driling, fre<uency, and urgency&
*levated levels of "rostate-s"ecific antigen (PB5) indicate prostatic pathology, although
not necessarily prostate cancer&
The conservative approach to management is /,atchful ,aiting&0
1+""%
Key Points
.nvasive therapies include radical "rostatectom. and cryosurgery& Treatment may also
include drugs, hormones, chemotherapy, and radiation&
The nursing role is to encourage patients, in consultation ,ith health care providers, to
have annual prostate screening (PB5 and digital rectal e)amination) starting at age C8 or
younger if ris' factors present&
P-$S,A,','S
The term "rostatitis descries a group of inflammatory and noninflammatory conditions
affecting the prostate gland&
.t includes acute acterial prostatitis, chronic acterial prostatitis, chronic
prostatitis1chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis&
5ntiiotics are used for acute and chronic acterial prostatitis&
P'D'D6M','S
"idid.mitis is an acute, painful inflammatory process of the epididymis secondary to
an infectious process, trauma, or urinary reflu) do,n the vas deferens&
5ntiiotic use is important for oth partners if transmission ,as through se)ual contact&
Conservative treatment consists of ed rest ,ith elevation of scrotum, use of ice pac's,
and analgesics&
th
edition
Key Points
Chapter CD: Nursing 5ssessment: Nervous Bystem
The human nervous system is a highly specialized system responsile for the control and
integration of the ody(s many activities&
The nervous system can e divided into the central nervous system (CNB) and parts of
the peripheral nervous system (PNB)&
o The central ner!ous s.stem consists of the rain and spinal cord&
o The "eri"heral ner!ous s.stem consists of the cranial and spinal nerves and the
autonomic nervous system (5NB)&
1+""C
Key Points
The nervous system is made up of t,o types of cells: neurons and neuroglia&
o The neurons of the nervous system come in many different shapes and sizes, ut
they all share common characteristics: (1) e"citability, or the aility to generate a
nerve impulse! (") conductivity, or the aility to transmit the impulse to other
portions of the cell! and ($) the aility to influence other neurons, muscle cells,
and glandular cells y transmitting nerve impulses to them&
o Neuroglia, or glial cells, provide support, nourishment, and protection to neurons&
Nerve impulses originate ,ithin a neuron as an action potential that moves along the
ody of the cell (a"on) until it reaches the end of the nerve fier& @rom there, it is
transmitted across the #unction et,een nerve cells y a chemical interaction and then,
the impulse ,ill move across the ne)t neuron as an action potential&
o 5 s.na"se is the structural and functional #unction et,een t,o neurons& .t is the
point at ,hich the nerve impulse is transmitted from one neuron to another or
from neuron to glands or muscles&
o 5 neurotransmitter is a chemical agent involved in the transmission of an
impulse across the synaptic cleft&
CN,-AL N-2$5S S6S,M
The ma#or structural components of the CNB are the spinal cord and rain&
Spinal Cord
The spinal cord is continuous ,ith the rainstem and e)its from the cranial cavity through
the foramen magnum& 5 cross section of the spinal cord reveals gray matter that is
centrally located and is surrounded y ,hite matter&
Bpecific ascending and descending path,ays in the ,hite matter can e identified&
o .n general, the ascending tracts carry specific sensory information to higher levels
of the CNB&
o =escending tracts carry impulses that are responsile for muscle movement&
Lower motor neurons are the final common path,ay through ,hich descending motor
tracts influence s'eletal muscle, the effector organ for movement& The cell odies of these
cells are located in spinal cord and the a)ons innervate the s'eletal muscles&
Brain
The rain consists of the cereral hemispheres, cereellum, and rainstem&
The cerebrum is composed of the right and left hemispheres& 6oth hemispheres can e
further divided into four ma#or loes&
1+""D
Key Points
o The frontal loe controls higher cognitive function, memory retention, voluntary
eye movements, voluntary motor movement, and e)pressive speech&
o The temporal loe contains -ernic'e(s area, ,hich is responsile for receptive
speech and for integration of somatic, visual, and auditory data&
o The parietal loe is composed of the sensory corte), controlling and interpreting
spatial information&
o Processing of sight ta'e place in the occipital loe&
The asal ganglia, thalamus, hypothalamus, and limic system are also located in the
cererum&
The brainstem includes the midrain, pons, and medulla& The vital centers concerned
,ith respiratory, vasomotor, and cardiac function are located in the medulla&
The rainstem contains the centers for sneezing, coughing, hiccupping, vomiting,
suc'ing, and s,allo,ing& 5lso located in the rainstem is the reticular formation, ,hich
relays sensory information, influences e)citatory and inhiitory control of spinal motor
neurons, and controls vasomotor and respiratory activity&
The cerebellum coordinates voluntary movement and to maintains trun' staility and
e<uilirium&
Cerebros"inal fluid circulates ,ithin the suarachnoid space that surrounds the rain,
rainstem, and spinal cord& This fluid provides cushioning for the rain and spinal cord,
allo,s fluid shifts from the cranial cavity to the spinal cavity, and carries nutrients&
P-'P)-AL N-2$5S S6S,M
The PNB includes all the neuronal structures that lie outside the CNB& .t consists of the
spinal and cranial nerves, their associated ganglia (groupings of cell odies), and portions
of the 5NB&
The spinal nerve contains a pair of dorsal (afferent) sensory nerve fiers and ventral
(efferent) motor fiers, ,hich innervate a specific region of the nec', trun', or lims&
This comined motor+sensory nerve is called a spinal nerve#
The cranial ner!es (CNs) are the 1" paired nerves composed of cell odies ,ith fiers
that e)it from the cranial cavity& 4nli'e the spinal nerves, ,hich al,ays have oth
afferent sensory and efferent motor fiers, some CNs have only afferent and some only
efferent fiers! others have oth&
The autonomic ner!ous s.stem (5NB) governs involuntary functions of cardiac muscle,
smooth (involuntary) muscle, and glands& The 5NB is divided into t,o components, the
sympathetic and parasympathetic nervous systems&
1+""9
Key Points
P-$,C,'2 MC)AN'SMS
The blood-brain barrier is a physiologic arrier et,een lood capillaries and rain
tissue& The structure of rain capillaries differs from that of other capillaries& Bome
sustances that normally pass readily into most tissues are prevented from entering rain
tissue&
The meninges are three layers of protective memranes that surround the rain and
spinal cord&
o The thic' dura mater forms the outermost layer, ,ith the arachnoid layer and pia
mater eing the ne)t t,o layers&
o The subarachnoid space lies et,een the arachnoid layer and the pia mater& This
space is filled ,ith CB@&
The ony s'ull protects the rain from e)ternal trauma& .t is composed of F cranial ones
and 1% facial ones&
The verteral column protects the spinal cord, supports the head, and provides fle)iility&
The verteral column is made up of $$ individual verterae: 9 cervical, 1" thoracic, C
lumar, C sacral (fused into 1), and % coccygeal (fused into 1)&
Assessment
Bpecial attention should e given to otaining a careful medication history, especially the
use of sedatives, opioids, tran<uilizers, and mood+elevating drugs&
The nurse should as' aout the patient(s health practices related to the nervous system,
such as sustance ause and smo'ing, maintenance of ade<uate nutrition, safe
participation in physical and recreational activities, use of seat elts and helmets, and
control of hypertension&
6o,el and ladder prolems are often associated ,ith neurologic prolems, such as
stro'e, head in#ury, spinal cord in#ury, multiple sclerosis, and dementia& .t is important to
determine if the o,el or ladder prolem ,as present efore or after the neurologic
event to plan appropriate interventions&
6ecause the nervous system controls cognition and sensory integration, many neurologic
disorders affect these functions& The nurse should assess memory, language, calculation
aility, prolem+solving aility, insight, and #udgment&
The aility to participate in se)ual activity should e assessed ecause many nervous
system disorders can affect se)ual response&
The physical e)amination assesses si) categories of functions: mental status, function of
CNs, motor function, cereellar function, sensory function, and refle) function&
1+""F
Key Points
o 5ssessment of mental status (cereral functioning) gives an indication of ho, the
patient is functioning as a ,hole and ho, the patient is adapting to the
environment&
o *ach CN should e assessed individually&
o The motor system e)amination includes assessment of ul', tone, and po,er of
the ma#or muscle groups of the ody, as ,ell as assessment of alance and
coordination&
o Beveral modalities are tested in the somatic sensory e)amination& *ach modality
is carried y a specific ascending path,ay in the spinal cord efore it reaches the
sensory corte)&
o 5 simple muscle stretch refle) is initiated y ris'ly tapping the tendon of a
stretched muscle, usually ,ith a refle) hammer&
Diagnostic Studies
2umar puncture is the most common method of otaining CB@ for analysis& CB@
analysis provides information aout a variety of CNB diseases&
Cereral angiography is indicated ,hen vascular lesions or tumors are suspected&
The techni<ue of electroencephalography (**A) involves the recording of the electrical
activity of the surface cortical neurons of the rain y F to 1D electrodes placed on
specific areas of the scalp&
+lectromyography (*:A) is the recording of electrical activity associated ,ith
innervation of s'eletal muscle&
Nerve conduction studies involve application of a rief electrical stimulus to a distal
portion of a sensory or mi)ed nerve and recording the resulting ,ave of depolarization at
some point pro)imal to the stimulation&
+vo7ed potentials are recordings of electrical activity associated ,ith nerve conduction
along sensory path,ays& The activity is generated y a specific sensory stimulus related
to the type of study (e&g&, chec'eroard patterns for visual evo'ed potentials, clic'ing
sounds for auditory evo'ed potentials, mild electrical pulses for somatosensory evo'ed
potentials)&
th
edition
Key Points
1+""E
Key Points
Chapter C9: Nursing :anagement: 5cute .ntracranial Prolems
N$-MAL 'N,-AC-AN'AL P-SS5-
'ntracranial "ressure (.CP) is the hydrostatic force measured in the rain CB@
compartment& Normal .CP is the total pressure e)erted y the three components ,ithin
the s'ull: rain tissue, lood, and CB@&
.f the volume of any one of the three components increases ,ithin the cranial vault and
the volume from another component is displaced, the total intracranial volume ,ill not
change&
.CP can e measured in the ventricles, suarachnoid space, sudural space, epidural
space, or rain parenchymal tissue using a pressure transducer& Normal intracranial .CP
ranges from 8 to 1C mm >g&
5 sustained pressure aove the upper limit is considered anormal& .CP may rise due to
head trauma, stro'e, suarachnoid hemorrhage, rain tumor, inflammation,
hydrocephalus, or rain tissue damage from other causes&
C-AN'AL /L$$D +L$7
Cerebral blood flow (C6@) is the amount of lood in milliliters passing through 188 g of
rain tissue in 1 minute&
Through a process 'no,n as autoregulation, the rain has the aility to regulate its o,n
lood flo, in response to its metaolic needs despite ,ide fluctuations in systemic
arterial pressure&
The cerebral perfusion pressure (CPP) is the pressure needed to ensure lood flo, to the
rain& 5s the CPP decreases, autoregulation fails and C6@ decreases, ,hich can lead to
ischemia and neuronal death&
Compliance is the e)pandaility of the rain& -ith lo, compliance, small changes in
volume result in greater increases in pressure&
'NC-ASD 'N,-AC-AN'AL P-SS5-
.ncreased .CP is a life+threatening situation that results from an increase in any or all of
the three components (rain tissue, lood, CB@) ,ithin the s'ull& Cerebral edema is an
important factor contriuting to increased .CP&
*levated .CP is clinically significant ecause it diminishes CPP, increases ris's of rain
ischemia and infarction, and is associated ,ith a poor prognosis&
The clinical manifestations of increased .CP can ta'e many forms, depending on the
cause, location, and rate at ,hich the pressure increase occurs& Complications of .CP
1+"$8
Key Points
include changes in the level of consciousness, changes in vital signs, dilation of pupils,
decrease in motor function, headache, and vomiting&
The earlier the condition is recognized and treated, the etter the patient outcome&
The ma#or complications of uncontrolled increased .CP are inade<uate cereral perfusion
and cereral herniation&
.CP monitoring is used to guide clinical care ,hen the patient is at ris' for or has
elevations in .CP& .t may e used in patients ,ith a variety of neurologic insults,
including hemorrhage, stro'e, tumor, infection, or traumatic rain in#ury&
The /gold standard0 for monitoring .CP is the ventriculostomy, in ,hich a specialized
catheter is inserted into the right lateral ventricle and coupled to an e)ternal transducer&
;ther devices no, allo, for an indirect assessment of cereral o)ygenation and
perfusion&
-ith the ventricular catheter and certain fieroptic systems, it is possile to control .CP
y removing CB@& The level of the .CP at ,hich to initiate drainage, amount of fluid to e
drained, height of the system, and fre<uency of drainage are ordered y the physician&
The goals of collaorative care are to identify and treat the underlying cause of increased
.CP and to support rain function&
=rug therapy plays an important part in the management of increased .CP& 5n osmotic
diuretic, corticosteroids, and ariturates may e prescried&
5ll patients must have their nutritional needs met, regardless of their state of
consciousness or health& *arly feeding follo,ing rain in#ury may improve outcomes&
The 4lasgow Coma Scale is a <uic', practical, and standardized system for assessing the
degree of impaired consciousness that should e used during nursing assessment& 5lso
during assessment, the pupils are compared to one another for size, shape, movement,
and reactivity&
The overall nursing goals are that the patient ,ith increased .CP ,ill (1) maintain a
patent air,ay, (") have .CP ,ithin normal limits, ($) demonstrate normal fluid and
electrolyte alance, and (%) have no complications secondary to immoility and
decreased level of consciousness&
:aintenance of a patent air,ay is critical in the patient ,ith increased .CP and is a
primary nursing responsiility& 5s the level of consciousness decreases, the patient is at
increased ris' of air,ay ostruction from the tongue dropping ac' and occluding the
air,ay or from accumulation of secretions&
1+"$1
Key Points
The patient ,ith increased .CP should e maintained in the head+up position& The nurse
must ta'e care to prevent e)treme nec' fle)ion, ,hich can cause venous ostruction and
contriute to elevated .CP&
The patient ,ith increased .CP and a decreased level of consciousness needs protection
from self+in#ury& Confusion, agitation, and the possiility of seizures increase the ris' for
in#ury&
)AD 'NB5-6
)ead in*ur. includes any trauma to the scalp, s'ull, or rain& The term head trauma is
used primarily to signify craniocereral trauma, ,hich includes an alteration in
consciousness, no matter ho, rief&
Scalp lacerations are an easily recognized type of e)ternal head trauma& 6ecause the
scalp contains many lood vessels ,ith poor constrictive ailities, the ma#or
complications associated ,ith scalp laceration are lood loss and infection&
S7ull fractures fre<uently occur ,ith head trauma& There are several ,ays to descrie
s'ull fractures: (1) linear or depressed! (") simple, comminuted, or compound! and ($)
closed or open&
5 concussion is a sudden transient mechanical head in#ury ,ith disruption of neural
activity and a change in the 2;C and is considered a minor head in#ury&
5 contusion, a ma#or head in#ury, is the ruising of the rain tissue ,ithin a focal area& 5
contusion may contain areas of hemorrhage, infarction, necrosis, and edema and
fre<uently occurs at a fracture site&
1acerations, another ma#or head trauma, involve actual tearing of the rain tissue and
often occur in association ,ith depressed and open fractures and penetrating in#uries&
Complications from a head in#ury may include an e"idural hematoma, a subdural
hematoma, and intracerebral hematoma(
CT scan is considered the est diagnostic test to evaluate for craniocereral trauma
ecause it allo,s rapid diagnosis and intervention in the acute setting& :?., P*T, and
evo'ed potential studies may also e used in the diagnosis and differentiation of head
in#uries&
The most important aspects of nursing assessment are noting the ACB score, assessing
and monitoring the neurologic status, and determining ,hether a CB@ lea' has occurred&
The overall nursing goals are that the patient ,ith an acute head in#ury ,ill (1) maintain
ade<uate cereral o)ygenation and perfusion! (") remain normothermic! ($) achieve
1+"$"
Key Points
control of pain and discomfort! (%) e free from infection! and (C) attain ma)imal
cognitive, motor, and sensory function&
:anagement at the in#ury scene can have a significant impact on the outcome of the head
in#ury& The general goal of acute nursing management of the head+in#ured patient is to
maintain cereral o)ygenation and perfusion and prevent secondary cereral ischemia&
The ma#or focus of nursing care for the rain+in#ured patient relates to increased .CP&
>o,ever, there may e other specific prolems that re<uire nursing intervention, such as
hyperthermia&
;nce the condition has stailized, the patient is usually transferred for acute rehailitation
management to prepare the patient for reentry into the community& :any of the principles
of nursing management of the patient ,ith a stro'e are appropriate&
/-A'N ,5M$-S
6rain tumors can occur in any part of the rain or spinal cord& Tumors of the rain may
e primary, arising from tissues ,ithin the rain, or secondary, resulting from a
metastasis from a malignant neoplasm else,here in the ody&
6rain tumors are generally classified according to the tissue from ,hich they arise& The
most common primary rain tumors originate in astrocytes and these tumors are called
gliomas&
4nless treated, all rain tumors eventually cause death from increasing tumor volume
leading to increased .CP& 6rain tumors rarely metastasize outside the central nervous
system (CNB) ecause they are contained y structural (meninges) and physiologic
(lood+rain) arriers&
-ide ranges of possile clinical manifestations are associated ,ith rain tumors&
>eadache is a common prolem and seizures are common in gliomas and rain
metastases&
5n e)tensive history and a comprehensive neurologic e)amination must e done in the
,or'up of a patient ,ith a suspected rain tumor& 5 ne, onset seizure disorder may e
the first indication of a rain tumor& The correct diagnosis of a rain tumor can e made
y otaining tissue for histologic study&
Burgical removal is the preferred treatment for rain tumors& ?adiation therapy is
commonly used as a follo,+up measure after surgery& The effectiveness of chemotherapy
has een limited y difficulty getting drugs across the lood+rain arrier, tumor cell
heterogeneity, and tumor cell drug resistance&
The overall nursing goals are that the patient ,ith a rain tumor ,ill (1) maintain normal
.CP, (") ma)imize neurologic functioning, ($) achieve control of pain and discomfort,
1+"$$
Key Points
and (%) e a,are of the long+term implications ,ith respect to prognosis and cognitive
and physical functioning&
=ue to ehavioral instaility, close supervision of activity, use of side rails, #udicious use
of restraints, appropriate sedative medications, padding of the rails and the area around
the ed, and a calm, reassuring approach to care are all essential techni<ues in the care of
these patients&
C-AN'AL S5-4-6
The cause or indication for cranial surgery may e related to a rain tumor, CNB infection
(e&g&, ascess), vascular anormalities, craniocereral trauma, seizure disorder, or
intractale pain&
Btereotactic surgery uses precision apparatus (often computer+guided) to assist the
surgeon to precisely target an area of the rain& Btereotactic iopsy can e performed to
otain tissue samples for histologic e)amination&
Stereotactic radiosurgery is a procedure that involves closed+s'ull destruction of an
intracranial target using ionizing radiation focused ,ith the assistance of an intracranial
guiding device& 5 sophisticated computer program is used ,hile the patient(s head is held
still in a stereotactic frame&
Craniotomy is another cranial surgical option& =epending on the location of the
pathologic condition, a craniotomy may e frontal, parietal, occipital, temporal, or a
comination of any of these&
The overall goals are that the patient ,ith cranial surgery ,ill (1) return to normal
consciousness, (") achieve control of pain and discomfort, ($) ma)imize neuromuscular
functioning, and (%) e rehailitated to ma)imum aility&
The primary goal of care after cranial surgery is prevention of increased .CP& @re<uent
assessment of the neurologic status of the patient is essential during the first %F hours&
The rehailitative potential for a patient after cranial surgery depends on the reason for
the surgery, the postoperative course, and the patient(s general state of health& Nursing
interventions must e ased on a realistic appraisal of these factors&
'N+LAMMA,$-6 C$ND','$NS $+ ,) /-A'N
:eningitis, encephalitis, and rain ascesses are the most common inflammatory
conditions of the rain and spinal cord& .nflammation can e caused y acteria, viruses,
fungi, and chemicals&
/acterial Meningitis
Meningitis is an acute inflammation of the meningeal tissues surrounding the rain and
the spinal cord& 6acterial meningitis is considered a medical emergency&
1+"$%
Key Points
:eningitis usually occurs in the fall, ,inter, or early spring, and is often secondary to
viral respiratory disease& ;lder adults and persons ,ho are deilitated are more often
affected than is the general population&
@ever, severe headache, nausea, vomiting, and nuchal rigidit. (nec' stiffness) are 'ey
signs of meningitis&
The most common acute complication of acterial meningitis is increased .CP& :ost
patients ,ill have increased .CP, and it is the ma#or cause of an altered mental status&
-hen a patient presents ,ith manifestations suggestive of acterial meningitis, a lood
culture should e done& =iagnosis is usually verified y doing a lumar puncture ,ith
analysis of the CB@&
-hen meningitis is suspected, antiiotic therapy is instituted after the collection of
specimens for cultures, even efore the diagnosis is confirmed&
5ll patients suffer some degree of mental distortion and hypersensitivity and may e
frightened and misinterpret the environment& *very attempt should e made to minimize
environmental stimuli and prevent in#ury&
@ever must e vigorously managed ecause it increases cereral edema and the fre<uency
of seizures&
:eningitis generally re<uires respiratory isolation until the cultures are negative&
:eningococcal meningitis is highly contagious ,hereas other causes of meningitis may
pose a minimal to no infection ris' ,ith patient contact&
5fter the acute period has passed, the patient re<uires several ,ee's of convalescence
efore normal activities can e resumed& .n this period, ade<uate nutrition should e
stressed, ,ith an emphasis on a high+protein, high+calorie diet in small, fre<uent feedings&
2iral Meningitis
The most common causes of viral meningitis are enteroviruses, aroviruses, human
immunodeficiency virus, and herpes simple) virus (>B3)&
3iral meningitis usually presents as a headache, fever, photophoia, and stiff nec'& There
are usually no symptoms of rain involvement&
3iral meningitis is managed symptomatically ecause the disease is self+limiting& @ull
recovery from viral meningitis is e)pected&
nce"halitis
1+"$C
Key Points
nce"halitis, an acute inflammation of the rain, is a serious, and sometimes fatal,
disease&
*ncephalitis is usually caused y a virus& :any different viruses have een implicated in
encephalitis, some of them associated ,ith certain seasons of the year and endemic to
certain geographic areas& Tic's and mos<uitoes transmit epidemic encephalitis&
Bigns of encephalitis appear on day t,o or three and may vary from minimal alterations
in mental status to coma& 3irtually any CNB anormality can occur, including
hemiparesis, tremors, seizures, cranial nerve palsies, personality changes, memory
impairment, amnesia, and dysphasia&
Collaorative and nursing management of encephalitis, including -est Nile virus
infection, is symptomatic and supportive& .n the initial stages of encephalitis, many
patients re<uire intensive care&
-abies
=espite the success of vaccines in domestic animals, raies remains a serious pulic
health concern due to the presence of the disease in ,ild animals& ;nce a human
contracts raies and develops symptoms, the disease almost al,ays ends in death&
5lthough raies is generally transmitted via saliva from the ite of an infected animal, it
can also e spread y scratches, y mucous memrane contact ,ith infected secretions,
and y inhalation of aerosolized virus into the respiratory tract& 5ny ,arm+looded
mammal can carry raies, including livestoc'&
T,o presentations of raies include encephalitic raies, ,hich is the most common, and
paralytic raies&
6ecause raies is nearly al,ays fatal, management efforts are directed at preventing the
transmission and onset of the disease&
/rain Abscess
/rain abscess is an accumulation of pus ,ithin the rain tissue that can result from a
local or a systemic infection& =irect e)tension from ear, tooth, mastoid, or sinus infection
is the primary cause&
The manifestations of rain ascess are similar to those of meningitis and encephalitis&
5ntimicroial therapy is the primary treatment for rain ascess& ;ther manifestations are
treated symptomatically&
th
edition
1+"$D
Key Points
Key Points
Chapter CF: Nursing :anagement: Btro'e
S,-$9
Stro0e occurs ,hen there is ischemia (inade<uate lood flo,) to a part of the rain or
hemorrhage into the rain that results in death of rain cells& @unctions, such as
movement, sensation, or emotions, that ,ere controlled y the affected area of the rain
are lost or impaired&
The term brain attac0 is increasingly eing used to descrie stro'e& This term
communicates the urgency of recognizing the clinical manifestations of a stro'e and
treating a medical emergency, similar to ,hat ,ould e done ,ith a heart attac'&
-is0 +actors
The most effective ,ay to decrease the urden of stro'e is prevention& Nonmodifiale
ris' factors include age, gender, race, and heredity&
>ypertension is the single most important modifiale ris' factor& ;ther modifiale ris'
factors include heart disease, diaetes, increased serum cholesterol, smo'ing, e)cessive
alcohol consumption, oesity, physical inactivity, poor diet, and drug ause&
,therosclerosis (hardening and thic'ening of arteries) is a ma#or cause of stro'e& .t can
lead to thromus formation and contriute to emoli&
5 transient ischemic attac0 (T.5) is a temporary focal loss of neurologic function
caused y ischemia of one of the vascular territories of the rain, lasting less than "%
hours and often lasting less than 1C minutes& :ost T.5s resolve ,ithin $ hours& T.5s are
a ,arning sign of progressive cererovascular disease&
Btro'es are classified as ischemic or hemorrhagic ased on the underlying
pathophysiologic findings&
Ischemic stroke:
o 5n ischemic stro0e results from inade<uate lood flo, to the rain from partial
or complete occlusion of an artery and accounts for appro)imately F8K of all
stro'es& .schemic stro'es are further divided into thromotic and emolic&
o 5 thrombotic stro0e occurs from in#ury to a lood vessel ,all and formation of a
lood clot& The lumen of the lood vessel ecomes narro,ed, and if it ecomes
occluded, infarction occurs&
o mbolic stro0e occurs ,hen an emolus lodges in and occludes a cereral artery,
resulting in infarction and edema of the area supplied y the involved vessel&
1+"$9
Key Points
Hemorrha*ic stroke:
o )emorrhagic stro0es account for appro)imately 1CK of all stro'es and result
from leeding into the rain tissue itself or into the suarachnoid space or
ventricles&
o 'ntracerebral hemorrhage is leeding ,ithin the rain caused y a rupture of a
vessel& The prognosis of intracereral hemorrhage is poor&
o Subarachnoid hemorrhage occurs ,hen there is intracranial leeding into the
cererospinal fluidNfilled space et,een the arachnoid and pia mater memranes
on the surface of the rain& Buarachnoid hemorrhage is commonly caused y
rupture of a cereral aneur.sm (congenital or ac<uired ,ea'ness and allooning
of vessels)&
Clinical Manifestations and Diagnostic Studies
5 stro'e can have an effect on many ody functions, including motor activity, ladder and
o,el elimination, intellectual function, spatial+perceptual alterations, personality, affect,
sensation, s,allo,ing, and communication&
o :otor deficits include impairment of (1) moility, (") respiratory function, ($)
s,allo,ing and speech, (%) gag refle), and (C) self+care ailities&
o The patient may e)perience a"hasia (total loss of comprehension and use of
language) ,hen a stro'e damages the dominant hemisphere of the rain or
d.s"hasia (difficulty related to the comprehension or use of language) due to
partial disruption or loss&
o :any stro'e patients also e)perience d.sarthria, a disturance in the muscular
control of speech& .mpairments may involve pronunciation, articulation, and
phonation&
o Patients ,ho have had a stro'e may have difficulty controlling their emotions&
o 6oth memory and #udgment may e impaired as a result of stro'e&
o :ost prolems ,ith urinary and o,el elimination occur initially and are
temporary&
The single most important diagnostic tool for patients ,ho have e)perienced a stro'e is the
noncontrast CT scan& The CT scan indicates the size and location of the lesion and
differentiates et,een ischemic and hemorrhagic stro'e&
Collaborati!e Care: Pre!ention
:easures to prevent the development of a thromus or emolus are used in patients at ris'
for stro'e& 5ntiplatelet drugs are usually the chosen treatment to prevent further stro'e in
patients ,ho have had a T.5 related to atherosclerosis&
Burgical interventions for the patient ,ith T.5s from carotid disease include carotid
endarterectomy, transluminal angioplasty, stenting, and e)tracranial+intracranial ypass&
Collaborati!e Care: Acute Phase
1+"$F
Key Points
The goals for collaorative care during the acute phase are preserving life, preventing
further rain damage, and reducing disaility& Treatment differs according to the type of
stro'e and changes as the patient progresses from the acute to the rehailitation phase&
*levated 6P is common immediately after a stro'e and may e a protective response to
maintain cereral perfusion&
@luid and electrolyte alance must e controlled carefully& The goal generally is to 'eep
the patient ade<uately hydrated to promote perfusion and decrease further rain in#ury&
?ecominant tissue plasminogen activator (tP5) administered .3 is used to reestalish
lood flo, through a loc'ed artery to prevent cell death in patients ,ith the acute onset
of ischemic stro'e symptoms&
5fter the patient has stailized and to prevent further clot formation, patients ,ith stro'es
caused y thromi and emoli may e treated ,ith platelet inhiitors and anticoagulants&
Burgical interventions for stro'e include immediate evacuation of aneurysm+induced
hematomas or cereellar hematomas larger than $ cm& @or ischemic stro'es, the
mechanical emolus retrieval in cereral ischemia (:erci) retriever allo,s physicians to
go inside the loc'ed artery of patients ,ho are e)periencing ischemic stro'es& The
retriever goes to the artery that is loc'ed, directly to the site of the prolem, and pulls
the clot out&
5fter the stro'e has stailized for 1" to "% hours, collaorative care shifts from
preserving life to lessening disaility and attaining optimal function&
Nursing Management
Typical nursing goals are that the patient ,ill:
(1) maintain a stale or improved level of consciousness
(") attain ma)imum physical functioning
($) attain ma)imum self+care ailities and s'ills
(%) maintain stale ody functions (e&g&, ladder control)
(C) ma)imize communication ailities
(D) maintain ade<uate nutrition
(9) avoid complications of stro'e
(F) maintain effective personal and family coping
Acute Phase
=uring the acute phase follo,ing a stro'e, management of the respiratory system is a
nursing priority& Btro'e patients are particularly vulnerale to respiratory prolems, such
as aspiration pneumonia&
The patient(s neurologic status must e monitored closely to detect changes suggesting
e)tension of the stro'e, increased .CP, vasospasm, or recovery from stro'e symptoms&
1+"$E
Key Points
Nursing goals for the cardiovascular system are aimed at maintaining homeostasis&
:any patients ,ith stro'e have decreased cardiac reserves secondary to cardiac disease&
The nursing goal for the musculos'eletal system is to maintain optimal function& This is
accomplished y the prevention of #oint contractures and muscular atrophy&
The s'in of the patient ,ith stro'e is particularly susceptile to rea'do,n related to
loss of sensation, decreased circulation, and immoility&
The most common o,el prolem for the patient ,ho has e)perienced a stro'e is
constipation& Patients may e prophylactically placed on stool softeners and1or fier&
.n the acute stage of stro'e, the primary urinary prolem is poor ladder control,
resulting in incontinence& *fforts should e made to promote normal ladder function
and to avoid the use of ind,elling catheters&
The patient may initially receive .3 infusions to maintain fluid and electrolyte alance,
as ,ell as for administration of drugs& Patients ,ith severe impairment may re<uire
enteral or parenteral nutrition support& B,allo,ing aility ,ill need to e assessed&
>omonymous hemianopsia (lindness in the same half of each visual field) is a
common prolem after a stro'e& Persistent disregard of o#ects in part of the visual field
should alert the nurse to this possiility&
The patient is usually discharged from the acute care setting to home, an intermediate or
long+term care facility, or a rehailitation facility& Criteria for transfer to rehailitation
may include the patient(s aility to participate in therapies for a minimum numer of
hours per day&
2eha%ilitation
?ehailitation is the process of ma)imizing the patient(s capailities and resources to
promote optimal functioning related to physical, mental, and social ,ell+eing&
?egardless of the care setting, ongoing rehailitation is essential to ma)imize the
patient(s ailities&
?ehailitation re<uires a team approach so the patient and family can enefit from the
comined, e)pert care of an interdisciplinary team& The interdisciplinary team is
composed of many memers, including nurses, physicians, psychiatrist, physical
therapist, occupational therapist, speech therapist, registered dietitian, respiratory
therapist, vocational therapist, recreational therapist, social ,or'er, psychologist,
pharmacist, and chaplains&
The goals for rehailitation of the patient ,ith stro'e are mutually set y the patient,
family, nurse, and other memers of the rehailitation team&
1+"%8
Key Points
The nurse initially emphasizes the musculos'eletal functions of eating, toileting, and
,al'ing for the rehailitation of the patient&
5fter the acute phase, a dietitian can assist in determining the appropriate daily caloric
inta'e ased on the patient(s size, ,eight, and activity level&
5 o,el management program is implemented for prolems ,ith o,el control,
constipation, or incontinence&
Patients ,ho have had a stro'e fre<uently have perceptual deficits& @or e)ample, patients
,ith a stro'e on the right side of the rain usually have difficulty in #udging position,
distance, and rate of movement&
The patient ,ith a stro'e may e)perience many losses, including sensory, intellectual,
communicative, functional, role ehavior, emotional, social, and vocational losses&
Nurses should help patients and families cope ,ith these losses&
Bpeech, comprehension, and language deficits are the most difficult prolems for the
patient and family& Bpeech therapists can assess and formulate a plan of care to support
communication&
th
edition
Key Points
Chapter CE: Nursing :anagement: Chronic Neurologic Prolems
)ADAC)
The primary classifications of headaches include tension+type, migraine, and cluster
headaches&
o ,ension-t."e headache, the most common type of headache, is characterized y
its ilateral location and pressing1tightening <uality& Tension+type headaches are
usually of mild or moderate intensity and not aggravated y physical activity&
o Migraine headache is a recurring headache characterized y unilateral or
ilateral throing pain, a triggering event or factor, strong family history, and
manifestations associated ,ith neurologic and autonomic nervous system
dysfunction&
o Cluster headaches are a rare form of headache ,ith a sharp staing pain&
Cluster headaches involve repeated headaches that can occur for ,ee's to months
at a time, follo,ed y periods of remission&
1+"%1
Key Points
Therapies used in the treatment of headaches include drugs, meditation, yoga,
iofeedac', cognitive+ehavioral therapy, and rela)ation training&
=rug therapies include:
o Tension+type: nonopioid analgesic is used alone or in comination ,ith a
sedative, muscle rela)ant, tran<uilizer, or codeine&
o :igraine: analgesic, triptans, and preventive treatment (i&e&, topiramate)&
o Cluster: drug therapy is not as useful as it is for the other types of headaches!
prophylactic drugs may e prescried&
>eadaches may e related to an inaility to cope ,ith daily stresses& The most effective
therapy may e to help patients e)amine their lifestyle, recognize stressful situations, and
learn to cope ,ith them more appropriately&
.n addition to using analgesics and analgesic comination drugs for the symptomatic
relief of headache, the patient should e encouraged to use rela)ation techni<ues ecause
they are effective in relieving tension+type and migraine headaches&
S'@5- D'S$-D-S AND P'LPS6
Sei#ure is a paro)ysmal, uncontrolled electrical discharge of neurons in the rain that
interrupts normal function& Beizures are often symptoms of an underlying illness&
"ile"s. is a condition in ,hich a person has spontaneously recurring seizures caused y
a chronic underlying condition&
Beizures are divided into t,o ma#or classes: generalized and partial&
4enerali#ed sei#ures involve oth sides of the rain and are characterized y ilateral
synchronous epileptic discharges in the rain from the onset of the seizure& 6ecause the
entire rain is affected at the onset of the seizures, there is no ,arning or aura&
o ,onic-clonic sei#ure is characterized y loss of consciousness and falling to the
ground if the patient is upright, follo,ed y stiffening of the ody (tonic phase)
for 18 to "8 seconds and suse<uent #er'ing of the e)tremities (clonic phase) for
another $8 to %8 seconds&
o Absence %"etit mal& sei#ure usually occurs only in children and rarely continues
eyond adolescence&
o At."ical absence sei#ure, ,hich is characterized y a staring spell accompanied
y other signs and symptoms, includes rief ,arnings, peculiar ehavior during
the seizure, or confusion after the seizure&
Partial sei#ures, also referred to as partial focal seizures, are caused y focal irritations&
They manifest ,ith unilateral manifestations that arise from localized rain involvement&
o Simple partial sei2ures ,ith elementary symptoms do not involve loss of
consciousness and rarely last longer than 1 minute&
1+"%"
Key Points
o Comple" partial sei2ures can involve a variety of ehavioral, emotional, affective,
and cognitive functions& These seizures usually last longer than 1 minute and are
fre<uently follo,ed y a period of postictal confusion&
Status e"ile"ticus is a state of continuous seizure activity or a condition in ,hich seizures
recur in rapid succession ,ithout return to consciousness et,een seizures& .t is the most
serious complication of epilepsy and is a neurologic emergency&
:ost seizures do not re<uire professional emergency medical care ecause they are self+
limiting and rarely cause odily in#ury& >o,ever, if status epilepticus occurs, if significant
odily harm occurs, or if the event is a first+time seizure, medical care should e sought
immediately&
Beizure disorders are treated primarily ,ith antiseizure drugs& Therapy is aimed at preventing
seizures ecause cure is not possile&
5 significant numer of patients ,hose epilepsy cannot e controlled ,ith drug therapy are
candidates for surgical intervention to remove the epileptic focus or prevent spread of
epileptic activity in the rain&
-hen a seizure occurs, the nurse should carefully oserve and record details of the event
ecause the diagnosis and suse<uent treatment often rest solely on the seizure description&
=uring the seizure it is important to maintain a patent air,ay& This may involve supporting
and protecting the head, turning the patient to the side, loosening constrictive clothing, or
easing the patient to the floor, if seated&
6ecause many seizure disorders cannot e cured, drugs must e ta'en regularly and
continuously, often for a lifetime& The nurse should ensure that the patient 'no,s this, as ,ell
as the specifics of the drug regimen and ,hat to do if a dose is missed&
M5L,'PL SCL-$S'S
Multi"le sclerosis (:B) is a chronic, progressive, degenerative disorder of the CNB
characterized y disseminated demyelination of nerve fiers of the rain and spinal cord&
The cause of :B is un'no,n, although research findings suggest that :B is related to
infectious (viral), immunologic, and genetic factors and is perpetuated as a result of
intrinsic factors (e&g&, faulty immunoregulation)&
:B is characterized y chronic inflammation, demyelination, and gliosis (scarring) in the
CNB&
The onset of the disease is often insidious and gradual, ,ith vague symptoms occurring
intermittently over months or years& Thus the disease may not e diagnosed until long
after the onset of the first symptom&
1+"%$
Key Points
The disease is characterized y chronic, progressive deterioration in some persons and y
remissions and e)acerations in others&
Common signs and symptoms of :B include motor, sensory, cereellar, and emotional
prolems&
6ecause there is no definitive diagnostic test for :B, diagnosis is ased primarily on
history, clinical manifestations, and the presence of multiple lesions over time as
measured y :?.&
6ecause there is currently no cure for :B, collaorative care is aimed at treating the
disease process and providing symptomatic relief&
=rug therapy used includes immunosuppressants, immunomodulators, and
adrenocorticotropic hormone&
Bpasticity is primarily treated ,ith antispasmodic drugs& >o,ever, surgery, dorsal+
column electrical stimulation, or intrathecal aclofen delivered y pump may e re<uired&
*)ercise improves the daily functioning for patients ,ith :B not e)periencing an
e)aceration& 3arious nutritional measures have een used in the management of :B,
including megavitamin therapy and diets consisting of lo,+fat and gluten+free food and
ra, vegetales&
=uring an acute e)aceration the patient may e immoile and confined to ed& The
focus of nursing intervention at this phase is to prevent ma#or complications of
immoility, such as respiratory and urinary tract infections and pressure ulcers&
Patient teaching should focus on uilding general resistance to illness, including avoiding
fatigue, e)tremes of heat and cold, and e)posure to infection&
PA-9'NS$N<S D'SAS
Par0inson<s disease (P=) is a disease of the asal ganglia characterized y slo,ness in
the initiation and e)ecution of movement, increased muscle tone, tremor at rest, and
impaired postural refle)es& .t is the most common form of par7insonism#
The onset of P= is gradual and insidious, ,ith a gradual progression and a prolonged
course& .t may involve only one side of the ody initially& The classic manifestations of
P= often include tremor, rigidity, and rady'inesia, ,hich are often called the triad of
P=&
o *remor can involve the hand, diaphragm, tongue, lips, and #a, ut rarely causes
sha'ing of the head&
o !igidity is the increased resistance to passive motion ,hen the lims are moved
through their range of motion&
1+"%%
Key Points
o 8rady7inesia is particularly evident in the loss of automatic movements, such as
lin'ing of the eyelids, s,inging of the arms ,hile ,al'ing, s,allo,ing of saliva,
self+e)pression ,ith facial and hand movements, and minor movement of postural
ad#ustment&
.n addition to the motor signs of P=, many nonmotor symptoms are common& They
include depression, an)iety, apathy, fatigue, pain, constipation, impotence, and short+term
memory impairment&
6ecause there is no cure for P=, collaorative management is aimed at relieving the
symptoms&
=rug therapy for P= is aimed at correcting an imalance of neurotransmitters ,ithin the
CNB& 5ntipar'insonian drugs either enhance the release or supply of dopamine
(dopaminergic) or antagonize or loc' the effects of the overactive cholinergic neurons in
the striatum (anticholinergic)&
Burgical procedures are aimed at relieving symptoms of P= and are usually used in
patients ,ho are unresponsive to drug therapy or ,ho have developed severe motor
complications&
=iet is of ma#or importance to the patient ,ith P= ecause malnutrition and constipation
can e serious conse<uences of inade<uate nutrition& Patients ,ho have dysphagia and
rady'inesia need appetizing foods that are easily che,ed and s,allo,ed&
Promotion of physical e)ercise and a ,ell+alanced diet are ma#or concerns for nursing
care& *)ercise can limit the conse<uences of decreased moility, such as muscle atrophy,
contractures, and constipation&
6ecause P= is a chronic degenerative disorder ,ith no acute e)acerations, nurses should
note that teaching and nursing care are directed to,ard maintenance of good health,
encouragement of independence, and avoidance of complications such as contractures&
M6AS,)N'A 4-A2'S
M.asthenia gra!is (:A) is an autoimmune disease of the neuromuscular #unction
characterized y the fluctuating ,ea'ness of certain s'eletal muscle groups&
:A is caused y an autoimmune process in ,hich antiodies attac' acetylcholine (5Ch)
receptors, resulting in a decreased numer of 5Ch receptor sites at the neuromuscular
#unction&
The muscles most often affected y the fluctuating ,ea'ness are those used for moving
the eyes and eyelids, che,ing, s,allo,ing, spea'ing, and reathing&
1+"%C
Key Points
The course of this disease is highly variale& Bome patients may have short+term
remissions, others may stailize, and others may have severe, progressive involvement&
M.asthenic crisis is an acute e)aceration of muscle ,ea'ness triggered y infection,
surgery, emotional distress, drug overdose, or inade<uate drugs& The ma#or complications
of :A result from muscle ,ea'ness in areas that affect s,allo,ing and reathing&
=rug therapy for :A includes anticholinesterase drugs, alternate+day corticosteroids, and
immunosuppressants&
6ecause the presence of the thymus gland in the patient ,ith :A appears to enhance the
production of 5Ch? antiodies, removal of the thymus gland results in improvement in a
ma#ority of patients&
Plasmapheresis can yield a short+term improvement in symptoms and is indicated for
patients in crisis or in preparation for surgery ,hen corticosteroids must e avoided&
The patient ,ith :A ,ho is admitted to the hospital usually has a respiratory tract
infection or is in an acute myasthenic crisis& Nursing care is aimed at maintaining
ade<uate ventilation, continuing drug therapy, and ,atching for side effects of therapy&
-S,LSS L4S S6ND-$M
-estless legs s.ndrome (?2B) is characterized y unpleasant sensory (paresthesias) and
motor anormalities of one or oth legs& There are t,o distinct types of ?2B, primary
(idiopathic) and secondary&
The ma#ority of cases are primary, and many patients ,ith this type of ?2B report a
positive family history&
The pathophysiology of primary ?2B is related to anormal iron metaolism and
functional alterations in central dopaminergic neurotransmitter systems&
The severity of ?2B sensory symptoms ranges from infre<uent minor discomfort
(paresthesias, including numness, tingling, and /pins and needles0 sensation) to severe
pain&
The pain at night can produce sleep disruptions and is often relieved y physical activity
such as ,al'ing, stretching, roc'ing, or 'ic'ing&
Nonpharmacologic approaches to ?2B management include estalishing regular sleep
haits, encouraging e)ercise, avoiding activities that cause symptoms, and eliminating
aggravating factors such as alcohol, caffeine, and certain drugs&
1+"%D
Key Points
.f nonpharmacologic measures fail to provide symptom relief, drug therapy may e
started& The main drugs used in ?2B are dopaminergic agents, opioids, and
enzodiazepines&
AM6$,-$P)'C LA,-AL SCL-$S'S
Am.otro"hic lateral sclerosis (52B) is a rare progressive neurologic disorder
characterized y loss of motor neurons& 52B usually leads to death ,ithin " to D years
after diagnosis&
@or un'no,n reasons, motor neurons in the rainstem and spinal cord gradually
degenerate in 52B&
The typical symptoms of 52B are ,ea'ness of the upper e)tremities, dysarthria, and
dysphagia& =eath usually results from respiratory infection secondary to compromised
respiratory function&
There is no cure for 52B, ut riluzole (?ilute') slo,s the progression&
The illness tra#ectory for 52B is devastating ecause the patient remains cognitively
intact ,hile ,asting a,ay& The challenge of nursing care is to guide the patient in use of
moderate intensity, endurance+type e)ercises for the trun' and lims, as this may help to
reduce 52B spasticity&
)5N,'N4,$N<S D'SAS
)untington<s disease (>=) is a genetically transmitted, autosomal dominant disorder
that affects oth men and ,omen of all races&
The clinical manifestations are characterized y anormal and e)cessive involuntary
movements %chorea&# These are ,rithing, t,isting movements of the face, lims, and
ody& The movements get ,orse as the disease progresses&
6ecause there is no cure, collaorative care is palliative& 5ntipsychotic, antidepressant,
and antichorea drugs are prescried and have some enefit&
th
edition
Key Points
Chapter D8: Nursing :anagement: 5lzheimer(s =isease and =ementia
1+"%9
Key Points
DMN,'A
Dementia is a syndrome characterized y dysfunction or loss of memory, orientation,
attention, language, #udgment, and reasoning& Personality changes and ehavioral
prolems such as agitation, delusions, and hallucinations may result&
The t,o most common causes of dementia are neurodegenerative conditions (e&g&,
5lzheimer(s disease) and vascular disorders& 2ascular dementia, also called multiinfarct
dementia, is the loss of cognitive function resulting from ischemic, ischemic+hypo)ic, or
hemorrhagic rain lesions caused y cardiovascular disease&
=epending on the cause of the dementia, the onset of symptoms may e insidious and
gradual or more arupt& ;ften dementia associated ,ith neurologic degeneration is
gradual and progressive over time&
?egardless of the cause of dementia, the initial symptoms are related to changes in
cognitive functioning& Patients may have complaints of memory loss, mild disorientation,
and1or troule ,ith ,ords and numers&
5n important first step in the diagnosis of dementia is a thorough medical, neurologic,
and psychologic history& 5lso, mental status testing is an important component of the
patient evaluation&
=epression is often mista'en for dementia in older adults, and, conversely, dementia for
depression&
M'LD C$4N','2 'MPA'-MN,
Mild cogniti!e im"airment (:C.) is a state of cognitive functioning that is elo,
defined norms, yet does not meet the criteria for dementia&
Causes of :C. may include stress, an)iety, depression, or physical illness&
The nurse caring for the patient ,ith :C. must recognize the importance of monitoring
the patient for changes in memory and thin'ing s'ills that ,ould indicate a ,orsening of
symptoms or a progression to dementia&
AL@)'M-<S D'SAS
Al#heimer<s disease (5=) is a chronic, progressive, degenerative disease of the rain& .t
is the most common form of dementia&
The e)act etiology of 5= is un'no,n& Bimilar to other forms of dementia, age is the most
important ris' factor for developing 5=&
Characteristic findings of 5= relate to changes in the rain(s structure and function: (1)
amyloid pla<ues, (") neurofibrillar. tangles, and ($) loss of connections et,een cells
and cell death&
1+"%F
Key Points
:ultiple genetic factors have een lin'ed to the development of 5=& .nflammation is also
elieved to contriute to 5=&
The manifestations of 5= can e categorized similar to those for dementia as mild,
moderate, and late&
5n initial sign of 5= is a sutle deterioration in memory& -ith progression of 5=,
additional cognitive impairments are noted, including dysphasia, apra)ia, visual agnosia,
and dysgraphia&
The diagnosis of 5= is primarily a diagnosis of e)clusion& No single clinical test can e
used to diagnose 5=&
5t this time there is no cure for 5=& The collaorative management of 5= is aimed at (1)
improving or controlling decline in cognition, and (") controlling the undesirale
ehavioral manifestations that the patient may e)hiit&
The diagnosis of 5= is traumatic for oth the patient and the family& .t is not unusual for
the patient to respond ,ith depression, denial, an)iety and fear, isolation, and feelings of
loss& The nurse is in an important position to assess for depression and suicidal ideation&
Currently, family memers and friends care for the ma#ority of individuals ,ith 5= in
their homes& ;thers ,ith 5= reside in various facilities, including long+term care and
assisted living facilities& ?egardless of the setting, the severity of the prolems and the
amount of nursing care intensify over time&
5s the patient ,ith 5= progresses to the late stages (severe impairment) of 5=, there is
increased difficulty ,ith the most asic functions, including ,al'ing and tal'ing& Total
care is re<uired&
6ehavioral prolems occur in aout E8K of patients ,ith 5=& These prolems include
repetitiveness, delusions, illusions, hallucinations, agitation, aggression, altered sleeping
patterns, ,andering, and resisting care& Nursing strategies that address difficult ehavior
include redirection, distraction, and reassurance&
5 specific type of agitation is termed sundowning, in ,hich the patient ecomes more
confused and agitated in the late afternoon or evening& 6ehaviors commonly e)hiited
include agitation, aggressiveness, ,andering, resistance to redirection, and increased
veral activity such as yelling&
The person ,ith 5= is at ris' for prolems related to personal safety& These ris's include
in#ury from falls, in#ury from ingesting dangerous sustances, ,andering, in#ury to others
and self ,ith sharp o#ects, fire or urns, and inaility to respond to crisis situations&
1+"%E
Key Points
-andering is a ma#or concern for caregivers& 5s ,ith other ehaviors, the nurse should
oserve for factors or events that may precipitate ,andering&
2oss of interest in food and decreased aility to feed self, as ,ell as comorid conditions,
can result in significant nutritional deficiencies in the patient ,ith 5=& Pureed foods,
thic'ened li<uids, and nutritional supplements can e used ,hen che,ing and s,allo,ing
ecome prolematic for the patient&
4rinary tract infection and pneumonia are the most common infections to occur in
patients ,ith 5=& Buch infections are ultimately the cause of death in many patients ,ith
5=&
=uring the middle and late stages of 5=, urinary and fecal incontinence lead to increased
need for nursing care&
5= is a disease that disrupts all aspects of personal and family life& Caregivers e)hiit
adverse conse<uences relating to their employment and to their emotional and physical
health, ,hich then results in family conflict and caregiver strain& The nurse should ,or'
,ith the caregiver to assess stressors and to identify coping strategies to reduce the
urden of caregiving&
$,)- N5-$D4N-A,'2 D'SASS
Lew. bod. dementia is a condition characterized y the presence of 2e,y odies
(intraneural cytoplasmic inclusions) in the rainstem and corte)& 5 common cause of
dementia, it is often unrecognized y health care providers&
Creut#feldt-Ba0ob disease is a rare and fatal rain disorder thought to e caused y a
prion protein& 5 prion is a small infectious pathogen containing protein ut lac'ing
nucleic acids&
Pic0<s disease, a type of frontotem"oral dementia, is a rare rain disorder characterized
y disturances in ehavior, sleep, personality, and eventually memory& The ma#or
distinguishing characteristic et,een these disorders and 5= is mar'ed symmetric loar
atrophy of the temporal and1or frontal loes&
Normal "ressure h.droce"halus is an uncommon disorder characterized y an
ostruction in the flo, of CB@, ,hich causes a uildup of this fluid in the rain&
DL'-'5M
Delirium, a state of temporary ut acute mental confusion, is a common, life+threatening,
and possily preventale syndrome in older adults&
Clinically, delirium is rarely caused y a single factor& .t is often the result of the
interaction of the patient(s underlying condition ,ith a precipitating event&
1+"C8
Key Points
5cute delirium occurs fre<uently in hospitalized older adults& This transient condition is
characterized y disorganized thin'ing, difficulty in concentrating, and sensory
misperceptions that last from 1 to 9 days&
:anifestations of delirium are sometimes confused ,ith dementia& 5 'ey distinction
et,een delirium and dementia is that the person ,ho e)hiits sudden cognitive
impairment, disorientation, or clouded sensorium is more li'ely to have delirium rather
than dementia&
.n caring for the patient ,ith delirium, the roles of the nurse include prevention, early
recognition, and treatment& Prevention of delirium involves recognition of high ris'
patients&
Care of the patient ,ith delirium is focused on eliminating precipitating factors& .f it is
drug+induced, medications are discontinued& .t is important to 'eep in mind that delirium
can also accompany drug and alcohol ,ithdra,al&
Care of the patient e)periencing delirium includes protecting the patient from harm&
Priority is given to creating a calm and safe environment&
Comprehensive, multicomponent interventions to prevent delirium are the most effective
and should e implemented through institutional+ased programs that are
interdisciplinary&
th
edition
Key Points
Chapter D1: Nursing :anagement: Peripheral Nerve and Bpinal Cord Prolems
C-AN'AL N-2 D'S$-D-S
Cranial nerve disorders are commonly classified as peripheral neuropathies& The 1" pairs
of cranial nerves are considered the peripheral nerves of the rain&
T,o cranial nerve disorders are trigeminal neuralgia and acute peripheral facial paralysis
(6ell(s palsy)&
Trigeminal Neuralgia
,rigeminal neuralgia (tic douloureu") is a relatively uncommon cranial nerve disorder&
>o,ever, it is the most commonly diagnosed neuralgic condition&
1+"C1
Key Points
The trigeminal nerve is the fifth cranial nerve (CN 3) and has oth motor and sensory
ranches& .n trigeminal neuralgia, the sensory or afferent ranches, primarily the
ma)illary and mandiular ranches, are involved&
The classic feature of trigeminal neuralgia is an arupt onset of paro)ysms of
e)cruciating pain descried as a urning, 'nifeli'e, or lightning+li'e shoc' in the lips,
upper or lo,er gums, chee', forehead, or side of the nose& .ntense pain, t,itching,
grimacing, and fre<uent lin'ing and tearing of the eye occur during the acute attac'&
The painful episodes are usually initiated y a triggering mechanism of light cutaneous
stimulation at a specific point %trigger 2one& along the distriution of the nerve ranches&
5lthough this condition is considered enign, the severity of the pain and the disruption
of lifestyle can result in almost total physical and psychologic dysfunction or even
suicide&
The ma#ority of patients otain ade<uate relief through antiseizure drugs such as
caramazepine (Tegretol), phenytoin (=ilantin), and valproate (=epa'ene)& Nerve
loc'ing ,ith local anesthetics is another treatment option& .f a conservative approach
including drug therapy is not effective, surgical therapy is availale&
The overall nursing goals are that the patient ,ith trigeminal neuralgia ,ill (1) e free of
pain, (") maintain ade<uate nutritional and oral hygiene status, ($) have minimal to no
an)iety, and (%) return to normal or previous socialization and occupational activities&
The nurse must teach the patient aout the importance of nutrition, hygiene, and oral care
and convey understanding if previous oral neglect is apparent& The nurse should provide
lu'e,arm ,ater and soft cloths or cotton saturated ,ith solutions not re<uiring rinsing
for cleansing the face&
The nurse is responsile for instruction related to diagnostic studies to rule out other
prolems, such as multiple sclerosis, dental or sinus prolems, and neoplasms, and for
preoperative teaching if surgery is planned&
?egular follo,+up care should e planned& The patient needs instruction regarding the
dosage and side effects of medications& 5lthough relief of pain may e complete, the
patient should e encouraged to 'eep environmental stimuli to a moderate level and to
use stress reduction methods&
Bells Palsy
/ell<s "als. (peripheral facial paralysis, acute enign cranial polyneuritis) is a disorder
characterized y a disruption of the motor ranches of the facial nerve (CN 3..) on one
1+"C"
Key Points
side of the face in the asence of any other disease such as a stro'e& 6ell(s palsy is an
acute, peripheral facial paresis of un'no,n cause&
The paralysis of the motor ranches of the facial nerve typically results in a flaccidity of
the affected side of the face, ,ith drooping of the mouth accompanied y drooling&
:ethods of treatment for 6ell(s palsy include moist heat, gentle massage, and electrical
stimulation of the nerve and prescried e)ercises& 6ell(s palsy is considered enign ,ith
full recovery after D months in most patients, especially if treatment is instituted
immediately&
The overall nursing goals are that the patient ,ith 6ell(s palsy ,ill (1) e pain free or
have pain controlled, (") maintain ade<uate nutritional status, ($) maintain appropriate
oral hygiene, (%) not e)perience in#ury to the eye, (C) return to normal or previous
perception of ody image, and (D) e optimistic aout disease outcome&
P$L6N5-$PA,)'S
4uillain-/arr= S.ndrome
4uillain-/arr= s.ndrome is an acute, rapidly progressing, and potentially fatal form of
polyneuritis& .t affects the peripheral nervous system and results in loss of myelin and
edema and inflammation of the affected nerves, causing a loss of neurotransmission to
the periphery&
The etiology of this disorder is un'no,n, ut it is elieved to e a cell+mediated
immunologic reaction directed at the peripheral nerves& The syndrome is often preceded
y immune system stimulation from a viral infection, trauma, surgery, viral
immunizations, or human immunodeficiency virus (>.3)&
The most serious complication of this syndrome is respiratory failure, ,hich occurs as the
paralysis progresses to the nerves that innervate the thoracic area& Constant monitoring of
the respiratory system provides information aout the need for immediate intervention&
:anagement is aimed at supportive care, particularly ventilatory support, during the
acute phase& 5ssessment of the patient is the most important aspect of nursing care during
the acute phase&
Botulism
/otulism is the most serious type of food poisoning& .t is caused y A. asorption of the
neuroto)in produced y Clostridium botulinum, an organism found in the soil& .mproper
home canning of foods is often the cause&
.t is thought that the neuroto)in destroys or inhiits the neurotransmission of
acetylcholine at the myoneural #unction, resulting in distured muscle innervation&
Neurologic manifestations include development of a descending flaccid paralysis ,ith
1+"C$
Key Points
intact sensation, photophoia, ptosis, paralysis of e)traocular muscles, lurred vision,
diplopia, dry mouth, sore throat, and difficulty in s,allo,ing&
The initial treatment of otulism is .3 administration of otulinum antito)in&
Primary prevention is the goal of nursing management y educating consumers to e alert
to situations that may result in otulism& Particular attention should e given to foods
,ith a lo, acid content, ,hich support germination and the production of otulin, a
deadly poison&
Tetanus
,etanus (loc'#a,) is an e)tremely severe polyradiculitis and polyneuritis affecting spinal
and cranial nerves& .t results from the effects of a potent neuroto)in released y the
anaeroic acillus Clostridium tetani#
The spores of the acillus are present in soil, garden mold, and manure& Thus Clostridium
tetani enters the ody through a traumatic or suppurative ,ound that provides an
appropriate lo,+o)ygen environment for the organisms to mature and produce to)in&
.nitial manifestations of generalized tetanus include stiffness in the #a, %trismus& and
nec', fever, and other symptoms of general infection& 5s the disease progresses, the nec'
muscles, ac', adomen, and e)tremities ecome progressively rigid&
The management of tetanus includes administration of a tetanus and diphtheria to)oid
ooster (Td) and tetanus immune gloulin (T.A) in different sites efore the onset of
symptoms to neutralize circulating to)ins& 5 much larger dose of T.A is administered to
patients ,ith manifestations of clinical tetanus&
Neurosyphilis
Neuros."hilis (tertiary syphilis) is an infection of any part of the nervous system y the
organism *reponema pallidum# .t is the result of untreated or inade<uately treated
syphilis&
Neurologic symptoms associated ,ith neurosyphilis are numerous and many times
nonspecific&
:anagement includes treatment ,ith penicillin, symptomatic care, and protection from
physical in#ury&
SP'NAL C$-D P-$/LMS
1+"C%
Key Points
Spinal Cord Injury
The segment of the population ,ith the greatest ris' for spinal cord in#ury is young adult
men et,een the ages of 1D and $8 years& Causes of spinal cord in#ury include many
types of trauma, ,ith motor vehicle crashes eing the most common&
5out C8K of people ,ith acute spinal cord in#ury e)perience a temporary neurologic
syndrome 'no,n as s"inal shoc0 that is characterized y decreased refle)es, loss of
sensation, and flaccid paralysis elo, the level of the in#ury& Neurogenic shoc0, in
contrast, is due to the loss of vasomotor tone caused y in#ury and is characterized y
hypotension and radycardia, ,hich are important clinical clues&
The degree of spinal cord involvement may e either complete or incomplete&
o Complete cord involvement results in total loss of sensory and motor function
elo, the level of the lesion (in#ury)&
o -ncomplete cord involvement results in a mi)ed loss of voluntary motor activity
and sensation and leaves some tracts intact&
:anifestations of spinal cord in#ury are related to the level and degree of in#ury&
o ?espiratory complications closely correspond to the level of the in#ury& Cervical
in#ury aove the level of C% presents special prolems ecause of the total loss of
respiratory muscle function&
o 5ny cord in#ury aove the level of TD greatly decreases the influence of the
sympathetic nervous system& 6radycardia occurs, peripheral vasodilation results
in hypotension, and a relative hypovolemia e)ists&
o 4rinary retention is a common development in acute spinal cord in#uries and
spinal shoc'&
o .f the cord in#ury has occurred aove the level of TC, the primary A. prolems are
related to hypomotility& .n the early period after in#ury ,hen spinal shoc' is
present and for patients ,ith an in#ury level of T1" or elo,, the o,el is
arefle)ic and sphincter tone is decreased&
o Poi0ilothermism is the ad#ustment of the ody temperature to the room
temperature& This occurs in spinal cord in#uries ecause the interruption of the
sympathetic nervous system prevents peripheral temperature sensations from
reaching the hypothalamus&
o =eep vein thromosis (=3T) is a common prolem accompanying spinal cord
in#ury during the first $ months&
.mmediate postin#ury prolems include maintaining a patent air,ay, ade<uate ventilation,
and ade<uate circulating lood volume and preventing e)tension of cord damage
(secondary damage)&
5fter stailization at the in#ury scene, the person is transferred to a medical facility& 5
thorough assessment is done to specifically evaluate the degree of deficit and to estalish
the level and degree of in#ury&
1+"CC
Key Points
The decision to perform surgery on a patient ,ith a spinal cord in#ury often depends on
the preference of a particular physician& -hen cord compression is certain or the
neurologic disorder progresses, enefit may e seen follo,ing immediate surgery&
Nursing Management
The patient must e moved in alignment as a unit or /logrolled0 during transfers and
,hen repositioning to prevent further in#ury&
Proper immoilization is critical to prevent e)tension of cord damage&
Bpinal cord edema may increase the level of dysfunction and respiratory distress may
occur& The nurse needs to regularly assess reath sounds, 56As, tidal volume, vital
capacity, s'in color, reathing patterns, su#ective comments aout the aility to
reathe, and the amount and color of sputum&
6ecause of unopposed vagal response, the heart rate is slo,ed, often to elo, D8 eats
per minute& 5ny increase in vagal stimulation such as turning or suctioning can result in
cardiac arrest& 3ital signs should e assessed fre<uently&
=uring the first %F to 9" hours after the in#ury the A. tract may stop functioning and a
nasogastric tue must e inserted& 6ecause the patient cannot have oral inta'e, fluid and
electrolyte needs must e carefully monitored&
o ;nce o,el sounds are present or flatus is passed, oral food and fluids can
gradually e introduced&
o 6ecause of severe cataolism, a high+protein, high+calorie diet is necessary for
energy and tissue repair&
o 2ess voluntary neurologic control over the o,el results in a neurogenic bowel(
.mmediately after in#ury, urine is retained ecause of the loss of autonomic and refle)
control of the ladder and sphincter& 6ecause there is no sensation of fullness,
overdistention of the ladder can result in reflu) into the 'idney ,ith eventual renal
failure&
o Conse<uently, an ind,elling catheter is usually inserted as soon as possile after
in#ury&
o 4T.s are a common prolem& The est method for preventing 4T.s is regular and
complete ladder drainage&
o 5 neurogenic bladder is any type of ladder dysfunction related to anormal or
asent ladder innervation&
6ecause there is no vasoconstriction, piloerection, or heat loss through perspiration elo,
the level of in#ury, temperature control is largely e)ternal to the patient& Therefore the
nurse must monitor the environment closely to maintain an appropriate temperature&
1+"CD
Key Points
The nurse must compensate for the patient(s asent sensations to prevent sensory
deprivation& This is done y stimulating the patient aove the level of in#ury&
Conversation, music, strong aromas, and interesting flavors should e a part of the
nursing care plan&
The return of refle)es after the resolution of spinal shoc' means that patients ,ith an
in#ury level at TD or higher may develop autonomic dysrefle)ia& Autonomic d.srefle1ia
is a massive uncompensated cardiovascular reaction mediated y the sympathetic nervous
system&
o The condition is a life+threatening situation that re<uires immediate resolution&
o The most common precipitating cause is a distended ladder or rectum, although
any sensory stimulation may cause autonomic dysrefle)ia&
o Nursing interventions in this serious emergency are elevation of the head of the
ed %C degrees or sitting the patient upright, notification of the physician, and
assessment to determine the cause&
The physiologic and psychologic rehailitation of the person ,ith spinal cord in#ury is
comple) and involved& ?ehailitation is a multidisciplinary endeavor carried out through
a team approach&
Patients ,ith spinal cord in#uries may feel an over,helming sense of loss& The nurse(s
role in grief ,or' is to allo, mourning as a component of the rehailitation process&
Spinal Cord Tumors
Bpinal cord tumors are classified as e)tradural (outside the spinal cord), intradural
e)tramedullary (,ithin the dura ut outside the actual spinal cord), and intradural
intramedullary (,ithin the spinal cord itself)&
6oth sensory and motor prolems may result ,ith the location and e)tent of the tumor
determining the severity and distriution of the prolem& The most common early
symptom of a spinal cord tumor outside the cord is pain in the ac' ,ith radicular pain
simulating intercostal neuralgia, angina, or herpes zoster&
Treatment for nearly all spinal cord tumors is surgical removal&
P$S,P$L'$ S6ND-$M
Polio, also 'no,n as poliomyelitis, is an infectious viral disease transmitted through the
oral route y ingestion of contaminated ,ater or food, or contact ,ith infected sources
such as un,ashed hands&
Polio survivors ,ho recovered from the disease decades ago, notaly those ,ho had
paralytic poliomyelitis, are no, e)periencing a recurrence of neuromuscular symptoms
as they age& These late effects of polio are collectively referred to as postpolio syndrome&
1+"C9
Key Points
Postpolio syndrome is manifested y a ne, onset of #oint and muscle ,ea'ness, easy
fatigaility, generalized fatigue, and pain& 4ncommonly, individuals may also e)hiit
speech, s,allo,ing, and respiratory difficulties&
There is no specific treatment for postpolio syndrome& :anagement approaches are
targeted at controlling symptoms, particularly fatigue, ,ea'ness, and pain& 5n
interdisciplinary team approach is essential to manage the patient&
th
edition
Key Points
Chapter D": Nursing 5ssessment: :usculos'eletal Bystem
The main functions of one are support, protection of internal organs, voluntary
movement, lood cell production, and mineral storage&
Cylinder+shaped structural units (haversian systems) fit closely together in compact one,
creating a dense one structure&
Types of one cells include osteolasts, osteocytes, and osteoclasts&
o .steoblasts synthesize organic one matri) (collagen) and are the asic one+
forming cells&
o .steocytes are the mature one cells&
o .steoclasts participate in one remodeling y assisting in the rea'do,n of one
tissue&
o 8one remodeling is removal of old one y osteoclasts (resorption) and the
deposition of ne, one y osteolasts (ossification)&
*ach long one consists of the epiphysis, diaphysis, and metaphysis&
o +piphysis, the ,idened area found at end of a long one, is composed of
cancellous one& *piphysis is the location of muscle attachment&
o Diaphysis is the main shaft of the one& .t provides structural support and is
composed of compact one& :arro, is in the center&
o Metaphysis is the flared area of cancellous one et,een the epiphysis and the
diaphysis&
5 joint (articulation) is ,here ends of t,o ones are in pro)imity and move in relation to
each other& \oints are classified according to degree of movement they allo,&
1+"CF
Key Points
Cartilage is a rigid connective tissue in synovial #oints that serves as support for soft
tissue and provides articular surface for #oint movement& Types of cartilage tissue include
hyaline, elastic, and firous&
Types of muscle tissue are cardiac (striated, involuntary), smooth (nonstriated,
involuntary), and s7eletal (striated, voluntary) muscle&

5 nerve fier and the s'eletal muscle fiers it stimulates are called a motor endplate# The
#unction et,een a)on of nerve cell and ad#acent muscle cell is called the myoneural or
neuromuscular junction#
2igaments and tendons are composed of dense, firous connective tissue& Tendons attach
muscles to ones, and ligaments connect ones to ones&
0ascia is defined as layers of connective tissue ,ith intermeshed fiers that can
,ithstand limited stretching&
8ursae are small sacs of connective tissue lined ,ith synovial memrane and contain
synovial fluid&
Assss!n"
:any functional prolems e)perienced y the aging adult relate to changes of the
musculos'eletal system&
o .ncreased one resorption and decreased one formation cause a loss of one
density, contriuting to development of osteoporosis&
o Tendons and ligaments ecome less fle)ile, movement ecomes rigid&
Common symptoms of musculos'eletal impairment include pain, ,ea'ness, and
deformity, limitation of movement, stiffness, and #oint cre"itation(
>ealth history <uestions should focus on past medical prolems, surgeries, and symptoms
of arthritic and connective tissue diseases&
:aintenance of normal ody ,eight, nutrition, avoidance of e)cessive stress on muscles
and #oints, and the use of proper ody mechanics ,hen lifting o#ects are noted&
.nspection is performed starting at head and nec' and proceeding to upper e)tremities,
lo,er e)tremities, and trun'& The opposite ody part is used for comparison ,hen an
anormality is suspected&
Palpation of oth muscles and #oints allo,s for evaluation of s'in temperature, local
tenderness, s,elling, and crepitation&
1+"CE
Key Points
Carefully evaluate oth passive and active range of motionD measurements should e
similar for oth maneuvers&
o ,ctive range of motion means patient ta'es his or her o,n #oints through all
movements ,ithout assistance&
o Passive range of motion occurs ,hen someone else moves patient(s #oints ,ithout
his or her participation&
.f patient ale to move independently, assess posture and gait y ,atching patient ,al',
stand, and sit&
-hen length discrepancies or su#ective prolems are noted, otain lim length and
circumferential muscle mass measurements&
Scoliosis is a lateral S+shaped curvature of thoracic and lumar spine&

4ne<ual shoulder
and scapula height is usually noted ,hen patient is oserved from ac'&
Dia#nos"i$ S"%dis
8-ra.s provide information aout one deformity, #oint congruity, one density, and
calcification in soft tissue&
o @racture diagnosis and management are indications for )+ray! also useful in
evaluation of hereditary, developmental, infectious, inflammatory, neoplastic,
metaolic, and degenerative disorders&
5 fieroptic tue called an arthroscope is used to directly e)amine interior of #oint cavity
in an arthrosco".(
o Torn tissue can e repaired through arthroscopic surgery, eliminating the need for
a larger incision and greatly decreasing the recovery time&
Arthrocentesis or #oint aspiration is usually performed for a synovial fluid analysis& The
fluid is e)amined grossly for volume, color, clarity, viscosity, and mucin clot formation&
th
edition
Key Points
Chapter D$: Nursing :anagement: :usculos'eletal Trauma and ;rthopedic
Burgery
The most common cause of musculos'eletal in#uries is a traumatic event resulting in
fracture, dislocation, and associated soft tissue in#uries&
1+"D8
Key Points
Nurses have an important role in pulic education aout the asic principles of safety and
accident prevention&
S$+,-,'SS5 'NB5-'S
5 s"rain is an in#ury to tendinoligamentous structures surrounding a #oint, usually caused
y ,renching or t,isting motion&
5 strain is an e)cessive stretching of a muscle and its fascial sheath& .t often involves the
tendon&
Bymptoms of sprains and strains are similar and include pain, edema, decrease in
function, and contusion&
:ild sprains and strains are usually self+limiting, ,ith full function returning ,ithin $ to
D ,ee's&
Bevere strains may re<uire surgical suturing of muscle and surrounding fascia&
?.C* (rest, ice, compression, elevation) can decrease inflammation and pain for most of
these in#uries&
Btretching and ,arm+up prior to e)ercising and efore vigorous activity significantly
reduces sprains and strains&
D'SL$CA,'$N
Dislocation is a severe in#ury of the ligamentous structures that surround a #oint&
The most ovious sign is deformity, also local pain, tenderness, loss of function of
in#ured part, and s,elling of soft tissues in #oint region&
?e<uires prompt attention ,ith the dislocated #oint first realigned in its original anatomic
position&
*)tremity then is immoilized y racing, taping, or using a sling to allo, torn ligaments
and tissue time to heal&
S5/L58A,'$N
Sublu1ation is a partial or incomplete displacement of the #oint surface&
:anifestations are similar to a dislocation ut are less severe& Treatment is similar to a
dislocation, ut sulu)ation may re<uire less healing time&
Nursing care of sulu)ation or dislocation is directed to,ard pain relief and support and
protection of in#ured #oint&
1+"D1
Key Points
-P,','2 S,-A'N 'NB5-6
-e"etiti!e strain in*ur. (?B.) is a cumulative traumatic disorder resulting from
prolonged, forceful, or a,',ard movements&
?B. can e prevented through education and ergonomics&
Treatment includes identifying the precipitating activity, modification of activity, pain
management ,ith heat1cold application, drugs, rest, physical therapy for strengthening
and conditioning, and lifestyle changes&
CA-PAL ,5NNL S6ND-$M
Car"al tunnel s.ndrome (CTB) is caused y compression of the median nerve, ,hich
enters the hand through the narro, confines of the carpal tunnel&
CTB is often caused y pressure from trauma or edema caused y inflammation of tendon
(tenosynovitis), rheumatoid arthritis, or soft tissue masses&
Bigns are ,ea'ness (especially in thum), urning pain, and numness&
>olding the ,rists for D8 seconds produces tingling and numness over the distriution
of the median nerve, a positive Phalen(s test&
Prevention involves educating employees and employers to identify ris' factors&
*arly symptoms usually relieved y stopping the aggravating movement and y placing
hand and ,rist at rest y immoilizing them in a hand splint& .n#ection of a corticosteroid
drug directly into carpal tunnel may provide some relief&
.f CTB continues, median nerve may need to e surgically decompressed& ?ehailitation
can last up to 9 ,ee's&
-$,A,$- C5++ 'NB5-6
?otator cuff in#ury may occur gradually from aging, repetitive stress, or in#ury to the
shoulder ,hile falling&
:anifestations include shoulder ,ea'ness and pain and decreased range of motion&
Conservative treatment involves rest, ice and heat, NB5.=s, corticosteroid in#ections into
#oint, and physical therapy&
Burgery may e done ,ith complete tear or no improvement ,ith conservative therapy&
MN'SC5S 'NB5-'S
:eniscus in#uries are associated ,ith ligament sprains that commonly occur in athletes&
1+"D"
Key Points
Pain is elicited y fle)ion, internal rotation, and then 'nee e)tension&
Burgery may e indicated for a torn meniscus&
Proper stretching may ma'e the patient less prone to meniscal in#ury ,hen a fall or
t,isting occurs&
/5-S','S
/ursitis results from repeated or e)cessive trauma or friction, rheumatoid arthritis, or
infection&
:anifestations are ,armth, pain, s,elling, and limited ?;: in the affected part&
?est is often the only treatment needed for ursitis&
+-AC,5-
+racture is a disruption or rea' in the continuity of the one structure&
Traumatic in#uries account for the ma#ority of fractures&
@ractures are often descried according to 1) type, ") communication or
noncommunication ,ith the e)ternal environment, and $) anatomic location&
Bigns include immediate localized pain, decreased function, and inaility to ear ,eight
or use affected part& ;vious one deformity may not e present&
@ractures re<uire nursing assessments of the peripheral vasculature (color, temperature,
capillary refill, peripheral pulses, and edema) and neurologic systems (sensation, motor
function, and pain)&
Treatment goals are anatomic realignment of one fragments, immoilization to maintain
realignment, and restoration of function&
2o,er e)tremity in#uries are often immoilized y casts, dressings, or
splints1immoilizers&
The ma#ority of fractures heal ,ithout complications, ,hich include one infection,
avascular necrosis, com"artment s.ndrome, venous thromosis, fat emolism, and
shoc'&
Nursing care involves comfort measures for pain, maintenance of nutrition, and
prevention of complications associated ,ith immoility&
5 Colles6 fracture is a fracture of the distal radius& 4sually managed y closed
manipulation, y immoilization y splint or a cast, or, if displaced, y internal or
1+"D$
Key Points
e)ternal fi)ation&
@ractures involving the shaft of the humerus are a common in#ury among young and
middle+aged adults& .f surgery is done, s'in or s'eletal traction may e used for
reduction and immoilization&
Pelvic fractures range from enign to life threatening depending on mechanism of in#ury
and associated vascular insult&
o Physical e)amination demonstrates local s,elling, tenderness, deformity,
unusual pelvic movement, and ecchymosis on adomen&
o Treatment depends on the in#ury severity and ranges from limited intervention
to pelvic sling traction, hip spica casts, e)ternal fi)ation, and open reduction&
)'P +-AC,5-S
>ip fractures are common in older adults&
:anifestations are e)ternal rotation, muscle spasm, shortening of affected e)tremity, and
severe pain in region of fracture&
Burgical repair is preferred for managing intracapsular and e)tracapsular fractures&
5fter surgeryGin addition to teaching on ho, to prevent prosthesis dislocationGthe
nurse should place a large pillo, et,een patient(s legs ,hen turning, avoid e)treme hip
fle)ion, and avoid turning the patient on affected side until approved y surgeon&
The nurse assists oth the patient and family in ad#usting to restrictions and dependence
imposed y hip fracture&
AMP5,A,'$N
;lder persons have the highest incidence of amputation due to effects of peripheral
vascular disease, atherosclerosis, and diaetes&
.ndications for amputation include circulatory impairment resulting from a peripheral
vascular disorder, traumatic and thermal in#uries, malignant tumors, and infection of the
e)tremity&
Aoal of surgery is to preserve e)tremity length and function ,hile removing all infected,
pathologic, or ischemic tissue&
Aoals for the nurse are that the patient ,ill have pain relief from the underlying health
prolem, satisfactory pain control, ma)imum rehailitation potential, and aility to cope
,ith the ody image changes&
B$'N, -PLACMN, S5-4-6
\oint replacement surgery is the most common orthopedic operation performed on older
1+"D%
Key Points
adults&
Burgery is aimed at relieving pain, improving #oint motion, correcting deformity and
malalignment, and removing intraarticular causes of erosion&
Types of #oint surgeries include s.no!ectom., osteotom., deridement, and arthroplasty#
Arthrodesis is the surgical #oint fusion ,hich may e done if articular surfaces are too
damaged or infected to allo, #oint replacement or for reconstructive surgery failures&
Postoperatively, neurovascular assessment is performed to assess nerve function and
circulatory status& 5nticoagulation therapy, analgesia, and antiiotics are administered&
5mulation is encouraged as early as possile to prevent immoility complications&
Patient discharge teaching includes instructions on reporting complications, including
infection and dislocation of the prosthesis (e&g&, pain, loss of function, shortening or
malalignment of an e)tremity)&
th
edition
Key Points
Chapter D%: Nursing :anagement: :usculos'eletal Prolems
$S,$M6L','S
$steom.elitis is a severe infection of one, one marro,, and surrounding soft tissue&
.nfecting microorganisms can invade y indirect or direct entry& 5fter entering the lood,
they lodge in an area of one and gro, ,hich results in increased pressure, eventually
leading to one ischemia&
;nce ischemia occurs, the one dies&
Chronic osteomyelitis is a continuous, persistent prolem or a process of e)acerations
and remission&
5cute symptoms are fever, night s,eats, malaise, and constant one pain&
Bome immoilization of affected lim (e&g&, splint, traction) is indicated to decrease pain&
1+"DC
Key Points
The patient is fre<uently on ed rest in the early stages of the acute infection&
3igorous and prolonged .3 antiiotic therapy is treatment of choice for acute
osteomyelitis&
;ral antiiotics, hyperaric o)ygen therapy, and surgery may e prescried for chronic
disease&
SA-C$MA
:ost primary one cancer is called sarcoma&
Barcomas can also develop in cartilage, muscle fiers, fatty tissue, and nerve tissue&
Common types are osteogenic sarcoma, chondrosarcoma, *,ing(s sarcoma, and
chordoma&
$S,$C)$ND-$MA
$steochondroma is a primary enign one tumor characterized y overgro,th of
cartilage and one near end of the one at the gro,th plate&
:anifestations include painless, hard, and immoile mass, one leg or arm longer than
other, and pressure or irritation ,ith e)ercise&
No treatment necessary if asymptomatic& .f patient has pain or neurologic symptoms due
to compression, surgical resection is usually done&
Nursing care does not differ significantly from the care given to patients ,ith a malignant
disease of any other ody system&
$steogenic Sarcoma
$steogenic sarcoma (osteosarcoma) is a primary one tumor that is e)tremely
aggressive and rapidly metastasizes to distant sites&
:anifestations are usually associated ,ith gradual onset of pain and s,elling, especially
around the 'nee&
Preoperative (neoad#uvant) chemotherapy is used to decrease tumor size&
2im+salvage procedures are considered ,hen there is a clear D+ to 9+cm margin
surrounding the lesion&
Metastatic /one Cancer
The most common type of malignant one tumor occurs as a result of metastasis from a
primary tumor&
1+"DD
Key Points
:etastatic one lesion is commonly found in verterae, pelvis, femur, humerus, or ris&
:etastasis to one may e suspected in patients ,ith local one pain and past cancer
history&
Treatment may e palliative and consists of radiation and pain management&
L$7 /AC9 PA'N
2o, ac' pain is common, affecting aout F8K of adults during their lifetime&
,cute low bac7 pain is usually associated ,ith activity that causes undue stress (often
hyperfle)ion) on the lo,er ac'&
o .f muscle spasms and pain are not severe, treatment includes avoiding activities
that aggravate pain, analgesics, muscle rela)ants, massage and ac' manipulation!
and heat and cold compresses&
o :ost acute cases spontaneously improve&
Chronic low bac7 pain causes include degenerative dis' disease, lac' of physical
e)ercise, prior in#ury, oesity, and structural and postural anormalities&
o Treatment can include ,eight reduction, analgesics, rest periods, heat or cold
application, and e)ercise and activity to 'eep muscles and #oints moilized&
o Burgery may e indicated for severe chronic lo, ac' pain that is not responding
to conservative care&
'N,-2-,/-AL L5M/A- D'S9 DAMA4
Btructural degeneration of the lumar dis' is often caused y degenerati!e dis0 disease
(===)&
This is a normal process of aging, and results in interverteral dis's losing their elasticity,
fle)iility, and shoc'+asoring capailities&
5n acute herniated inter!ertebral dis0 (slipped dis') can e the result of === or
repeated stress and spinal trauma&
?adicular pain, ,hich radiates do,n uttoc' and elo, the 'nee, generally indicates dis'
herniation&
Treatment initially is at least % ,ee's of conservative therapy including drug therapy,
limitation of spinal movement ,ith race or corset, local heat or ice, ultrasound and
massage, transcutaneous electrical nerve stimulation, and epidural steroid in#ections& .f
there is no improvement, various surgical techni<ues may e used&
Postoperative nursing interventions focus on maintaining proper alignment of the spine at
all times until healing has occurred&
1+"D9
Key Points
;nce symptoms suside, ac' strengthening e)ercises are egun t,ice a day and
encouraged for a lifetime&
+$$, D'S$-D-S
:ost of the pain and disaility is attriuted to improperly fitting shoes, ,hich cause toe
cro,ding and inhiition of normal foot muscle movement&
The older adult is prone to foot prolems ecause of poor circulation, atherosclerosis, and
decreased sensation in lo,er e)tremities&
Therapy includes analgesics, shoc'+,ave therapy, icing, physical therapy, alterations in
foot,ear, stretching, ,arm soa's, orthotics, ultrasound, and corticosteroid in#ections&
.f there is no relief, then surgery may e done&
$S,$MALAC'A
$steomalacia is a rare condition of adult one associated ,ith vitamin = deficiency,
resulting in decalcification and softening of one&
Common features are localized one pain, difficulty rising from a chair, and ,al'ing&
Care is directed to,ard correction of vitamin = deficiency& 3itamin =
$
(cholecalciferol)
and vitamin =
"
(ergocalciferol) can e supplemented& Calcium salts or phosphorus
supplements may also e prescried&
*)posure to sunlight (and ultraviolet rays) is also valuale, along ,ith ,eight+earing
e)ercise&
$S,$P$-$S'S
$steo"orosis is a chronic, progressive metaolic one disease characterized y lo, one
mass and structural deterioration of one tissue&
6ones can eventually ecome so fragile that they cannot ,ithstand normal mechanical
stress&
5t least 18 million persons in the 4nited Btates (F8K are ,omen) have osteoporosis&
?is' factors are female se), increasing age, family history of osteoporosis, ,hite or 5sian
race, small stature, early menopause, sedentary lifestyle, and insufficient dietary calcium&
People may not 'no, they have osteoporosis until their ones ecome so ,ea' that a
sudden fall causes a hip or verteral fracture&
Collapsed verterae may initially e manifested as ac' pain, loss of height, or spinal
1+"DF
Key Points
deformities such as 'yphosis or severely stooped posture&
=ual+energy )+ray asorptiometry (=*M5) studies are used in diagnosis and to assess the
treatment effectiveness&
Collaorative care focuses on proper nutrition, calcium supplementation, e)ercise,
prevention of fractures, and drugs&
PA4,<S D'SAS
Paget<s disease is a s'eletal one disorder in ,hich there is e)cessive one resorption
follo,ed y replacement of normal marro, y vascular, firous connective tissue&
The etiology is un'no,n, although a viral cause has een proposed&
.nitial manifestations are usually insidious development of one pain (may progress to
severe intractale pain), fatigue, and progressive development of a ,addling gait&
Pathologic fracture is the most common complication&
M+rays may demonstrate that the normal contour of the affected one is curved and the
corte) is thic'ened and irregular&
Care is usually limited to symptomatic and supportive care and correction of secondary
deformities y either surgical intervention or races&
4-$N,$L$4'C C$NS'D-A,'$NS: M,A/$L'C /$N D'SASS
:etaolic one diseases increase the possiility of pathologic fractures&
The nurse must use e)treme caution ,hen patient is turned or moved&
.t is important to 'eep the patient as active as possile to retard demineralization of one
resulting from disuse or e)tended immoilization&
th
edition
Key Points
Chapter DC: Nursing :anagement: 5rthritis and Connective Tissue =iseases
1+"DE
Key Points
A-,)-','S
Arthritis is inflammation of a #oint&
The most prevalent types of arthritis are osteoarthritis, rheumatoid arthritis, and gout&
$S,$A-,)-','S
$steoarthritis (;5), the most common form of #oint (articular) disease in North
5merica, is a slo,ly progressive noninflammatory disorder of the diarthrodial (synovial)
#oints&
@actors lin'ed to ;5 include increasing age, genetics, oesity, occupations ,ith fre<uent
'neeling, and lac' of e)ercise&
;5 results from cartilage damage, leading to fissuring, firillation, and erosion of
articular surfaces&
Bystemic manifestations (fatigue, fever) are not present in ;5, ,hereas they are present
in inflammatory #oint disorders such as rheumatoid arthritis&
:anifestations range from mild discomfort to significant disaility, ,ith #oint pain eing
the ma#or symptom&
5s ;5 progresses, increasing pain contriutes significantly to disaility and loss of
function&
Care focuses on managing pain and inflammation, preventing disaility, and maintaining
and improving #oint function&
Bymptoms are initially managed conservatively through medication, #oint rest, heat and
cold, nutrition, and e)ercise&
5rthroscopy to repair cartilage or remove one its or cartilage may e recommended
,ith ;5 progression&
Teaching should include information aout nature and treatment of ;5, pain
management, posture and ody mechanics, use of assistive devices, principles of #oint
protection and energy conservation&
-)5MA,$'D A-,)-','S
-heumatoid arthritis (?5) is a chronic, systemic disease ,ith inflammation in
connective tissue of the diarthrodial (synovial) #oints, often remission and e)acerations&
The etiology of ?5 is un'no,n! it is proaly due to autoimmune and genetic factors&
;nset is typically insidious ,ith fatigue, ,eight loss, and generalized stiffness&
1+"98
Key Points
5rticular signs include pain, stiffness, limitation of motion, and inflammation (e&g&, heat,
s,elling, tenderness)& \oint stiffness after periods of inactivity is common&
5s ?5 progresses, muscle atrophy and destruction of tendons around #oint cause one
articular surface to slip past the other (sulu)ation)&
?5 can affect nearly every ody system& :ost common e)traarticular signs are
rheumatoid nodules and B#^gren(s and @elty syndromes&
o Treatment goals include reduction of inflammation, management of pain,
maintenance of #oint function, and prevention1correction of #oint deformity
o .nitial care usually involves drug therapy and education&
AN96L$S'N4 SP$ND6L','S
An0.losing s"ond.litis (5B) is a chronic inflammatory disease primarily affecting the
a)ial s'eleton (sacroiliac #oints, interverteral dis' spaces, and costoverteral
articulations)&
:ost persons are positive for >25+6"9 antigen&
*)traarticular inflammation can affect eyes, lungs, heart, 'idneys, and peripheral nervous
system&
Bigns of 5B are lo, ac' pain, stiffness, and limitation of motion&
Care is aimed at maintaining ma)imal s'eletal moility ,hile decreasing pain and
inflammation& >eat applications, e)ercise, and medications are often recommended&
Burgery may e done for severe deformity and moility impairment&
PS$-'AS'S
Psoriasis is a common enign, inflammatory s'in disorder ,ith a possile genetic
predisposition&
5ppro)imately 18K of people ,ith psoriasis for reasons un'no,n develop psoriatic
arthritis, a progressive inflammatory disease&
Psoriasis can occur in different forms, all having a degree of arthritis&
Treatment includes splinting, #oint protection, drugs, and physical therapy&
-AC,'2 A-,)-','S
-eacti!e arthritis (?eiter(s syndrome) occurs more commonly in young men and is
associated ,ith a symptom comple) that includes urethritis (cervicitis in ,omen),
con#unctivitis, and mucocutaneous lesions&
1+"91
Key Points
The etiology is un'no,n, ut it appears to occur after genitourinary or gastrointestinal
tract infection&
The prognosis is favorale! most patients have a complete recovery after " to 1D ,ee's&
Bince reactive arthritis is associated ,ith C# trachomatis infection, patients and their
se)ual partners are often treated ,ith antiiotics&
SP,'C A-,)-','S
Se"tic arthritis (infectious or acterial arthritis) is caused y invasion of #oint cavity ,ith
microorganisms&
2arge #oints ('nee and hip) are fre<uently involved, causing severe pain, erythema, and
s,elling&
This condition re<uires prompt treatment ,ith antiiotics to prevent #oint destruction&
Nursing care includes assessment and monitoring of #oint inflammation, pain, and fever&
L6M D'SAS
L.me disease is a spirochetal infection transmitted y ite of an infected deer tic'&
5 characteristic symptom of the early localized disease is erythema migrans, a s'in lesion
occurring at site of tic' ite " to $8 days after e)posure&
3iral+li'e symptoms, such as fever, chills, headache, s,ollen lymph nodes, and migratory
#oint and muscle pain, also occur&
.n late disease, arthritis pain and s,elling may occur in large #oints&
5ntiiotics are used for active disease and to prevent late disease&
?educing e)posure to tic's is the est ,ay to prevent 2yme disease&
4$5,
4out is caused y an increase in uric acid production, undere)cretion of uric acid, or
increased inta'e of foods containing purines, ,hich are metaolized to uric acid y the ody&
=eposits of sodium urate crystals occur in articular, periarticular, and sucutaneous
tissues& This leads to recurrent attac's of acute arthritis&
?is' factors are oesity (in men), hypertension, diuretic use, and e)cessive alcohol
consumption&
1+"9"
Key Points
5ffected #oints may appear dus'y or cyanotic and are e)tremely tender& .nflammation of
great toe (podagra) is a common initial prolem&
Chronic gout is characterized y multiple #oint involvement and visile deposits of
sodium urate crystals (tophi)&
Treatment includes drug therapy for pain management and to terminate an acute attac'&
@uture attac's are prevented y drugs, ,eight reduction as needed, and possile
avoidance of alcohol and food high in purine (red and organ meats)&
Nursing interventions include supportive care of inflamed #oints&
S6S,M'C L5P5S -6,)MA,$S5S
S.stemic lu"us er.thematosus (B2*) is a chronic multisystem inflammatory disease
,ith immune system anormalities&
The etiology of anormal immune response is un'no,n! a genetic influence is suspected&
*)tremely variale in its severity, ranging from a relatively mild disorder to rapidly
progressive and affecting many organ systems&
Commonly affected are the s'in (utterfly rash over nose, chee's), muscles
(polyarthralgia ,ith morning stiffness), lungs (tachypnea), heart (dysrhythmias), nervous
tissue (seizures), and 'idneys (nephritis)&
;ther signs include anemia, mild leu'openia, and thromocytopenia& .nfection is a ma#or
cause of death&
5 ma#or treatment challenge is to manage active disease ,hile preventing treatment
complications that cause long+term tissue damage&
Patients ,ith mild polyarthralgias or polyarthritis are treated ,ith NB5.=s&
Corticosteroids are given for severe cutaneous B2*& 5ntimalarial agents and
immunosuppressive drugs may also e used&
Nursing care emphasizes health teaching and importance of patient cooperation for
successful home management&
S6S,M'C SCL-$S'S
S.stemic sclerosis (BB), or scleroderma, is a connective tissue disorder ,ith firotic,
degenerative, and occasionally inflammatory changes in the s'in, lood vessels,
synovium, s'eletal muscle, and internal organs&
The cause of BB is un'no,n& .mmunologic dysfunction and vascular anormalities may
1+"9$
Key Points
play a role in systemic disease&
.n this disorder, collagen is overproduced& =isruption of cell is follo,ed y platelet
aggregation and firosis& Proliferation of collagen disrupts normal functioning of internal
organs&
:anifestations range from diffuse cutaneous thic'ening ,ith rapidly progressive and
fatal visceral involvement, to the more enign variant of limited cutaneous BB&
Clinical manifestations are descried y the acronym C?*BT, including calcinosis,
?aynaud(s phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia&
No specific drug(s) have een proven effective for treating BB& >o,ever many drugs can
e used in treating the various manifestations of BB&
Physical and occupational therapy maintains #oint moility, preserves muscle strength,
and assists in maintaining functional ailities&
P$L6M6$S','S AND D-MA,$M6$S','S
Pol.m.ositis (P:) and dermatom.ositis (=:) are diffuse, idiopathic, inflammatory
myopathies of striated muscle that produce ilateral ,ea'ness, usually most severe in
pro)imal or lim+girdle muscles&
The e)act cause of P: and =: is un'no,n! theories include infectious agent,
neoplasms, drugs or vaccinations, and stress&
Patients ,ith =: and P: e)perience ,eight loss and increasing fatigue, ,ith gradual
,ea'ness of muscles that leads to difficulty in performing routine activities&
=: s'in changes include classic violet+colored (heliotrope), cyanotic, or erythematous
symmetric rash ,ith edema around eyelids&
=: and P: diagnosis is confirmed y *:A findings, muscle iopsy, and serum enzyme
levels&
P: and =: are initially treated ,ith high+dose corticosteroids& .f corticosteroids are
ineffective and1or organ involvement is occurring, immunosuppressive drugs may e
given&
The nurse should assist the patient to organize activities and use pacing techni<ues to
conserve energy&
SBE4-N<S S6ND-$M
S*Fgren<s s.ndrome is an autoimmune disease that targets moisture+producing glands,
leading to )erostomia (dry mouth) and 'eratocon#unctivitis sicca (dry eyes)&
1+"9%
Key Points
.t appears to e caused y genetic and environmental factors&
2ymphocytes attac' and damage the lacrimal and salivary glands in this syndrome&
Treatment is symptomatic, including instillation of preservative+free artificial tears for
hydration and lurication, surgical punctual occlusion, and increased fluids ,ith meals&
M6$+ASC'AL PA'N S6ND-$M
M.ofascial "ain s.ndrome is characterized y musculos'eletal pain and tenderness in
one anatomic region of the ody&
?egions of pain are often ,ithin taut ands and fascia of s'eletal muscles& -ith pressure,
trigger points are thought to activate a pattern of pain&
Treatment can include massage, physical therapy, acupuncture, and iofeedac'&
+'/-$M6AL4'A S6ND-$M
+ibrom.algia s.ndrome (@:B) is a chronic disorder characterized y ,idespread,
nonarticular musculos'eletal pain and fatigue ,ith multiple tender points&
Nonrestorative sleep, morning stiffness, irritale o,el syndrome, and an)iety may also
e noted&
The cause and pathology of @:B are eing studied& .t is 'no,n to e a disorder of central
processing ,ith neuroendocrine1neurotransmitter dysregulation&
Treatment is symptomatic and re<uires a high level of patient motivation, including rest,
medication, rela)ation strategies, and massage&
C)-$N'C +A,'45 S6ND-$M
Chronic fatigue s.ndrome (C@B), also called chronic fatigue and immune dysfunction
syndrome, is a disorder characterized y deilitating fatigue&
The etiology and pathology are largely un'no,n&
.t is often difficult to distinguish et,een C@B and @:B, as many of the clinical features
are similar&
There is no definitive treatment& Bupportive management is essential&
This condition does not appear to progress& :ost patients recover or at least gradually
improve over time&
1+"9C
Key Points
th
edition
Key Points
Chapter DD: Nursing :anagement: Critical Care
Critical care units or intensive care units (.C4s) are designed to meet the special needs of
acutely and critically ill patients&
.C4 care has e)panded from delivering care in a standard unit to ringing .C4 care to
patients ,herever they might e&
o The electronic or virtual -C9 is designed to augment the edside .C4 team y
monitoring the patient from a remote location&
o The rapid response team, composed of a critical care nurse, a respiratory
therapist, and critical care physician or advanced practice nurse, goes outside the
.C4 to ring rapid and immediate care to unstale patients in nonNcritical care
units&
Progressive care units, also called high+dependency units, intermediate care units, or
stepdo,n units, serve as transition units et,een the .C4 and the general care unit or
discharge&
o The 5merican 5ssociation of Critical Care Nurses( (55CN) offers certification
for progressive care nurses (PCCN) ,or'ing ,ith acutely ill adult patient&
The critical care nurse is responsile for assessing life+threatening conditions, instituting
appropriate interventions, and evaluating the outcomes of the interventions&
o Critical care nursing re<uires in+depth 'no,ledge of anatomy, physiology,
pathophysiology, pharmacology, and advanced assessment s'ills, as ,ell as the
aility to use advanced iotechnology&
o The 55CN offers critical care certification (CC?N) in adult, pediatric, and
neonatal critical care nursing&
5dvanced practice critical care nurses have a graduate (master(s or doctorate) degree and
are employed in a variety of roles: patient and staff educators, consultants, administrators,
researchers, or e)pert practitioners&
o 5 clinical nurse specialist (CNB) typically functions in one or more of these roles&
Certification for the CNB in acute and critical care (CCNB) is availale through
the 55CN&
o 5n acute care nurse practitioner (5CNP) provides comprehensive care to select
critically ill patients and their families that includes conducting comprehensive
assessments, ordering and interpreting diagnostic tests, managing health prolems
and disease+related symptoms, and prescriing treatments& Certification as an
5CNP is availale through the 55CN&
1+"9D
Key Points
C$MM$N P-$/LMS $+ C-','CAL CA- PA,'N,S
Nutrition:
o The primary goal of nutritional support is to prevent or correct nutritional
deficiencies& This is usually accomplished y the early provision of enteral
nutrition (i&e&, delivery of calories via the gastrointestinal HA.I tract) or parenteral
nutrition (i&e&, delivery of calories intravenously)&
o Parenteral nutrition should e considered only ,hen the enteral route is
unsuccessful in providing ade<uate nutrition or contraindicated (e&g&, paralytic
ileus, diffuse peritonitis, intestinal ostruction, pancreatitis, A. ischemia,
intractale vomiting, and severe diarrhea)&
5n)iety:
o The primary sources of an)iety for patients include the perceived or anticipated
threat to physical health, actual loss of control or ody functions, and an
environment that is foreign&
o 5ssessing patients for an)iety is very important and clinical indicators can include
agitation, increased lood pressure, increased heart rate, patient veralization of
an)iety, and restlessness&
o To help reduce an)iety, the nurse should encourage patients and families to
e)press concerns, as' <uestions, and state their needs! and include the patient and
family in all conversations and e)plain the purpose of e<uipment and procedures&
o 5ntian)iety drugs and complementary therapies may reduce the stress response
and should e considered&
Pain:
o The control of pain in the .C4 patient is paramount as inade<uate pain control is
often lin'ed ,ith agitation and an)iety and can contriute to the stress response&
o .C4 patients at high ris' for pain include patients (1) ,ho have medical
conditions that include ischemic, infectious, or inflammatory processes! (") ,ho
are immoilized! ($) ,ho have invasive monitoring devices, including
endotracheal tues! (%) and ,ho are scheduled for any invasive or noninvasive
procedures&
o Continuous intravenous sedation and an analgesic agent are a practical and
effective strategy for sedation and pain control&
.mpaired communication:
o .naility to communicate can e distressing for the patient ,ho may e unale to
spea' ecause of sedative and paralyzing drugs or an endotracheal tue&
o The nurse should e)plore alternative methods of communication, including the
use of devices such as picture oards, notepads, magic slates, or computer
'eyoards& @or patients ,ho do not spea' *nglish, the use of an interpreter is
recommended&
o Nonveral communication is important& Comforting touch ,ith ongoing
evaluation of the patient(s response should e provided& @amilies should e
1+"99
Key Points
encouraged to touch and tal' ,ith the patient even if the patient is unresponsive or
comatose&
Bensory+perceptual prolems:
o =elirium in .C4 patients ranges from 1CK to %8K&
=emographic factors predisposing the patient to delirium include
advanced age, pree)isting cereral illnesses, use of medications that loc'
rapid eye movement sleep, and a history of drug or alcohol ause&
*nvironmental factors that can contriute to delirium include sleep
deprivation, an)iety, sensory overload, and immoilization&
Physical conditions such as hemodynamic instaility, hypo)emia,
hypercaria, electrolyte disturances, and severe infections can precipitate
delirium&
Certain drugs (e&g&, sedatives, furosemide, antimicroials) have een
associated ,ith the development of delirium&
The .C4 nurse must identify predisposing factors that may precipitate
delirium and improve the patient(s mental clarity and cooperation ,ith
appropriate therapy (e&g&, correction of o)ygenation, use of cloc's and
calendars)&
.f the patient demonstrates unsafe ehavior, hyperactivity, insomnia, or
delusions, symptoms may e managed ,ith neuroleptic drugs (e&g&,
haloperidol)&
The presence of family memers may help reorient the patient and reduce
agitation&
o Bensory overload can also result in patient distress and an)iety&
*nvironmental noise levels are particularly high in the .C4 and the nurse
should limit noise and assist the patient in understanding noises that
cannot e prevented&
Bleep prolems:
o Patients may have difficulty falling asleep or have disrupted sleep ecause of
noise, an)iety, pain, fre<uent monitoring, or treatment procedures&
o Bleep disturance is a significant stressor in the .C4, contriuting to delirium and
possily affecting recovery&
o The environment should e structured to promote the patient(s sleep+,a'e cycle
y clustering activities, scheduling rest periods, dimming lights at nighttime,
opening curtains during the daytime, otaining physiologic measurements ,ithout
disrupting the patient, limiting noise, and providing comfort measures&
o 6enzodiazepines and enzodiazepine+li'e drugs can e used to induce and
maintain sleep&
'SS5S -LA,D ,$ +AM'L'S
@amily memers play a valuale role in the patient(s recovery and should e considered
memers of the health care team& They contriute to the patient(s ,ell+eing y:
o Providing a lin' to the patient(s personal life
1+"9F
Key Points
o 5dvising the patient in health care decisions or functioning as the decision ma'er
,hen the patient cannot
o >elping ,ith activities of daily living
o Providing positive, loving, and caring support
To provide family+centered care effectively, the nurse must e s'illed in crisis
intervention&
o .nterventions can include active listening, reduction of an)iety, and support of
those ,ho ecome upset or angry&
o ;ther health team memers (e&g&, chaplains, psychologists, patient
representatives) may e helpful in assisting the family to ad#ust and should e
consulted as necessary&
The ma#or needs of families of critically ill patients have een categorized as
informational needs, reassurance needs, and convenience needs&
o 2ac' of information is a ma#or source of an)iety for the family& The family needs
reassurance regarding the ,ay in ,hich the patient(s care is managed and decisions
are made and the family should e invited to meet the health care team memers,
including physicians, dietitian, respiratory therapist, social ,or'er, physical therapist,
and chaplain&
o ?igid visitation policies in .C4s should e revie,ed, and a move to,ard less
restrictive, individualized visiting policies is strongly recommended y the 55CN&
o ?esearch has demonstrated that family memers of patients undergoing invasive
procedures, including cardiopulmonary resuscitation, should e given the option of
eing present at the edside during these events&
)M$D6NAM'C M$N',$-'N4
)emod.namic monitoring refers to the measurement of pressure, flo,, and o)ygenation
,ithin the cardiovascular system& 6oth invasive and noninvasive hemodynamic
measurements are made in the .C4&
3alues commonly measured include systemic and pulmonary arterial pressures, central
venous pressure (C3P), pulmonary artery ,edge pressure (P5-P), cardiac output1inde),
stro'e volume1inde), and o)ygen saturation of the hemogloin of arterial lood (Ba;
"
)
and mi)ed venous lood (Bv;
"
)&
Cardiac output (C;) is the volume of lood pumped y the heart in 1 minute& Cardiac
inde" (C.) is the measurement of the C; ad#usted for ody size&
The volume e#ected ,ith each hearteat is the stro7e volume (B3)& Stro7e volume inde"
(B3.) is the measurement of B3 ad#usted for ody size&
The opposition to lood flo, offered y the vessels is called systemic vascular resistance
(B3?) or pulmonary vascular resistance (P3?)&
1+"9E
Key Points
Preload, afterload, and contractility determine B3 (and thus C; and lood pressure)&
Preload is the volume ,ithin the ventricle at the end of diastole&
P5-P, a measurement of pulmonary capillary pressure, reflects left ventricular end+
diastolic pressure under normal conditions&
C3P, measured in the right atrium or in the vena cava close to the heart, is the right
ventricular preload or right ventricular end+diastolic pressure under normal conditions&
,fterload refers to the forces opposing ventricular e#ection and includes systemic arterial
pressure, the resistance offered y the aortic valve, and the mass and density of the lood
to e moved&
Systemic vascular resistance (B3?) is the resistance of the systemic vascular ed&
Pulmonary vascular resistance (P3?) is the resistance of the pulmonary vascular ed&
6oth of these measures can e ad#usted for ody size&
Contractility descries the strength of contraction& 5gents that increase or improve
contractility are termed positive inotropes# Contractility is diminished y negative
inotropes, such as certain drugs (e&g&, calcium channel loc'ers, V+adrenergic loc'ers)
and conditions (e&g&, acidosis)&
Princi"les of 'n!asi!e Pressure Monitoring
To accurately measure pressure, e<uipment must e referenced and zero alanced to the
environment and dynamic response characteristics optimized&
?eferencing means positioning the transducer so that the zero reference point is at the
level of the atria of the heart or the "hlebostatic a1is(
:eroing confirms that ,hen pressure ,ithin the system is zero, the monitor reads zero&
Jeroing is recommended during initial setup, immediately after insertion of the arterial
line, ,hen the transducer has een disconnected from the pressure cale or the pressure
cale has een disconnected from the monitor, and ,hen the accuracy of the
measurements is <uestioned&
;ptimizing dynamic response characteristics involves chec'ing that the e<uipment
reproduces, ,ithout distortion, a signal that changes rapidly& 5 dynamic response test
%s/uare wave test& is performed every F to 1" hours and ,hen the system is opened to air
or the accuracy of the measurements is <uestioned&
,."es of 'n!asi!e Pressure Monitoring
Continuous arterial pressure monitoring is indicated for patients e)periencing acute
hypertension and hypotension, respiratory failure, shoc', neurologic in#ury, coronary
interventional procedures, continuous infusion of vasoactive drugs, and fre<uent 56A
1+"F8
Key Points
sampling&
o >igh+ and lo,+pressure alarms should e set ased on the patient(s current status&
:easurements are otained at end e)piration to limit the effect of the respiratory
cycle on arterial pressure&
o 5rterial lines carry the ris' of hemorrhage, infection, thromus formation,
neurovascular impairment, and loss of lim&
o To help maintain line patency and limit thromus formation, a continuous flush
irrigation system is used to deliver $ to D ml of heparinized saline per hour&
Neurovascular status distal to the arterial insertion site is assessed hourly&
Neurovascular impairment can result in loss of a lim and is an
emergency&
Pulmonary artery (P5) pressure monitoring is used to guide acute+phase management of
patients ,ith complicated cardiac, pulmonary, and intravascular volume prolems&
o P5 diastolic (P5=) pressure and P5-P are sensitive indicators of cardiac function
and fluid volume status and are routinely monitored&
o :onitoring P5 pressures can allo, precise therapeutic manipulation of preload,
,hich allo,s C; to e maintained ,ithout placing the patient at ris' for
pulmonary edema&
o 5 P5 flo,+directed catheter (e&g&, B,an+Aanz) is used to measure P5 pressures,
including P5-P& -hen properly positioned, the distal lumen port (catheter tip) is
,ithin the P5 and is used to monitor P5 pressures and sample mi)ed venous
lood specimens (e&g&, to evaluate o)ygen saturation)&
o 5dditional lumens have e)it ports in the right atrium or right atrium and right
ventricle (if t,o)&
The right atrium port is used for measurement of C3P, in#ection of fluid
for C; determination, and ,ithdra,al of lood specimens&
.f a second pro)imal port is availale, it is used for infusion of fluids and
drugs or lood sampling&
o 5 thermistor (temperature sensor) lumen port located near the distal tip is used for
monitoring lood or core temperature and is used in the thermodilution method of
measuring C;&
o P5 measurements are otained at the end of e)piration&
o P5-P measurement is otained y slo,ly inflating the alloon ,ith air (not to
e)ceed alloon capacity) until the P5 ,aveform changes to a P5-P ,aveform&
The alloon should e inflated for no more than four respiratory cycles or
F to 1C seconds&
C3P is a measurement of right ventricular preload& .t can e measured ,ith a P5 catheter
using one of the pro)imal lumens or ,ith a central venous catheter placed in the internal
#ugular or suclavian vein&
The P5 catheter is commonly used to measure C; via the intermittent olus
thermodilution C; method or the continuous C; method&
1+"F1
Key Points
B3?, B3? inde), B3, and B3 inde) can e calculated each time that C; is measured&
o .ncreased B3? indicates vasoconstriction from shoc', hypertension, increased
release or administration of epinephrine and other vasoactive inotropes, or left
ventricular failure&
o =ecreased B3? indicates vasodilation, ,hich may occur during shoc' states (e&g&,
septic, neurogenic) or ,ith drugs that reduce afterload&
o Changes in B3 are ecoming more important indicators of the pumping status of
the heart than other parameters&
Nonin!asi!e )emod.namic Monitoring
'm"edance cardiogra"h. (.CA) is a continuous or intermittent, noninvasive method of
otaining C; and assessing thoracic fluid status&
.mpedance+ased hemodynamic parameters (C;, B3, and B3?) can e calculated from
Jo, dJ1dt, :5P, C3P, and the *CA&
:a#or indications for .CA include early signs and symptoms of pulmonary or cardiac
dysfunction, differentiation of cardiac or pulmonary cause of shortness of reath,
evaluation of etiology and management of hypotension, monitoring after discontinuing a
P5 catheter or #ustification for insertion of a P5 catheter, evaluation of pharmacotherapy,
and diagnosis of re#ection follo,ing cardiac transplantation&
2enous $1.gen Saturation
6oth C3P and P5 catheters can include sensors to measure o)ygen saturation of
hemogloin in venous lood termed mi"ed venous o"ygen saturation (Bcv;
"
, Bv;
"
)&
Bv;
"
1Bcv;
"
reflects the dynamic alance et,een o)ygenation of the arterial lood,
tissue perfusion, and tissue o)ygen consumption (3;
"
)&
o Normal Bv;
"
1Bcv;
"
at rest is D8K to F8K&
o Bustained decreases in Bv;
"
1Bcv;
"
may indicate decreased arterial o)ygenation,
lo, C;, lo, hemogloin level, or increased o)ygen consumption or e)traction& .f
the Bv;
"
1Bcv;
"
falls elo, D8K, the nurse determines ,hich of these factors has
changed&
o Bustained increases in Bv;
"
1Bcv;
"
may indicate a clinical improvement (e&g&,
increased arterial o)ygen saturation, decreased metaolic rate) or prolems (e&g&,
sepsis)&
Com"lications with PA Catheters
.nfection and sepsis are serious prolems associated ,ith P5 catheters&
o Careful surgical asepsis for insertion and maintenance of the catheter and attached
tuing is mandatory&
o @lush ag, pressure tuing, transducer, and stopcoc' should e changed every ED
hours&
5ir emolus is another ris' associated ,ith P5 catheters&
1+"F"
Key Points
Pulmonary infarction or P5 rupture from: (1) alloon rupture, releasing air and fragments
that could emolize! (") prolonged alloon inflation ostructing lood flo,! ($) catheter
advancing into a ,edge position, ostructing lood flo,! and (%) thromus formation and
emolization&
o 6alloon must never e inflated eyond the alloon(s capacity (usually 1 to 1&C ml
of air)& 5nd must not e left inflated for more than four reaths (e)cept during
insertion) or F to 1C seconds&
o P5 pressure ,aveforms are monitored continuously for evidence of catheter
occlusion, dislocation, or spontaneous ,edging&
o P5 catheter is continuously flushed ,ith a slo, infusion of heparinized (unless
contraindicated) saline solution&
3entricular dysrhythmias can occur during P5 catheter insertion or removal or if the tip
migrates ac' from the P5 to the right ventricle and irritates the ventricular ,all&
The nurse may oserve that the P5 catheter cannot e ,edged and may need to e
repositioned y the physician or a <ualified nurse&
Nonin!asi!e Arterial $1.genation Monitoring
Pulse o"imetry is a noninvasive and continuous method of determining arterial
o)ygenation (Bp;
"
), and monitoring Bp;
"
may reduce the fre<uency of 56A sampling&
Bp;
"
is normally ECK to 188K&
5ccurate Bp;
"
measurements may e difficult to otain on patients ,ho are hypothermic,
receiving intravenous vasopressor therapy, or e)periencing hypoperfusion&
5lternate locations for placement of the pulse o)imetry proe may need to e considered
(e&g&, forehead, earloe)&
Nursing Management: )emod.namic Monitoring
6aseline data regarding the patient(s general appearance, level of consciousness, s'in
color and temperature, vital signs, peripheral pulses, and urine output are otained&
6aseline data are correlated ,ith data otained from iotechnology (e&g&, *CA! arterial,
C3P, P5, P5-P pressures! Bv;
"
1Bcv;
"
)&
Bingle hemodynamic values are rarely significant! the nurse monitors trends in these
values and evaluates the ,hole clinical picture ,ith the goals of recognizing early clues
and intervening efore prolems escalate&
C'-C5LA,$-6 ASS'S, D2'CS
Circulator. assist de!ices (C5=s) decrease cardiac ,or' and improve organ perfusion
,hen conventional drug therapy is no longer ade<uate&
1+"F$
Key Points
C5=s provide interim support in three types of situations: (1) the left, right, or oth
ventricles re<uire support ,hile recovering from acute in#ury! (") the heart re<uires
surgical repair (e&g&, a ruptured septum), ut the patient must e stailized! and ($) the
heart has failed, and the patient is a,aiting cardiac transplantation&
'ntraaortic /alloon Pum"
The intraaortic balloon "um" (.56P) provides temporary circulatory assistance to the
compromised heart y reducing afterload (via reduction in systolic pressure) and
augmenting the aortic diastolic pressure resulting in improved coronary lood flo, and
perfusion of vital organs&
The .56P consists of a sausage+shaped alloon, a pump that inflates and deflates the
alloon, control panel for synchronizing the alloon inflation to the cardiac cycle, and
fail+safe features&
.56P therapy is referred to as counterpulsation ecause the timing of alloon inflation is
opposite to ventricular contraction&
The .5P6 assist ratio is 1:1 in the acute phase of treatment, that is, one .56P cycle of
inflation and deflation for every hearteat&
Complications of .56P therapy may include vascular in#uries such as dislodging of
pla<ue, aortic dissection, and compromised distal circulation&
o Thromus and emolus formation add to the ris' of circulatory compromise to the
e)tremity&
o :echanical complications are rare and include improper timing of alloon
inflation causing increased afterload, decreased C;, myocardial ischemia, and
increased myocardial o)ygen demand&
o To reduce ris's of .56P therapy, cardiovascular, neurovascular, and
hemodynamic assessments are necessary every 1C to D8 minutes depending on the
patient(s status&
The patient is relatively immoile, limited to side+lying or supine positions ,ith the head
of the ed elevated less than %C degrees& The leg in ,hich the catheter is inserted must
not e fle)ed at the hip to avoid 'in'ing or dislodgement of the catheter&
2entricular Assist De!ices
2entricular assist de!ices (35=s) provide longer+term support for the failing heart
(usually months) and allo, more moility than the .56P&
35=s are inserted into the path of flo,ing lood to augment or replace the action of the
ventricle& Bome 35=s are implanted (e&g&, peritoneum), and others are positioned
e)ternally&
1+"F%
Key Points
Bome 35=s provide iventricular support&
.ndications for 35= therapy include (1) e)tension of CP6 for failure to ,ean or
postcardiotomy cardiogenic shoc', (") ridge to recovery or cardiac transplantation, and
($) patients ,ith Ne, Wor' >eart 5ssociation Classification .3 ,ho have failed medical
therapy&
Nursing Management: Circulator. Assist De!ices
Nursing care of the patient ,ith a 35= is similar to that of the patient ,ith an .56P&
o Patients are oserved for leeding, cardiac tamponade, ventricular failure,
infection, dysrhythmias, renal failure, hemolysis, and thromoemolism&
o 5 patient ,ith 35= may e moile and re<uire an activity plan&
.deally, patients ,ith C5=s ,ill recover through ventricular improvement, heart
transplantation, or artificial heart implantation&
>o,ever, many patients die, or the decision to terminate the device is made and death
follo,s& 6oth the patient and family re<uire psychologic support&
A-,'+'C'AL A'-7A6S
ndotracheal intubation (*T intuation) involves the placement of a tue into the
trachea via the mouth or nose past the laryn)#
.ndications for *T intuation include (1) upper air,ay ostruction (e&g&, secondary to
urns, tumor, leeding), (") apnea, ($) high ris' of aspiration, (%) ineffective clearance of
secretions, and (C) respiratory distress&
5 tracheotomy is a surgical procedure that is performed ,hen the need for an artificial
air,ay is e)pected to e long term&
.ral +* intubation is the procedure of choice for most emergencies ecause the air,ay
can e secured rapidly, a larger diameter tue can e used thus reducing the ,or' of
reathing (-;6) and ma'ing it easier to remove secretions and perform fieroptic
ronchoscopy&
5asal +* intubation is indicated ,hen head and nec' manipulation is ris'y&
ndotracheal 'ntubation Procedure
5ll patients undergoing intuation need to have a self+inflating bag-!al!e-mas0 (63:)
availale and attached to o)ygen, suctioning e<uipment ready and intravenous access&
Premedication varies, depending on the patient(s level of consciousness (e&g&, a,a'e,
otunded) and the nature of the procedure (e&g&, emergent, nonemergent)&
?apid se<uence intuation (?B.) is the rapid, concurrent administration of a comination
1+"FC
Key Points
of oth a paralytic agent and a sedative agent during emergency air,ay management to
decrease the ris's of aspiration, comativeness, and in#ury to the patient& ?B. is not
indicated in patients ,ho are comatose or during cardiac arrest&
6efore intuation is attempted, the patient is preo)ygenated using a self+inflating 63:
,ith 188K ;
"
for $ to C minutes&
o *ach intuation attempt is limited to less than $8 seconds& .f unsuccessful, the
patient is ventilated et,een successive attempts using the 63: ,ith 188K ;
"
&
@ollo,ing intuation, the cuff is inflated, and the placement of the *T tue is confirmed
,hile manually ventilating the patient ,ith 188K ;
"
&
o 5n end+tidal C;
"
detector is to confirm proper placement y measuring the
amount of e)haled C;
"
from the lungs&
The detector is placed et,een the 63: and the *T tue and either
oserved for a color change (indicating the presence of C;
"
) or a numer&
.f no C;
"
is detected, than the tue is in the esophagus&
o The lung ases and apices are auscultated for ilateral reath sounds, and the
chest is oserved for symmetric chest ,all movement&
o 5 portale chest )+ray is immediately otained to confirm tue location ($ to C cm
aove the carina in the adult)&
The *T tue is connected either to humidified air, ;
"
, or a mechanical ventilator&
56As should e otained ,ithin "C minutes after intuation to determine o)ygenation
and ventilation status&
Continuous pulse o)imetry monitoring provides an estimate of arterial o)ygenation&
Nursing Management: Artificial Airwa.
Maintaining Correct ,ube Placement
o The nurse must monitor the patient ,ith an *T tue for proper placement at least
every " to % hours&
o Proper tue position is maintained y confirming that the e)it mar' on the tue
remains constant ,hile at rest, during patient care, repositioning, and patient
transport&
o The nurse oserves for symmetric chest ,all movement and auscultates to confirm
ilateral reath sounds&
o .t is an emergency if the *T tue is not positioned properly&
The nurse stays ,ith the patient, maintains the air,ay, supports ventilation,
and secures the appropriate assistance to immediately reposition the tue&
.t may e necessary to ventilate the patient ,ith a 63:&
Maintaining Pro"er Cuff 'nflation
o The cuff is an inflatale, pliale sleeve encircling the outer ,all of the *T tue that
stailizes and seals the *T tue ,ithin the trachea and prevents escape of ventilating
1+"FD
Key Points
gases&
o The cuff can cause tracheal damage&
To avoid damage, the cuff is inflated ,ith air, and the pressure in the cuff is
measured and monitored&
Normal arterial tracheal perfusion is estimated at $8 mm >g and cuff pressure
should e maintained at "8 to "C mm >g&
=epending on the institution(s policy, cuff pressure is measured and recorded
after intuation and on a routine asis (e&g&, every F hours) using the minimal
occluding volume (:;3) techni<ue or the minimal lea7 techni/ue (:2T)&
The steps of the :;3 techni<ue are as follo,s: (1) for the
mechanically ventilated patient, place a stethoscope over the trachea
and inflate the cuff to :;3 y adding air until no air lea' is heard at
pea' inspiratory pressure (end of ventilator inspiration)! (") for the
spontaneously reathing patient, inflate until no sound is heard after a
deep reath or after inhalation ,ith a 63:! ($) use a manometer to
verify that cuff pressure is et,een "8 and "C mm >g! and (%) record
cuff pressure in the chart&
The procedure for :2T is similar ,ith one e)ception& 5 small amount
of air is removed from the cuff until a slight lea' is auscultated at pea'
inflation&
6oth techni<ues are intended to prevent the ris's of tracheal trauma
due to high cuff pressures&
.f ade<uate cuff pressure cannot e maintained or larger volumes of air
are needed to 'eep the cuff inflated, the cuff could e lea'ing or there
could e tracheal dilation at the cuff site and the *T tue should e
repositioned or changed and the physician should e notified&
Monitoring $1.genation and 2entilation
o ."ygenation 5ssessment of 56As, Bp;
"
, Bv;
"
1Bcv;
"
, and clinical signs of
hypo)emia such as a change in mental status (e&g&, confusion), an)iety, dus'y s'in,
and dysrhythmias&
o ;entilation 5ssessment of PaC;
"
, continuous partial pressure of end+tidal C;
"
(P*TC;
"
), and clinical signs of respiratory distress such as use of accessory muscles,
hyperventilation ,ith circumoral and peripheral numness and tingling, and
hypoventilation ,ith dus'y s'in&
Continuous P+*C.
'
monitoring can e used to assess the patency of the
air,ay and the presence of reathing&
Aradual changes in P*TC;
"
values may accompany an increase in C;
"
production (e&g&, sepsis) or decrease in C;
"
production (e&g&, hypothermia)&
Maintaining ,ube Patenc.
o The patient should e assessed routinely to determine a need for suctioning, ut the
patient should not e suctioned routinely&
.ndications for suctioning include (1) visile secretions in the *T tue, (")
sudden onset of respiratory distress, ($) suspected aspiration of secretions, (%)
1+"F9
Key Points
increase in pea' air,ay pressures, (C) auscultation of adventitious reath
sounds over the trachea and1or ronchi, (D) increase in respiratory rate and1or
sustained coughing, and (9) sudden or gradual decrease in Pa;
"
and1or Bp;
"
&
o The closed-suction techni3ue (CBT) uses a suction catheter that is enclosed in a
plastic sleeve connected directly to the patient+ventilator circuit&
-ith the CBT, o)ygenation and ventilation are maintained during suctioning
and e)posure to secretions is reduced&
CBT should e considered for patients ,ho re<uire high levels of positive end+
e)piratory pressure (P**P), ,ho have loody or infected pulmonary
secretions, ,ho re<uire fre<uent suctioning, and ,ho e)perience clinical
instaility ,ith the o"en-suction techni3ue (;BT)&
o Potential complications associated ,ith suctioning include hypo)emia,
ronchospasm, increased intracranial pressure, dysrhythmias, hyper1hypotension,
mucosal damage, pulmonary leeding, and infection&
5ssess patient efore, during, and after the suctioning procedure&
.f the patient does not tolerate suctioning (e&g&, decreased Bp;
"
, development
of dysrhythmias), stop procedure and manually hyperventilate patient ,ith
188K o)ygen or if performing CBT, hypero)ygenate until e<uiliration
occurs&
>ypo)emia is prevented y hypero)ygenating the patient efore and after
each suctioning pass and limiting each suctioning pass to 18 seconds or less&
.f Bv;
"
1Bcv;
"
and1or Bp;
"
are used, trends should e assessed throughout the
suctioning procedure&
Tracheal mucosal damage may occur ecause of e)cessive suction pressures
(U1"8 mm >g), overly vigorous catheter insertion, and the characteristics of
the suction catheter itself&
Becretions may e thic' and difficult to suction ecause of inade<uate
hydration, inade<uate humidification, infection, or inaccessiility of the left
mainstem ronchus or lo,er air,ays&
5de<uately hydrating the patient (e&g&, oral or intravenous fluids) and
providing supplemental humidification of inspired gases may assist in
thinning secretions&
.nstillation of normal saline into the *T tue is discouraged& .f
infection is the cause of thic' secretions, administer antiiotics&
Postural drainage, percussion, and turning the patient every " hours
may help move secretions into larger air,ays&
Pro!iding $ral Care and Maintaining S0in 'ntegrit.
o ;ral care should include teeth rushing t,ice a day along ,ith use of moistened
mouth s,as and oral1pharyngeal suctioning every " to % hours and as needed to
provide comfort and to prevent in#ury to the gums and pla<ue accumulation&
o The *T tue should e repositioned and retaped every "% hours and as needed&
o .f the patient is an)ious or uncooperative, t,o caregivers should perform the
repositioning procedure to prevent accidental dislodgment&
o :onitor patient for signs of respiratory distress throughout the procedure&
1+"FF
Key Points
+ostering Comfort and Communication
o .ntuated patients often e)perience an)iety ecause of the inaility to communicate
and not 'no,ing ,hat to e)pect&
o The physical discomfort associated ,ith *T intuation and mechanical ventilation
often necessitates sedating the patient and administering an analgesic to achieve an
acceptale level of patient comfort&
o .nitiating alternative therapies (e&g&, music therapy, guided imagery) to complement
drug therapy is recommended&
Com"lications of ndotracheal 'ntubation
o 4nplanned e1tubation (i&e&, removal of the *T tue from the trachea) can e a
catastrophic event and is usually due to patient removal of the *T tue or accidental
(i&e&, result of movement or procedural+related) removal&
Bigns of unplanned e)tuation may include patient vocalization, activation of
the lo,+pressure ventilator alarm, diminished or asent reath sounds,
respiratory distress, and gastric distention&
The nurse is responsile for preventing unplanned e)tuation y ensuring
ade<uate securement of the *T tue! support of the *T tue during
repositioning, procedures, patient transfer! immoilizing the patient(s hands
through the use of soft ,rist restraints! and providing sedation and analgesia
as ordered&
Bhould an unplanned e)tuation occur, the nurse stays ,ith the patient, calls
for help, manually ventilates the patient ,ith 188K o)ygen, and provides
psychologic support to the patient&
o 5spiration is a potential hazard for the patient ,ith an *T tue as the tue passes
through the epiglottis, splinting it in an open position& Bome *T tues provide
continuous suctioning of secretions aove the cuff&
;ral intuation increases salivation, yet s,allo,ing is difficult, so the mouth
must e suctioned fre<uently&
5dditional ris' factors for aspiration include improper cuff inflation, patient
positioning, and tracheoesophageal fistula&
@re<uently, an orogastric (;A) or nasogastric (NA) tue is inserted and
connected to lo,, intermittent suction ,hen a patient is intuated&
5ll intuated patients and patients receiving enteral feedings should have the
head of the ed (>;6) elevated a minimum of '( to )* degrees unless
medically contraindicated.
MC)AN'CAL 2N,'LA,'$N
Mechanical !entilation is the process y ,hich the fraction of inspired o)ygen (@.;
"
) at
"1K (room air) or greater is moved into and out of the lungs y a mechanical ventilator&
.ndications for mechanical ventilation include (1) apnea or impending inaility to
reathe, (") acute respiratory failure generally defined as p> 9&"C ,ith a PaC;
"
_C8 mm
>g, ($) severe hypo)ia, and (%) respiratory muscle fatigue&
1+"FE
Key Points
,."es of Mechanical 2entilation
Negati!e "ressure !entilation involves the use of chamers that encase the chest or
ody and surround it ,ith intermittent suatmospheric or negative pressure&
o Negative pressure ventilation is delivered as noninvasive ventilation and an
artificial air,ay is not re<uired&
o Negative pressure ventilators are not used e)tensively for acutely ill patients&
>o,ever, some research has demonstrated positive outcomes ,ith the use of
negative pressure ventilation in acute e)acerations of chronic respiratory failure&
Positi!e "ressure !entilation (PP3), used primarily ,ith acutely ill patients, pushes air
into the lungs under positive pressure during inspiration& *)piration occurs passively as
in normal e)piration& :odes of PP3 are categorized into t,o groups:
o 2olume !entilation involves a predetermined tidal volume (3
T
) that is delivered
,ith each inspiration, ,hile the amount of pressure needed to deliver the reath
varies ased on the compliance and resistance factors of the patient+ventilator
system&
o Pressure !entilation involves a predetermined pea' inspiratory pressure ,hile
the 3
T
delivered to the patient varies ased on the selected pressure and the
compliance and resistance factors of the patient+ventilator system&
Careful attention must e given to the 3
T
to prevent unplanned
hyperventilation or hypoventilation&
Settings of Mechanical 2entilators
:echanical ventilator settings regulate the rate, depth, and other characteristics of
ventilation and are ased on the patient(s status (e&g&, 56As, ody ,eight, level of
consciousness, muscle strength)& The ventilator is tuned as finely as possile to match the
patient(s ventilatory pattern&
:odes of volume ventilation:
o 3entilator mode is ased on ho, much -;6 the patient ought to or can perform and
is determined y the patient(s ventilatory status, respiratory drive, and 56As&
o 3entilator modes are controlled or assisted&
-ith controlled ventilatory support, the ventilator does all of the -;6&
-ith assisted ventilatory support, the ventilator and the patient share the
-;6&
o Controlled mandator. !entilation (C:3) delivers reaths that are delivered at a set
rate per minute and a set 3
T
, ,hich are independent of the patient(s ventilatory
efforts&
Patients perform no -;6 and cannot ad#ust respirations to meet changing
demands&
o Assist-control !entilation (5C3) delivers a preset 3
T
at a preset fre<uency, and
,hen the patient initiates a spontaneous reath, the preset 3
T
is delivered&
The patient can reathe faster than the preset rate ut not slo,er&
This mode allo,s the patient some control over ventilation ,hile providing
1+"E8
Key Points
some assistance and is used in patients ,ith a variety of conditions (e&g&,
Auillain+6arrR syndrome, pulmonary edema, acute respiratory failure)&
Patients re<uire vigilant assessment and monitoring of ventilatory status,
including respiratory rate, 56As, Bp;
"
, and Bv;
"
1Bcv;
"
&
.f it is too difficult for the patient to initiate a reath, the -;6 is
increased and the patient may tire and or develop ventilator
asynchrony (i&e&, the patient /fights0 the ventilator)&
o S.nchroni#ed intermittent mandator. !entilation (B.:3) delivers a preset 3
T
at a
preset fre<uency in synchrony ,ith the patient(s spontaneous reathing&
6et,een ventilator+delivered reaths, the patient is ale to reathe
spontaneously&
The patient receives the preset @.;
"
concentration during the spontaneous
reaths ut self+regulates the rate and volume of those reaths&
Potential enefits of B.:3 include improved patient+ventilator synchrony,
lo,er mean air,ay pressure, and prevention of muscle atrophy as the patient
ta'es on more of the -;6&
:odes of pressure ventilation:
o -ith "ressure su""ort !entilation (PB3), positive pressure is applied to the air,ay
only during inspiration and is used in con#unction ,ith the patient(s spontaneous
respirations&
The patient must e ale to initiate a reath in this modality&
5 preset level of positive air,ay pressure is selected so that the gas flo, rate
is greater than the patient(s inspiratory flo, rate&
5dvantages to PB3 include increased patient comfort, decreased -;6,
decreased o)ygen consumption, and increased endurance conditioning&
o Pressure$controlled< inverse ratio ventilation (PC+.?3) comines pressure+limited
ventilation ,ith an inverse ratio of inspiration (.) to e)piration (*)& Normal .1* is 1:"&
-ith .?3, the .1* ratio egins at 1:1 and may progress to %:1&
.?3 progressively e)pands collapsed alveoli and the short e)piratory time has
a P**P+li'e effect, preventing alveolar collapse&
.?3 re<uires sedation ,ith or ,ithout paralysis&
PC+.?3 is indicated for patients ,ith acute respiratory distress syndrome ,ho
continue to have refractory hypo)emia despite high levels of P**P&
;ther ventilatory maneuvers
o Positi!e end-e1"irator. "ressure (P**P) is a ventilatory maneuver in ,hich
positive pressure is applied to the air,ay during e)halation& -ith P**P, e)halation
remains passive, ut pressure falls to a preset level greater than zero, often $ to "8 cm
>
"
;&
P**P increases functional residual capacity (@?C) y increasing aeration of
patent alveoli, aerating previously collapsed alveoli, and preventing alveolar
collapse throughout the respiratory cycle&
P**P is titrated to the point that o)ygenation improves ,ithout compromising
hemodynamics and is termed est or optimal P**P&
1+"E1
Key Points
C cm >
"
; P**P (referred to as physiologic P**P) is used prophylactically to
replace the glottic mechanism, help maintain a normal @?C, and prevent
alveolar collapse&
5uto+P**P is a result of inade<uate e)halation time& 5uto+P**P is additional
P**P over ,hat is set y the clinician and can e measured at end+e)piratory
hold utton located on most ventilators&
5uto+P**P may result in increased -;6, arotrauma, and
hemodynamic instaility&
.nterventions to limit auto+P**P include sedation and analgesia, large
diameter *TT, ronchodilators, short inspiratory times, decreased
respiratory rates, and reducing ,ater accumulation in the ventilator
circuit y fre<uent emptying or use of heated circuits&
The ma#or purpose of P**P is to maintain or improve o)ygenation ,hile
limiting ris' of o)ygen to)icity&
P**P is generally contraindicated or used ,ith e)treme caution in patients
,ith highly compliant lungs (e&g&, C;P=), unilateral or nonuniform disease,
hypovolemia, and lo, C;& .n these situations the adverse effects of P**P
may out,eigh any enefits&
o Continuous "ositi!e airwa. "ressure (CP5P) restores @?C and is similar to P**P&
The pressure in CP5P is delivered continuously during spontaneous reathing,
thus preventing the patient(s air,ay pressure from falling to zero&
CP5P is commonly used in the treatment of ostructive sleep apnea and can
e administered noninvasively y a tight+fitting mas' or an *T or tracheal
tue&
CP5P increases -;6 ecause the patient must forcily e)hale against the
CP5P and so must e used ,ith caution in patients ,ith myocardial
compromise&
o 8ilevel positive airway pressure (6iP5P) provides t,o levels of positive pressure
support, and higher inspiratory positive air,ay pressure (.P5P) and a lo,er
e)piratory positive air,ay pressure (*P5P) along ,ith o)ygen&
.t is a noninvasive modality and is delivered through a tight fitting face mas',
nasal mas', or nasal pillo,s&
Patients must e ale to spontaneously reathe and cooperate ,ith the
treatment&
.ndications include acute respiratory failure in patients ,ith C;P= and heart
failure, and sleep apnea&
o )igh-fre3uenc. !entilation (>@3) involves delivery of a small tidal volume
(usually 1 to C ml per 'g of ody ,eight) at rapid respiratory rates (188 to $88 reaths
per minute) in an effort to recruit and maintain lung volume and reduce
intrapulmonary shunting&
>igh+fre<uency #et ventilation (>@\3) delivers humidified gas from a high
pressure source through a small+ore cannula positioned in the air,ay&
>igh+fre<uency percussive ventilation (>@P3) attempts to comine the
positive effects of oth >@3 and conventional mechanical ventilation&
>igh+fre<uency oscillatory ventilation (>@;3) uses a diaphragm or a piston
1+"E"
Key Points
in the ventilator to generate virations (or oscillations) of suphysiologic
volumes of gas&
Patients receiving >@3 must e paralyzed to suppress spontaneous
respiration& .n addition, patients must receive concurrent sedation and
analgesia as necessary ad#uncts ,hen inducing paralysis&
o The use of perfluron (2i<ui3ent) in "artial li3uid !entilation (P23) for patients
,ith 5?=B is eing investigated&
Perfluron, an inert, iocompatile, clear, odorless li<uid that has an affinity
for oth o)ygen and caron dio)ide and surfactant+li'e <ualities, is tric'led
do,n a specially designed *T tue through a side port into the lungs of a
mechanically ventilated patient&
The amount used is usually e<uivalent to a patient(s @?C&
Perfluron evaporates <uic'ly and must e replaced to maintain a constant
level during the therapy&
o Prone positioning is the repositioning of a patient from a supine or lateral position to
a prone (on the stomach ,ith face do,n) position&
*ffects include improved lung recruitment&
Proning is used as supportive therapy in critically ill patients ,ith acute lung
in#ury or 5?=B to improve o)ygenation&
o +"tracorporeal membrane o"ygenation (*C:;) is an alternative form of pulmonary
support for the patient ,ith severe respiratory failure&
*C:; is a modification of cardiac ypass and involves partially removing
lood from a patient through the use of large ore catheters, infusing o)ygen,
removing C;
"
, and returning the lood ac' to the patient&
Com"lications of Positi!e Pressure 2entilation
"ario'ascular $ystem
PP3 can affect circulation ecause of the transmission of increased mean air,ay pressure
to the thoracic cavity&
-ith increased intrathoracic pressure, thoracic vessels are compressed resulting in
decreased venous return to the heart, decreased left ventricular end+diastolic volume
(preload), decreased C;, and hypotension& :ean air,ay pressure is further increased if
titrating P**P (UC cm >
"
;) to improve o)ygenation&
Pulmonary $ystem
5s lung inflation pressures increase, ris' of barotrauma increases&
o Patients ,ith compliant lungs (e&g&, C;P=) are at greater ris' for arotraumas&
o 5ir can escape into the pleural space from alveoli or interstitium, accumulate, and
ecome trapped causing a pneumothora)&
o @or some patients, chest tues may e placed prophylactically&
Pneumomediastinum usually egins ,ith rupture of alveoli into the lung interstitium!
progressive air movement then occurs into the mediastinum and sucutaneous nec'
tissue& This is commonly follo,ed y pneumothora)&
1+"E$
Key Points
;olutrauma in PP3 relates to the lung in#ury that occurs ,hen large tidal volumes are
used to ventilate noncompliant lungs (e&g&, 5?=B)&
o 3olutrauma results in alveolar fractures and movement of fluids and proteins into
the alveolar spaces&
>ypoventilation can e caused y inappropriate ventilator settings, lea'age of air from
the ventilator tuing or around the *T tue or tracheostomy cuff, lung secretions or
ostruction, and lo, ventilation1perfusion ratio&
o .nterventions include turning the patient every 1 to " hours, providing chest
physical therapy to lung areas ,ith increased secretions, encouraging deep
reathing and coughing, and suctioning as needed&
?espiratory al'alosis can occur if the respiratory rate or 3
T
is set too high (mechanical
overventilation) or if the patient receiving assisted ventilation is hyperventilating#
o .f hyperventilation is spontaneous, it is important to determine the cause (e&g&,
hypo)emia, pain, fear, an)iety, or compensation for metaolic acidosis) and treat
it&
;entilator$associated pneumonia (35P) is defined as a pneumonia that occurs %F hours
or more after endotracheal intuation and occurs in EK to "9K of all intuated patients
,ith C8K of the occurrences developing ,ithin the first % days of mechanical ventilation&
o Clinical evidence suggesting 35P includes fever, elevated ,hite lood cell count,
purulent sputum, odorous sputum, crac'les or rhonchi on auscultation, and
pulmonary infiltrates noted on chest )+ray&
o *videnced + ased guidelines on 35P prevention include (1) >;6 elevation at a
minimum of '( degrees to )* degrees unless medically
contraindicated, (+) no routine changes o# the patient,s -entilator
circuit tubing, and (') the use o# an ./ with a dorsal lumen abo-e
the cu## to allow continuous suctioning o# secretions in the
subglottic area. 0ondensation that collects in the ventilator tuing should e
drained a,ay from the patient as it collects&
Progressive fluid retention often occurs after %F to 9" hours of PP3 especially PP3 ,ith
P**P& .t is associated ,ith decreased urinary output and increased sodium retention&
o @luid alance changes may e due to decreased C;&
o ?esults include diminished renal perfusion, the release of renin ,ith suse<uent
production of angiotensin and aldosterone resulting in sodium and ,ater
retention&
o Pressure changes ,ithin the thora) are associated ,ith decreased release of atrial
natriuretic peptide, also causing sodium retention&
o 5s a part of the stress response, release of antidiuretic hormone (5=>) and
cortisol may e increased, contriuting to sodium and ,ater retention&
3eurolo*ic $ystem
1+"E%
Key Points
.n patients ,ith head in#ury, PP3, especially ,ith P**P, can impair cereral lood flo,&
*levating the head of the ed and 'eeping the patient(s head in alignment may decrease
the deleterious effects of PP3 on intracranial pressure&
/astrointestinal $ystem
3entilated patients are at ris' for developing stress ulcers and A. leeding&
?eduction of C; caused y PP3 may contriute to ischemia of the gastric and intestinal
mucosa and possily increase the ris' of translocation of A. acteria&
Peptic ulcer prophyla)is includes the administration of histamine (>
"
)+receptor loc'ers,
proton pump inhiitors, and tue feedings to decrease gastric acidity and diminish the
ris' of stress ulcer and hemorrhage&
Aastric and o,el dilation may occur as a result of gas accumulation in the A. tract from
s,allo,ed air& =ecompression of the stomach can e accomplished y the insertion of an
NA1;A tue&
.mmoility, sedation, circulatory impairment, decreased oral inta'e, use of opioid pain
medications, and stress contriute to decreased peristalsis& The patient(s inaility to
e)hale against a closed glottis may ma'e defecation difficult predisposing the patient to
constipation&
4usculoskeletal $ystem
:aintenance of muscle strength and prevention of the prolems associated ,ith
immoility are important&
Progressive amulation of patients receiving long+term PP3 can e attained ,ithout
interruption of mechanical ventilation&
Passive and active e)ercises, consisting of movements to maintain muscle tone in the
upper and lo,er e)tremities, should e done in ed&
Prevention of contractures, pressure ulcers, foot drop, and e)ternal rotation of the hip and
legs y proper positioning is important&
Psychosocial 3ees
Patients may e)perience physical and emotional stress due to the inaility to spea', eat,
move, or reathe normally&
Tues and machines may cause pain, fear, and an)iety&
;rdinary activities of daily living such as eating, elimination, and coughing are e)tremely
complicated&
1+"EC
Key Points
Patients have identified four needs: need to 'no, (information), need to regain control,
need to hope, and need to trust& -hen these needs ,ere met, they felt safe&
Patients should e involved in decision ma'ing as much as possile&
The nurse should encourage hope and uild trusting relationships ,ith the patient and
family&
Patients receiving PP3 usually re<uire some type of sedation and1or analgesia to facilitate
optimal ventilation&
5t times the decision is made to paralyze the patient ,ith a neuromuscular loc'ing agent
to provide more effective synchrony ,ith the ventilator and increased o)ygenation&
o .f the patient is paralyzed, the nurse should rememer that the patient can hear,
see, thin', and feel&
o .ntravenous sedation and analgesia must al,ays e administered concurrently
,hen the patient is paralyzed&
o 5ssessment of the patient should include train+of+four (T;@) peripheral nerve
stimulation, physiologic signs of pain or an)iety (changes in heart rate and lood
pressure), and ventilator synchrony&
:any patients have fe, memories of their time in the .C4, ,hereas others rememer
vivid details&
5lthough appearing to e asleep, sedated, or paralyzed, patients may e a,are of their
surroundings and should al,ays e addressed as though a,a'e and alert&
Machine Disconnection or Malfunction
:ost deaths from accidental ventilator disconnection occur ,hile the alarm is turned off,
and most accidental disconnections in critical care settings are discovered y lo,+
pressure alarm activation&
The most fre<uent site for disconnection is et,een the tracheal tue and the adapter&
5larms can e paused (not inactivated) during suctioning or removal from the ventilator
and should al,ays e reactivated efore leaving the patient(s edside&
3entilator malfunction may also occur and may e related to several factors (e&g&, po,er
failure, failure of o)ygen supply)&
Patients should e disconnected from the machine and manually ventilated ,ith 188K
o)ygen if machine failure1malfunction is determined&
Nutritional ,hera".: Patient -ecei!ing Positi!e Pressure 2entilation
1+"ED
Key Points
PP3 and the hypermetaolism associated ,ith critical illness can contriute to inade<uate
nutrition&
Patients li'ely to e ,ithout food for $ to C days should have a nutritional program
initiated&
Poor nutrition and the disuse of respiratory muscles contriute to decreased respiratory
muscle strength&
.nade<uate nutrition can delay ,eaning, decrease resistance to infection, and decrease the
speed of recovery&
*nteral feeding via a small+ore feeding tue is the preferred method to meet caloric
needs of ventilated patients&
*vidence+ased guidelines regarding verification of feeding tue placement include: (1)
)+ray confirmation efore initial use, (") mar'ing and ongoing assessment of the tue(s
e)it site, and ($) ongoing revie, of routine )+rays and aspirate&
5 concern regarding the nutritional support of patients receiving PP3 is the carohydrate
content of the diet&
o :etaolism of carohydrates may contriute to an increase in serum C;
"
levels
resulting in a higher re<uired minute ventilation and an increase in -;6&
o 2imiting carohydrate content in the diet may lo,er C;
"
production&
o The dietitian should e consulted to determine the caloric and nutrient needs of these
patients&

7eaning from Positi!e Pressure 2entilation and 1tubation
7eaning is the process of reducing ventilator support and resuming spontaneous
ventilation&
The ,eaning process differs for patients re<uiring short+term ventilation (up to $ days)
versus long+term ventilation (more than $ days)&
o Patients re<uiring short+term ventilation (e&g&, after cardiac surgery) ,ill
e)perience a linear ,eaning process&
o Patients re<uiring prolonged PP3 ,ill e)perience a ,eaning process that consists
of pea's and valleys&
-eaning can e vie,ed as consisting of three phases& The pre,eaning, or assessment,
phase determines the patient(s aility to reathe spontaneously&
-eaning assessment parameters include criteria to assess muscle strength
and endurance, and minute ventilation and rapid shallo, reathing inde)&
2ungs should e reasonaly clear on auscultation and chest )+ray&
Nonrespiratory factors include the assessment of the patient(s neurologic
status, hemodynamics, fluid and electrolytes1acid+ase alance, nutrition,
1+"E9
Key Points
and hemogloin&
=rugs should e titrated to achieve comfort ,ithout causing e)cessive
dro,siness&
o *videnced+ased clinical guidelines recommend a spontaneous reathing trial
(B6T) in patients ,ho demonstrate ,eaning readiness, the second phase&
5n B6T should e at least $8 minutes ut no longer than 1"8 minutes and
may e done ,ith lo, levels of CP5P, lo, levels of PB or a /T0 piece&
Tolerance of the trial may lead to e)tuation ut failure to tolerate a B6T
should prompt a search for reversile factors and a return to a nonfatiguing
ventilator modality&
The use of a standard approach for ,eaning or ,eaning protocols have sho,n to decrease
ventilator days&
-eaning is usually carried out during the day, ,ith the patient ventilated at night in a rest
mode&
The patient eing ,eaned and the family should e provided ,ith e)planations regarding
,eaning and ongoing psychologic support&
The patient should e placed in a sitting or semirecument position and aseline vital
signs and respiratory parameters measured&
=uring the ,eaning trial, the patient must e monitored closely for noninvasive criteria
that may signal intolerance and result in cessation of the trial (e&g&, tachypnea,
tachycardia, dysrhythmias, sustained desaturation HBp;
"
]E1KI, hypertension, agitation,
an)iety, sustained 3
T
]C ml1'g, changes in level of consciousness)&
The ,eaning outcome phase refers to the period ,hen ,eaning stops and the patient is
e)tuated or ,eaning is stopped ecause no further progress is eing made&
5fter e)tuation, the patient should e encouraged to deep reathe and cough, and the
pharyn) should e suctioned as needed&
Bupplemental o)ygen should e applied and naso+oral care provided&
3ital signs, respiratory status, and o)ygenation are monitored immediately follo,ing
e)tuation, ,ithin 1 hour, and per institutional policy&
th
edition
Key Points
1+"EF
Key Points
Chapter D9: Nursing :anagement: Bhoc', Bystemic .nflammatory ?esponse
Byndrome, and :ultiple ;rgan =ysfunction Byndrome
S)$C9
Shoc0 is a syndrome characterized y decreased tissue perfusion and impaired cellular
metaolism resulting in an imalance et,een the supply of and demand for o)ygen and
nutrients&
Bhoc' can e classified as low blood flow (cardiogenic and hypovolemic shoc') or
maldistribution of blood flow (septic, anaphylactic, and neurogenic shoc')&
Cardiogenic Shoc0
Cardiogenic shoc0 occurs ,hen either systolic or diastolic dysfunction of the pumping
action of the heart results in compromised cardiac output (C;)&
Precipitating causes of cardiogenic shoc' include myocardial infarction (:.),
cardiomyopathy, lunt cardiac in#ury, severe systemic or pulmonary hypertension, cardiac
tamponade, and myocardial depression from metaolic prolems&
>emodynamic profile ,ill demonstrate an increase in the pulmonary artery ,edge
pressure (P5-P) and pulmonary vascular resistance&
Clinical manifestations of cardiogenic shoc' may include tachycardia, hypotension, a
narro,ed pulse pressure, tachypnea, pulmonary congestion, cyanosis, pallor, cool and
clammy s'in, decreased capillary refill time, an)iety, confusion, and agitation&
)."o!olemic Shoc0
)."o!olemic shoc0 occurs ,hen there is a loss of intravascular fluid volume&
Absolute h."o!olemia results ,hen fluid is lost through hemorrhage, gastrointestinal
(A.) loss (e&g&, vomiting, diarrhea), fistula drainage, diaetes insipidus, hyperglycemia, or
diuresis&
-elati!e h."o!olemia results ,hen fluid volume moves out of the vascular space into
e)travascular space (e&g&, interstitial or intracavitary space) and this is called third
spacing#
The physiologic conse<uences of hypovolemia include a decrease in venous return,
preload, stro'e volume, and C; resulting in decreased tissue perfusion and impaired
cellular metaolism&
Clinical manifestations depend on the e)tent of in#ury or insult, age, and general state of
health and may include an)iety! an increase in heart rate, C;, and respiratory rate and
depth! and a decrease in stro'e volume, P5-P, and urine output&
1+"EE
Key Points
Neurogenic Shoc0
Neurogenic shoc0 is a hemodynamic phenomenon that can occur ,ithin $8 minutes of a
spinal cord in#ury at the fifth thoracic (TC) vertera or aove and last up to D ,ee's, or in
response to spinal anesthesia&
Clinical manifestations include hypotension, radycardia, temperature dysregulation
(resulting in heat loss), dry s'in, and poi7ilothermia (ta'ing on the temperature of the
environment)&
Ana"h.lactic Shoc0
Ana"h.lactic shoc0 is an acute and life+threatening hypersensitivity (allergic) reaction to
a sensitizing sustance (e&g&, drug, chemical, vaccine, food, insect venom)&
.mmediate reaction causes massive vasodilation, release of vasoactive mediators, and an
increase in capillary permeaility resulting in fluid lea's from the vascular space into the
interstitial space&
Clinical manifestations can include an)iety, confusion, dizziness, chest pain,
incontinence, s,elling of the lips and tongue, ,heezing, stridor, flushing, pruritus,
urticaria, and angioedema&
Se"tic Shoc0
Se"sis is a systemic inflammatory response to a documented or suspected infection&
Bevere sepsis is sepsis complicated y organ dysfunction&
Se"tic shoc0 is the presence of sepsis ,ith hypotension despite fluid resuscitation along
,ith the presence of tissue perfusion anormalities&
.n severe sepsis and septic shoc', the initiated ody response to an antigen is e)aggerated
resulting in an increase in inflammation and coagulation, and a decrease in firinolysis&
*ndoto)ins from the microorganism cell ,all stimulate the release of cyto'ines and other
proinflammatory mediators that act through secondary mediators such as platelet+
activating factor&
o Platelet+activating factor results in the formation of microthromi and ostruction
of the microvasculature resulting in damage to the endothelium, vasodilation,
increased capillary permeaility, neutrophil and platelet aggregation, and adhesion
to the endothelium&
Clinical presentation for sepsis is comple) and no single or group of symptoms are
specific to the diagnosis&
o Patients ,ill usually e)perience a hyperdynamic state characterized y increased
C; and decreased B3?&
o Persistence of a high C; and a lo, B3? eyond "% hours is ominous and often
1+$88
Key Points
associated ,ith hypotension and multiple organ dysfunction syndrome (:;=B)&
o .nitially patients ,ill hyperventilate as a compensatory mechanism, resulting in
respiratory al'alosis follo,ed y respiratory acidosis and respiratory failure&
o ;ther clinical signs include alteration in neurologic status, decreased urine output,
and A. dysfunction&
Stages of Shoc0
The initial stage of shoc' that occurs at a cellular level is usually not clinically apparent&
The compensatory stage is clinically apparent and involves neural, hormonal, and
iochemical compensatory mechanisms in an attempt to overcome the increasing
conse<uences of anaeroic metaolism and to maintain homeostasis&
The progressive stage of shoc' egins as compensatory mechanisms fail and aggressive
interventions are necessary to prevent the development of :;=B&
.n the final stage of shoc', the refractory stage, decreased perfusion from peripheral
vasoconstriction and decreased C; e)acerate anaeroic metaolism and the patient ,ill
demonstrate profound hypotension and hypo)emia, and organ failure& .n this final stage,
recovery is unli'ely&
Diagnostic Studies
The process egins ,ith a thorough history and physical e)amination&
*valuation of serum lactate and a possile ase deficit&
;ther diagnostic studies include a 1"+lead *CA, continuous cardiac monitoring, chest )+
ray, continuous pulse o)imetry, and hemodynamic monitoring&
Collaborati!e Care: 4eneral Measures
Buccessful management of the patient in shoc' includes the follo,ing: (1) identification
of patients at ris' for the development of shoc'! (") integration of the patient(s history,
physical e)amination, and clinical findings to estalish a diagnosis! ($) interventions to
control or eliminate the cause of the decreased perfusion! (%) protection of target and
distal organs from dysfunction! and (C) provision of multisystem supportive care&
Aeneral management strategies for a patient in shoc' egin ,ith ensuring that the patient
has a patent air,ay and o)ygen delivery is optimized& The cornerstone of therapy for
septic, hypovolemic, and anaphylactic shoc' is volume e)pansion ,ith the administration
of the appropriate fluid&
.t is generally accepted that isotonic crystalloids, such as normal saline, are used in the
initial resuscitation of shoc'& .f the patient does not respond to " to $ 2 of crystalloids,
lood administration and central venous monitoring may e instituted& T,o ma#or
complications of fluid resuscitation are hypothermia and coagulopathy&
1+$81
Key Points
The primary goal of drug therapy for shoc' is the correction of decreased tissue
perfusion&
o Bympathomimetic drugs cause peripheral vasoconstriction and are referred to as
vasopressor drugs (e&g&, epinephrine, norepinephrine)&
The goals of vasopressor therapy are to achieve and maintain a mean
arterial pressure (:5P) of D8 to DC mm >g and the use of these drugs is
reserved for patients unresponsive to other therapies&
o The goal of vasodilator therapy, as in vasopressor therapy, is to maintain :5P at
D8 to DC mm >g or greater&
3asodilator agents most often used are nitroglycerin (in cardiogenic
shoc') and nitroprusside (in noncardiogenic shoc')&
Protein+calorie malnutrition is one of the primary manifestations of hypermetaolism in
shoc' and nutrition is vital to decreasing moridity from shoc'&
o *nteral nutrition should e initiated ,ithin the first "% hours& Parenteral nutrition is
used if enteral feedings are contraindicated or fail to meet at least F8K of the patient(s
caloric re<uirements&
o Berum protein, nitrogen alance, 64N, serum glucose, and serum electrolytes are all
monitored to assess nutritional status&
Collaborati!e Care: S"ecific Measures
"ario*enic $hock
;verall goal is to restore lood flo, to the myocardium y restoring the alance et,een
o)ygen supply and demand&
=efinitive measures include thromolytic therapy, angioplasty ,ith stenting, emergency
revascularization, and valve replacement&
Care involves hemodynamic monitoring, drug therapy (e&g&, diuretics to reduce preload),
and use of circulatory assist devices (e&g&, intraaortic alloon pump, ventricular assist
device)&
Hypo'olemic $hock
The underlying principles of managing patients ,ith hypovolemic shoc' focus on
stopping the loss of fluid and restoring the circulating volume&
o @luid replacement is calculated using a $:1 rule ($ ml of isotonic crystalloid for every
1 ml of estimated lood loss)&
$eptic $hock
Patients in septic shoc' re<uire large amounts of fluid replacement, sometimes as much
as D to 18 2 of isotonic crystalloids and " to % 2 of colloids, to restore perfusion&
>emodynamic monitoring and arterial pressure monitoring are often necessary&
3asopressor drug therapy may e added and vasopressin may e given to patients
refractory to vasopressor therapy&
1+$8"
Key Points
.ntravenous corticosteroids are recommended for patients ,ho re<uire vasopressor
therapy, despite fluid resuscitation, to maintain ade<uate 6P&
5ntiiotics are early component of therapy and are started after otaining cultures (e&g&,
lood, ,ound e)udate, urine, stool, sputum)&
=rotrecogin alpha (Migris), a recominant form of activated protein C, has demonstrated
promise in treating patients ,ith severe sepsis& 6leeding is the most common serious
adverse effect&
Alucose levels should e maintained at less than 1C8 mg1dl&
Btress ulcer prophyla)is ,ith histamine (>
"
)+receptor loc'ers and deep vein thromosis
prophyla)is ,ith lo, dose unfractionated heparin or lo, molecular ,eight heparin are
recommended&
3euro*enic $hock
Treatment of neurogenic shoc' is dependent on the cause&
o .n spinal cord in#ury, general measures to promote spinal staility are initially used&
o =efinitive treatment of the hypotension and radycardia involves the use of
vasopressors and atropine respectively&
o @luids are administered cautiously as the cause of the hypotension is generally not
related to fluid loss&
o The patient is monitored for hypothermia&
Anaphylactic $hock
*pinephrine is the drug of choice to treat anaphylactic shoc'&
=iphenhydramine is administered to loc' the massive release of histamine&
:aintaining a patent air,ay is critical and the use of neulized ronchodilators is highly
effective&
*ndotracheal intuation or cricothyroidotomy may e necessary&
5ggressive fluid replacement, predominantly ,ith colloids, is necessary&
.ntravenous corticosteroids may e helpful in anaphylactic shoc' if significant
hypotension persists after 1 to " hours of aggressive therapy&
Nursing Management: Shoc0
3ursin* Assessment
The initial assessment is geared to,ard the 56Cs: air,ay, reathing, and circulation&
@urther assessment focuses on the assessment of tissue perfusion and includes evaluation
of vital signs, peripheral pulses, level of consciousness, capillary refill, s'in (e&g&,
1+$8$
Key Points
temperature, color, moisture), and urine output&
Plannin*
The overall goals for a patient in shoc' include (1) assurance of ade<uate tissue
perfusion, (") restoration of normal 6P, ($) return1recovery of organ function, and (%)
avoidance of complications from prolonged states of hypoperfusion&
3ursin* Implementation
)ealth Promotion
o To prevent shoc', the nurse needs to identify patients at ris' (e&g&, patients ,ho are
older, those ,ith deilitating illnesses, those ,ho are immunocompromised, surgical
or accidental trauma patients)&
o Planning is essential to help prevent shoc' after a susceptile individual has een
identified (e&g&, monitoring fluid alance to prevent hypovolemic shoc', maintenance
of hand ,ashing to prevent spread of infection)&
Acute 'nter!ention
o The role of the nurse in shoc' involves (1) monitoring the patient(s ongoing physical
and emotional status to detect sutle changes in the patient(s condition! (") planning
and implementing nursing interventions and therapy! ($) evaluating the patient(s
response to therapy! (%) providing emotional support to the patient and family! and
(C) collaorating ,ith other memers of the health team ,hen ,arranted y the
patient(s condition&
o Neurologic status, including orientation and level of consciousness, should e
assessed every hour or more often&
o >eart rate1rhythm, 6P, central venous pressure, and P5 pressures including
continuous cardiac output (if availale) should e assessed at least every 1C minutes
and P5-P every 1 to " hours&
Trends in these parameters yield more important information than individual
numers&
Trendelenurg (head do,n) position during hypotensive crisis is not
supported y research and may compromise pulmonary function and increase
intracranial pressure&
The patient(s *CA should e continuously monitored to detect dysrhythmias
that may result from the cardiovascular and metaolic derangements
associated ,ith shoc'& >eart sounds should e assessed for the presence of an
B
$
or B
%
sound or ne, murmurs& The presence of an B
$
sound in an adult
usually indicates heart failure& The fre<uency of this monitoring is decreased
as the patient(s condition improves&
o The respiratory status of the patient in shoc' must e fre<uently assessed to ensure
ade<uate o)ygenation, detect complications early, and provide data regarding the
patient(s acid+ase status&
Pulse o)imetry is used to continuously monitor o)ygen saturation&
5rterial lood gases (56As) provide definitive information on ventilation and
o)ygenation status, and acid+ase alance&
1+$8%
Key Points
:ost patients in shoc' ,ill e intuated and on mechanical ventilation&
o >ourly urine output measurements assess the ade<uacy of renal perfusion and a urine
output of less than 8&C ml1'g1hour may indicate inade<uate 'idney perfusion&
64N and serum creatinine values are also used to assess renal function&
o Tympanic or pulmonary arterial temperatures should e otained hourly if
temperature is elevated or sunormal, other,ise every % hours&
o Capillary refill should e assessed and s'in monitored for temperature, pallor,
flushing, cyanosis, diaphoresis, or piloerection&
o 6o,el sounds should e auscultated at least every % hours, and adominal distention
should e assessed&
.f a nasogastric tue is inserted, drainage should e chec'ed for occult lood
as should stools&
o ;ral care for the patient in shoc' is essential and passive range of motion should e
performed three or four times per day&
o 5n)iety, fear, and pain may aggravate respiratory distress and increase the release of
catecholamines&
The nurse should tal' to the patient, even if the patient is intuated, sedated, and paralyzed or
appears comatose& .f the intuated patient is capale of ,riting, a /magic slate0 or a pencil and
paper should e provided&
@amily and significant others (1) lin' the patient to the outside ,orld! (")
facilitate decision+ma'ing and advise the patient! ($) assist ,ith activities of
daily living! (%) act as liaisons to advise the health care team of the patient(s
,ishes for care! and (C) provide safe, caring, familiar relationships for the
patient& @amily time ,ith the patient should e facilitated, provided this time
is perceived as comforting y the patient&
Ambulator. and )ome Care
o ?ehailitation of the patient ,ho is recovering from shoc' necessitates correction of
the precipitating cause and prevention or early treatment of complications&
Complications may include decreased range of motion, decreased physical
endurance, chronic 'idney disease follo,ing acute tuular necrosis, and the
development of firotic lung disease as a result of 5?=B&
Patients may re<uire diverse services (e&g&, transitional care Hfor mechanical
ventilation ,eaningI, rehailitation, home health care)&
S6S,M'C 'N+LAMMA,$-6 -SP$NS S6ND-$M AND M5L,'PL $-4AN
D6S+5NC,'$N S6ND-$M
S.stemic inflammator. res"onse s.ndrome (B.?B) is a systemic inflammatory
response to a variety of insults, including infection (referred to as sepsis), ischemia,
infarction, and in#ury&
B.?B is characterized y generalized inflammation in organs remote from the initial
insult and can e triggered y mechanical tissue trauma (e&g&, urns, crush in#uries),
ascess formation, ischemic or necrotic tissue (e&g&, pancreatitis, myocardial infarction),
microial invasion, and gloal and regional perfusion deficits&
1+$8C
Key Points
Multi"le organ d.sfunction s.ndrome (:;=B) results from B.?B and is the failure of
t,o or more organ systems such that homeostasis cannot e maintained ,ithout
intervention&
o The respiratory system is often the first system to sho, signs of dysfunction in
B.?B and :;=B often culminating in 5?=B&
o Cardiovascular changes include myocardial depression and massive vasodilation
in response to increasing tissue demands&
o Neurologic dysfunction commonly manifests as mental status changes ,ith B.?B
and :;=B&
o 5cute renal failure (5?@) is fre<uently seen in B.?B and :;=B&
o .n the early stages of B.?B and :;=B, lood is shunted a,ay from the A.
mucosa, ma'ing it highly vulnerale to ischemic in#ury&
?is' for ulceration and A. leeding&
Potential for acterial translocation from the A. tract into circulation&
o 6oth syndromes trigger a hypermetaolic response&
Catecholamines and glucocorticoids are released and result in
hyperglycemia and insulin resistance&
Net result is a cataolic state, and a reduction in lean ody mass (muscle)&
:ay see liver dysfunction as a result of hypermetaolic state&
o @ailure of the coagulation system manifests as =.C&
o *lectrolyte imalances, ,hich are common, are related to hormonal and metaolic
changes and fluid shifts&
These changes e)acerate mental status changes, neuromuscular
dysfunction, and dysrhythmias&
The release of antidiuretic hormone and aldosterone results in sodium and
,ater retention&
Nursing and Collaborati!e Management: S'-S and M$DS
The prognosis for the patient ,ith :;=B is poor and the most important goal is to
prevent the progression of B.?B to :;=B&
5 critical component of the nursing role is vigilant assessment and ongoing monitoring to
detect early signs of deterioration or organ dysfunction&
Collaorative care for patients ,ith :;=B focuses on (1) prevention and treatment of
infection, (") maintenance of tissue o)ygenation, ($) nutritional and metaolic support,
and (%) appropriate support of individual failing organs&
Prevention and treatment of infection:
o 5ggressive infection control strategies are essential to decrease the ris' for
nosocomial infections&
o ;nce an infection is suspected, interventions to control the source must e
instituted&
1+$8D
Key Points
:aintenance of tissue o)ygenation:
o .nterventions that decrease o)ygen demand are essential and may include
sedation, mechanical ventilation, analgesia, paralysis, and rest&
o ;)ygen delivery may e optimized y maintaining normal levels of hemogloin
and Pa;
"
, using individualized tidal volumes ,ith positive end+e)piratory
pressure, increasing preload or myocardial contractility to enhance C;, or
reducing afterload to increase C;&
Nutritional and metaolic needs:
o >ypermetaolism in B.?B or :;=B can result in profound ,eight loss, cache)ia,
and further organ failure&
o Total energy e)penditure is often increased 1&C to " times the normal metaolic
rate&
o Plasma transferrin and prealumin levels are monitored to assess hepatic protein
synthesis&
o The goal of nutritional support is to preserve organ function and the use of the
enteral route is preferale to parenteral nutrition&

Bupport of failing organs:
o Bupport of any failing organ is a primary goal of therapy (e&g&, the patient ,ith
5?=B re<uires aggressive o)ygen therapy and mechanical ventilation, =.C
should e treated appropriately He&g&, lood productsI, renal failure may re<uire
dialysis)&
th
edition
Key Points
Chapter DF: Nursing :anagement: ?espiratory @ailure and 5cute ?espiratory
=istress Byndrome
AC5, -SP'-A,$-6 +A'L5-
!espiratory failure results ,hen gas e)change, ,hich involves the transfer of o)ygen
(;
"
) and caron dio)ide (C;
"
) et,een the atmosphere and the lood, is inade<uate&
?espiratory failure is not a disease! it is a condition that occurs as a result of one or more
diseases involving the lungs or other ody systems&
?espiratory failure can e classified as hypo)emic or hypercapnic&
o )."o1emic res"irator. failure:
Commonly defined as a Pa;
"
]D8 mm >g ,hen the patient is receiving an
1+$89
Key Points
inspired ;
"
concentration UD8K&
=isorders that interfere ,ith ;
"
transfer into the lood include pneumonia,
pulmonary edema, pulmonary emoli, heart failure, shoc', and alveolar
in#ury related to inhalation of to)ic gases and lung damage related to
alveolar stress1ventilator+induced lung in#ury&
@our physiologic mechanisms may cause hypo)emia and suse<uent
hypo)emic respiratory failure: (1) mismatch et,een ventilation and
perfusion, commonly referred to as ;<= mismatch> (") shunt! ($) diffusion
limitation! and (%) hypoventilation&
>ypo)emic respiratory failure fre<uently is caused y a comination of
t,o or more of these mechanisms&
o )."erca"nic res"irator. failure:
5lso referred to as ventilatory failure since the primary prolem is
insufficient C;
"
removal&
Commonly defined as a PaC;
"
U%C mm >g in comination ,ith acidemia
(arterial p> ]9&$C)&
=isorders that compromise C;
"
removal include drug overdoses ,ith
central nervous system (CNB) depressants, neuromuscular diseases, acute
asthma, and trauma or diseases involving the spinal cord and its role in
lung ventilation&
>ypercapnic respiratory failure results from an imalance et,een
ventilatory supply and ventilatory demand& ;entilatory supply is the
ma)imum ventilation that the patient can sustain ,ithout developing
respiratory muscle fatigue, and ventilatory demand is the amount of
ventilation needed to 'eep the PaC;
"
,ithin normal limits&
Though Pa;
"
and PaC;
"
determine the definition of respiratory failure, the ma#or threat
of respiratory failure is the inaility of the lungs to meet the o)ygen demands of the
tissues& This may occur as a result of inade<uate tissue ;
"
delivery or ecause the tissues
are unale to use the ;
"
delivered to them&
:anifestations of respiratory failure:
o 5re related to the e)tent of change in Pa;
"
or PaC;
"
, the rapidity of change
(acute versus chronic), and the aility to compensate to overcome this change&
o Clinical manifestations are variale and it is important to monitor trends in 56As
and1or pulse o)imetry to evaluate the e)tent of change&
o 5 change in mental status is fre<uently the initial indication of respiratory failure&
o Tachycardia and mild hypertension can also e early signs of respiratory failure&
o 5 severe morning headache may suggest that hypercapnia may have occurred
during the night, increasing cereral lood flo, y vasodilation and causing a
morning headache&
o Cyanosis is an unreliale indicator of hypo)emia and is a late sign of respiratory
failure ecause it does not occur until hypo)emia is severe (Pa;
"
`%C mm >g)&
o )."o1emia occurs ,hen the amount of ;
"
in arterial lood is less than the
normal value, and h."o1ia occurs ,hen the Pa;
"
falls sufficiently to cause signs
1+$8F
Key Points
and symptoms of inade<uate o)ygenation&
o >ypo)emia can lead to hypo)ia if not corrected, and if hypo)ia or hypo)emia is
severe, the cells shift from aeroic to anaeroic metaolism&
Clinical Manifestations
Clinical findings include a rapid, shallo, reathing pattern or a respiratory rate that is
slo,er than normal& 5 change from a rapid rate to a slo,er rate in a patient in acute
respiratory distress such as that seen ,ith acute asthma suggests e)treme progression of
respiratory muscle fatigue and increased proaility of respiratory arrest&
The position that the patient assumes is an indication of the effort associated ,ith
reathing&
o The patient may e ale to lie do,n (mild distress), e ale to lie do,n ut prefer
to sit (moderate distress), or e unale to reathe unless sitting upright (severe
distress)& The patient may re<uire pillo,s to reathe ,hen attempting to lie flat
and this is termed orthopnea&
o 5 common position is to sit ,ith the arms propped on the overed tale&
Pursed+lip reathing may e used&
The patient may spea' in sentences (mild or no distress), phrases (moderate distress), or
,ords (severe distress)&
There may e a change in the inspiratory %-& to e"piratory %+& ratio# Normally, the .:*
ratio is 1:", ut in patients in respiratory distress, the ratio may increase to 1:$ or 1:%&
There may e retractions of the intercostal spaces or the supraclavicular area and use of
the accessory muscles during inspiration or e)piration& 4se of the accessory muscles
signifies moderate distress&
Parado"ic breathing indicates severe distress and results from ma)imal use of the
accessory muscles of respiration&
6reath sounds:
o Crac'les and rhonchi may indicate pulmonary edema and C;P=&
o 5sent or diminished reath sounds may indicate atelectasis or pleural effusion&
o The presence of ronchial reath sounds over the lung periphery often results
from lung consolidation that is seen ,ith pneumonia&
o 5 pleural friction ru may also e heard in the presence of pneumonia that has
involved the pleura&
Diagnostic Studies
56As are done to otain o)ygenation (Pa;
"
) and ventilation (PaC;
"
) status, as ,ell as
information related to acid+ase alance&
1+$8E
Key Points
5 chest )+ray is done to help identify possile causes of respiratory failure&
;ther diagnostic studies include a complete lood cell count, serum electrolytes,
urinalysis, and electrocardiogram&
o Cultures of the sputum and lood are otained as necessary to determine sources
of possile infection&
o @or the patient in severe respiratory failure re<uiring endotracheal intuation, end+
tidal C;
"
(*tC;
"
) may e used to assess tue placement ,ithin the trachea
immediately follo,ing intuation&
o .n severe respiratory failure, a pulmonary artery catheter may e inserted to
measure heart pressures and cardiac output, as ,ell as mi)ed venous o)ygen
saturation (Bv;
"
)&
Nursing and Collaborati!e Management: Acute -es"irator. +ailure
The overall goals for the patient in acute respiratory failure include: (1) 56A values
,ithin the patient(s aseline, (") reath sounds ,ithin the patient(s aseline, ($) no
dyspnea or reathing patterns ,ithin the patient(s aseline, and (%) effective cough and
aility to clear secretions&
Prevention involves a thorough physical assessment and history to identify the patient at
ris' for respiratory failure and, then, the initiation of appropriate nursing interventions
(coughing, deep reathing, incentive spirometry, and amulation as appropriate)&
The ma#or goals of care for acute respiratory failure include maintaining ade<uate
o)ygenation and ventilation&
o The primary goal of ;
"
therapy is to correct hypo)emia&
o The type of ;
"
delivery system chosen for the patient in acute respiratory failure
should (1) e tolerated y the patient, and (") maintain Pa;
"
at CC to D8 mm >g or
more and Ba;
"
at E8K or more at the lo,est ;
"
concentration possile&
o 5dditional ris's of ;
"
therapy are specific to the patient ,ith chronic hypercapnia
as this may lunt the response of chemoreceptors in the medulla, a condition
termed C.
'
narcosis&
o ?etained pulmonary secretions may cause or e)acerate acute respiratory failure
and can e moilized through effective coughing, ade<uate hydration and
humidification, chest physical therapy (chest physiotherapy), and tracheal
suctioning&
o .f secretions are ostructing the air,ay, the patient should e encouraged to
cough&
,ugmented coughing is performed y placing the palm of the hand or
hands on the adomen elo, the )iphoid process& 5s the patient ends a
deep inspiration and egins the e)piration, the hands should e moved
forcefully do,n,ard, increasing adominal pressure and facilitating the
cough& This measure helps increase e)piratory flo, and therey facilitates
secretion clearance&
Huff coughing is a series of coughs performed ,hile saying the ,ord
1+$18
Key Points
/huff&0 The huff cough is effective in clearing only the central air,ays, ut
it may assist in moving secretions up,ard&
The staged cough is performed y having the patient sit in a chair, reathe
three or four times in and out through the mouth, and cough ,hile ending
for,ard and pressing a pillo, in,ard against the diaphragm&
o Positioning the patient either y elevating the head of the ed at least %C degrees
or y using a reclining chair or chair ed may help ma)imize thoracic e)pansion,
therey decreasing dyspnea and improving secretion moilization&
o 2ateral or side+lying positioning may e used in patients ,ith disease involving
only one lung and this position is termed good lung do,n&
o 5de<uate fluid inta'e (" to $ 21day) is necessary to 'eep secretions thin and easy
to e)pel&
5ssessment for signs of fluid overload (e&g&, crac'les, dyspnea,
increased central venous pressure) at regular intervals is paramount&
5erosols of sterile normal saline, administered y a neulizer, may e
used to li<uefy secretions&
:ucolytic agents such as neulized acetylcysteine mi)ed ,ith a
ronchodilator may e used to thin secretions ut, as a side effect, may
also cause air,ay erythema and ronchospasm&
o Chest physical therapy is indicated in patients ,ho produce more than $8 ml of
sputum per day or have evidence of severe atelectasis or pulmonary infiltrates&
o .f the patient is unale to e)pectorate secretions, nasopharyngeal, oropharyngeal,
or nasotracheal suctioning is indicated&
Buctioning through an artificial air,ay, such as endotracheal or
tracheostomy tues, may also e performed&
5 mini+tracheostomy (or mini+trach) may e used to suction patients
,ho have difficulty moilizing secretions& Contraindications for a
mini+trach include an asent gag refle), history of aspiration, and the
need for long+term mechanical ventilation&
o .f intensive measures fail to improve ventilation and o)ygenation, positive
pressure ventilation (PP3) may e provided invasively through orotracheal or
nasotracheal intuation or noninvasively through a nasal or face mas'&
o Noninvasive PP3 may e used as a treatment for patients ,ith acute or chronic
respiratory failure&
-ith N.PP3 it is possile to decrease the ,or' of reathing ,ithout
the need for endotracheal intuation&
6ilevel positive air,ay pressure (6iP5P) is a form of N.PP3 in ,hich
different positive pressure levels are set for inspiration and e)piration&
Continuous positive air,ay pressure (CP5P) is another form of N.PP3
in ,hich a constant positive pressure is delivered to the air,ay during
inspiration and e)piration&
N.PP3 is most useful in managing chronic respiratory failure in
patients ,ith chest ,all and neuromuscular disease&
Aoals of drug therapy for patients in acute respiratory failure include (1) relief of
1+$11
Key Points
ronchospasm, (") reduction of air,ay inflammation and pulmonary congestion, ($)
treatment of pulmonary infection, and (%) reduction of severe an)iety and restlessness&
o Bhort+acting ronchodilators, such as metaproterenol and aluterol, are fre<uently
administered to reverse ronchospasm using either a handheld neulizer or a
metered+dose inhaler ,ith a spacer&
o Corticosteroids may e used in con#unction ,ith ronchodilating agents ,hen
ronchospasm and inflammation are present&
o =iuretics and nitroglycerin are used to decrease the pulmonary congestion caused
y heart failure&
o .f atrial firillation is present, calcium channel loc'ers and V+adrenergic loc'ers
may e used to decrease heart rate and improve cardiac output&
o .f infection is present, .3 antiiotics, such as vancomycin or ceftria)one, are
fre<uently administered to inhiit acterial gro,th&
o Bedation and analgesia ,ith drug therapy such as propofol, enzodiazepines, and
narcotics may e used to decrease an)iety, agitation, and pain&
o Patients ,ho are asynchronous ,ith mechanical ventilation may re<uire
neuromuscular loc'ade ,ith agents such as vecuronium to produce s'eletal
muscle rela)ation y interference ,ith neuromuscular transmission, ultimately
producing synchrony ,ith mechanical ventilation&
Patients receiving neuromuscular loc'ade should receive sedation and
analgesia to the point of unconsciousness for patient comfort, to eliminate
patient a,areness, and to avoid the terrifying e)perience of eing a,a'e
and in pain ,hile paralyzed&
:onitoring levels of sedation in patients receiving neuromuscular loc'ade
is done ,ith noninvasive **A+ased technology, or through the use of a
peripheral nerve stimulator&
Aoals of medical therapy are to treat the underlying cause of the respiratory failure, and
maintain an ade<uate cardiac output and hemogloin concentration&
o =ecreased cardiac output is treated y administration of .3 fluids, medications, or
oth&
Cardiac output may e decreased y changes in intrathoracic or
intrapulmonary pressures from PP3 placing patients at ris' for alveolar
hyperinflation, increased right ventricular afterload and e)cessive
intrathoracic pressures&
o 5 hemogloin concentration of UE g1dl (E8 g12) typically ensures ade<uate ;
"
saturation of the hemogloin&
:aintenance of protein and energy stores is especially important in patients ,ho
e)perience acute respiratory failure ecause nutritional depletion causes a loss of muscle
mass, including the respiratory muscles, and may prolong recovery&
o *nteral or parenteral nutrition is usually initiated ,ithin "% hours in malnourished
patients and ,ithin three days in ,ell+nourished patients&
5 high+carohydrate diet may need to e avoided in the patient ,ho
retains C;
"
ecause carohydrates metaolize into C;
"
and increase the
1+$1"
Key Points
C;
"
load of the patient&
:ultiple factors contriute to an increased ris' of respiratory failure in older adults,
including the reduction in ventilatory capacity, decreased respiratory muscle strength, and
delayed responses in respiratory rate and depth to falls in Pa;
"
and rises in PaC;
"
&
AC5, -SP'-A,$-6 D'S,-SS S6ND-$M
Acute res"irator. distress s.ndrome (5?=B) is a sudden and progressive form of acute
respiratory failure in ,hich the alveolar capillary memrane ecomes damaged and more
permeale to intravascular fluid&
o 5lveoli fill ,ith fluid, resulting in severe dyspnea, hypo)emia refractory to
supplemental ;
"
, reduced lung compliance, and diffuse pulmonary infiltrates&
o The most common cause of 5?=B is sepsis&
o =irect lung in#ury may cause 5?=B, or 5?=B may develop as a conse<uence of
the systemic inflammatory response syndrome, or multiple organ dysfunction
syndrome&
The pathophysiologic changes of 5?=B are thought to e due to stimulation of the
inflammatory and immune systems, ,hich causes an attraction of neutrophils to the
pulmonary interstitium& The neutrophils cause a release of iochemical, humoral, and
cellular mediators that produce changes in the lung&
The injury or e"udative phase of 5?=B occurs appro)imately 1 to 9 days (usually "% to
%F hours) after the initial direct lung in#ury or host insult&
o The primary pathophysiologic changes that characterize this phase are interstitial
and alveolar edema (noncardiogenic pulmonary edema) and atelectasis resulting
in 31P mismatch, shunting of pulmonary capillary lood, and hypo)emia
unresponsive to increasing concentrations of ;
"
(termed refractor. h."o1emia)&
o >ypo)emia and the stimulation of #u)tacapillary receptors in the stiff lung
parenchyma (\ refle)) initially cause an increase in respiratory rate, decrease in
tidal volume, respiratory al'alosis, and an increase in cardiac output&
The reparative or proliferative phase of 5?=B egins 1 to " ,ee's after the initial lung
in#ury&
o =uring this phase, there is an influ) of neutrophils, monocytes, and lymphocytes
and firolast proliferation as part of the inflammatory response&
o 2ung compliance continues to decrease as a result of interstitial firosis and
hypo)emia&
o .f the reparative phase persists, ,idespread firosis results& .f the reparative phase
is arrested, the lesions resolve&
The fibrotic or chronic phase of 5?=B occurs appro)imately " to $ ,ee's after the initial
lung in#ury&
o The lung is completely remodeled y sparsely collagenous and firous tissues and
1+$1$
Key Points
there is diffuse scarring and firosis, resulting in decreased lung compliance&
o Pulmonary hypertension results from pulmonary vascular destruction and firosis&
Progression of 5?=B varies among patients and several factors determine the course of
5?=B, including the nature of the initial in#ury, e)tent and severity of coe)isting
diseases, and pulmonary complications&
Clinical Manifestations
5?=B is considered to e present if the patient has (1) refractory hypo)emia, (") a chest
)+ray ,ith ne, ilateral interstitial or alveolar infiltrates, ($) a pulmonary artery ,edge
pressure of 1F mm >g or less and no evidence of heart failure, and (%) a predisposing
condition for 5?=B ,ithin %F hours of clinical manifestations&
.nitially the patient may e)hiit only dyspnea, tachypnea, cough, and restlessness and
chest auscultation may e normal or reveal fine, scattered crac'les&
56As usually indicate mild hypo)emia and respiratory al'alosis caused y
hyperventilation&
Chest )+ray may e normal, e)hiit evidence of minimal scattered interstitial infiltrates,
or demonstrate diffuse and e)tensive ilateral infiltrates (termed whiteout or white lung)&
5s 5?=B progresses, tachypnea and intercostal and suprasternal retractions may e
present and pulmonary function tests reveal decreased compliance and decreased lung
volumes&
Tachycardia, diaphoresis, changes in sensorium ,ith decreased mentation, cyanosis, and
pallor may develop&
Pulmonary artery ,edge pressure does not increase in 5?=B ecause the cause of
pulmonary edema is noncardiogenic&
>ypo)emia and a Pa;
"
1@.;
"
ratio elo, "88 (e&g&, F818&F Z 188) despite increased @.;
"
are the hallmar's of 5?=B&
Complications may develop as a result of 5?=B itself or its treatment&
o 5 fre<uent complication of 5?=B is hospital+ac<uired pneumonia&
Btrategies to prevent hospital+ac<uired pneumonia include infection
control measures (e&g&, strict hand ,ashing and sterile techni<ue during
endotracheal suctioning) and elevating the head of the ed $8 to %C
degrees to prevent aspiration&
o 8arotrauma may result from rupture of overdistended alveoli during mechanical
ventilation leading to pulmonary interstitial emphysema, pneumothora),
sucutaneous emphysema, and tension pneumothora)&
To avoid arotraumas, patients may e ventilated ,ith smaller tidal
1+$1%
Key Points
volumes and positive end+e)piratory pressure (P**P)&
;ne conse<uence of this protocol is an elevation in PaC;
"
, termed
permissive hypercapnia ecause the PaC;
"
is allo,ed (permitted) to rise
aove normal limits&
o ;olu$pressure trauma results in alveolar fractures and movement of fluids and
proteins into the alveolar spaces& Bmaller tidal volumes or pressure ventilation are
used to reduce volu+pressure trauma&
o Critically ill patients ,ith acute respiratory failure are at high ris' for stress ulcers,
and prophylactic management (e&g&, ranitidine) is recommended&
o ?enal failure can occur from decreased renal tissue o)ygenation as a result of
hypotension, hypo)emia, or hypercapnia&
Nursing and Collaborati!e Management: Acute -es"irator. Distress S.ndrome
Collaorative care for acute respiratory failure is applicale to 5?=B&
;verall goals for the patient ,ith 5?=B include a Pa;
"
of at least D8 mm >g, and
ade<uate lung ventilation to maintain normal p>&
Aoals for a patient recovering from 5?=B include (1) Pa;
"
,ithin normal limits for age
or aseline values on room air (@.;
"
of "1K), (") Ba;
"
greater than E8K, ($) patent
air,ay, and (%) clear lungs on auscultation&
The general standard for ;
"
administration is to give the patient the lo,est concentration
that results in a Pa;
"
of D8 mm >g or greater&
o -hen the @.;
"
e)ceeds D8K for more than %F hours, the ris' for ;
"
to)icity
increases&
o Patients ,ith 5?=B need intuation ,ith mechanical ventilation ecause the
Pa;
"
cannot other,ise e maintained at acceptale levels&
o =uring mechanical ventilation, it is common to apply P**P (e&g&, 18 to "8 cm
>
"
;) to maintain Pa;
"
at D8 mm >g or greater&
P**P can also cause hyperinflation of the alveoli, compression of the
pulmonary capillary ed, a reduction in preload and lood pressure, as
,ell as arotrauma and volu+pressure trauma&
o 5lternative modes of ventilation may e used and include pressure support ventilation,
pressure release ventilation, pressure control ventilation, inverse ratio ventilation, high+
fre<uency ventilation, and permissive hypercapnia&
o Bome patients ,ith 5?=B demonstrate a mar'ed improvement in Pa;
"
,hen turned from
the supine to prone position ,ith no change in inspired ;
"
concentration&
o ;ther positioning strategies to improve o)ygenation that can e considered for patients
,ith 5?=B include continuous lateral rotation therapy and 'inetic therapy&
Patients on PP3 and P**P fre<uently e)perience decreased cardiac output and may re<uire
crystalloid fluids or colloid solutions or lo,er P**P& 4se of inotropic drugs such as
doutamine or dopamine may also e necessary&
>emogloin level is usually 'ept at levels of E g1dl or more ,ith an o)ygen saturation of
1+$1C
Key Points
E8K or greater (,hen Pa;
"
is more than D8 mm >g)&
Nutrition consults are initiated to determine optimal caloric needs and parenteral or enteral
feedings are started to meet the high energy re<uirements of these patients& *arly research has
sho,n that enteral formulas enriched ,ith omega+$ fatty acids may improve the clinical
outcomes of patients ,ith 5?=B&
S2- AC5, -SP'-A,$-6 S6ND-$M
Severe acute respiratory syndrome (B5?B) is a serious, acute respiratory infection caused
y a coronavirus&
The virus spreads y close contact et,een people and is most li'ely spread via droplets
in the air&
.n general, B5?B egins ,ith a fever greater than 188&%Q @ (U$F&8Q C)&
o ;ther manifestations may include sore throat, rhinorrhea, chills, rigors, myalgia,
headache, and diarrhea&
o 5fter " to 9 days, B5?B patients may develop a dry cough and have troule
reathing&
Treatment needs to e started ased on the symptoms and efore the cause of the illness
is confirmed&
o Patients ,ho are suspected of having B5?B should e placed in isolation&
o 5ntiviral medications, antiiotics, and corticosteroids may e used&
o 5out F8K to E8K of infected people start to recover after D to 9 days&
o 18K to "8K of infected people ,ill develop respiratory failure and may need
intuation and mechanical ventilation&
th
edition
Key Points
Chapter DE: Nursing :anagement: *mergency and =isaster Nursing
:ost patients ,ith life+threatening or potentially life+threatening prolems arrive at the hospital through the
emergency department (*=)&
,riage refers to the process of rapidly determining the acuity of the patient(s prolem, and it represents one of
the most important assessment s'ills needed y the emergency nurse&
1+$1D
Key Points
The triage process is ased on the premise that patients ,ho have a threat to life, vision, or lim should e
treated efore other patients&
o 5 triage system categorizes patients so that the most critical ones are treated first&
o The +mergency Severity -nde" (*B.) is a C+level triage system that incorporates concepts of
illness severity and resource utilization to determine ,ho should e treated first&
5fter the initial assessment to determine the presence of actual or potential threats to life, appropriate
interventions are initiated for the patient(s condition&
The "rimar. sur!e. focuses on air,ay, reathing, circulation, and disaility and serves to identify life+
threatening conditions so that appropriate interventions can e initiated&
.f life+threatening conditions related to air,ay, reathing, circulation, and disaility are identified
at any point during the primary survey, interventions are started immediately and efore
proceeding to the ne)t step of the survey&
5ir,ay ,ith cervical spine stailization and1or immoilization:
Primary signs and symptoms in a patient ,ith a compromised air,ay include dyspnea,
inaility to vocalize, presence of foreign ody in the air,ay, and trauma to the face or
nec'&
5ir,ay maintenance should progress rapidly from the least to the most invasive method
and includes opening the air,ay using the *aw-thrust maneu!er, suctioning and1or
removal of foreign ody, insertion of a nasopharyngeal or oropharyngeal air,ay, and
endotracheal intuation&
The cervical spine must e stailized and1or immoilized in any patient ,ith face, head,
or nec' trauma and1or significant upper torso in#uries&
6reathing:
6reathing alterations are caused y many conditions (e&g&, fractured ris, pneumothora),
allergic reactions, pulmonary emoli, asthma) resulting in dyspnea, parado)ical or
asymmetric chest ,all movement, decreased or asent reath sounds, cyanosis,
tachycardia, and hypotension&
>igh+flo, o)ygen (188K) via a non+rereather mas' should e administered and the
patient(s response monitored& 2ife+threatening conditions may re<uire ag+valve+mas'
ventilation ,ith 188K o)ygen and intuation&
Circulation:
5 central pulse is chec'ed ecause peripheral pulses may e asent as a result of direct
in#ury or vasoconstriction&
B'in is assessed for color, temperature, and moisture&
5ltered mental status and delayed capillary refill are the most significant signs of shoc'&
T,o large+ore .3 catheters should e inserted and aggressive fluid resuscitation initiated
using normal saline or lactated ?inger(s solution&
=isaility:
The degree of disaility is measured y the patient(s level of consciousness&
5 simple mnemonic can e used: 53P4: A Z alert, 2 Z responsive to voice, P Z
responsive to pain, and 5 Z unresponsive&
The Alasgo, Coma Bcale is used to further assess the arousal aspect of the patient(s
consciousness&
Pupils are assessed for size, shape, response to light, and e<uality&
The secondar. sur!e. is a rief, systematic process that is aimed at identifying all in#uries&
*)posure1environmental control& 5ll trauma patients should have their clothes removed so that a
thorough physical assessment can e performed&
1+$19
Key Points
@ull set of vital signs1five interventions1facilitate family presence:
5 complete set of vital signs, including lood pressure, heart rate, respiratory rate, and
temperature, is otained after the patient is e)posed&
@ive interventions: 1) *CA monitoring is initiated! ") pulse o)imetry is initiated! $) an
ind,elling catheter is inserted! %) an orogastric or a nasogastric tue is inserted! C) lood
for laoratory studies is collected&
+amil. "resence: family memers ,ho ,ish to e present during invasive procedures
and resuscitation vie, themselves as active participants in the care process and their
presence should e supported&
Aive comfort measures& Pain management strategies should include a comination of
pharmacologic and nonpharmacologic measures&
>istory and head+to+toe assessment:
5 thorough history of the event, illness, in#ury is otained from the patient, family, and
emergency personnel&
5 thorough head+to+toe assessment is necessary&
.nspect the posterior surfaces& The trauma patient should e logrolled (,hile maintaining cervical
spine immoilization) to inspect the posterior surfaces&
5ll patients should e evaluated to determine their need for tetanus prophyla)is&
;ngoing patient monitoring and evaluation of interventions are critical and the nurse is responsile for
providing appropriate interventions and assessing the patient(s response&
=epending on the patient(s in#uries and1or illness, the patient may e (1) transported for diagnostic tests such as
)+ray or CT scan! (") admitted to a general unit, telemetry, or intensive care unit! or ($) transferred to
another facility&
DA,) 'N ,) M-4NC6 DPA-,MN,
The emergency nurse should recognize the importance of certain hospital rituals in preparing the ereaved to
grieve, such as collecting the elongings, arranging for an autopsy, vie,ing the ody, and ma'ing mortuary
arrangements&
:any patients ,ho die in the *= could potentially e a candidate for non?heart beating donation> certain
tissues and organs such as corneas, heart valves, s'in, one, and 'idneys can e harvested from patients
after death&

4-$N,$L$4'C C$NS'D-A,'$NS: M-4NC6 CA-
*lderly people are at high ris' for in#ury primarily from falls&
The three most common causes of falls in the elderly are generalized ,ea'ness, environmental hazards, and
orthostatic hypotension&
-hen assessing a patient ,ho has e)perienced a fall, it is important to determine ,hether the physical findings
may have actually caused the fall or may e due to the fall itself&
)A, 8)A5S,'$N
1+$1F
Key Points
Prolonged e)posure to heat over hours or days leads to heat e1haustion, a clinical syndrome characterized
y fatigue, light+headedness, nausea, vomiting, diarrhea, and feelings of impending doom&
Tachypnea, hypotension, tachycardia, elevated ody temperature, dilated pupils, mild confusion,
ashen color, and profuse diaphoresis are also present&
>ypotension and mild to severe temperature elevation (EE&DQ to 18%Q @ H$9&CQ to %8Q CI) are due to
dehydration&
Treatment egins ,ith placement of the patient in a cool area and removal of constrictive clothing&
;ral fluid and electrolyte replacement is initiated unless the patient is nauseated! a 8&EK normal saline .3
solution is initiated ,hen oral solutions are not tolerated&
5 moist sheet placed over the patient decreases core temperature&
)A,S,-$9
)eatstro0e results from failure of the hypothalamic thermoregulatory processes&
.ncreased s,eating, vasodilation, and increased respiratory rate deplete fluids and electrolytes, specifically
sodium&
*ventually, s,eat glands stop functioning, and core temperature increases (U18%Q @ (%8Q C)&
5ltered mentation, asence of perspiration, and circulatory collapse can follo,&
Cereral edema and hemorrhage may occur as a result of direct thermal in#ury to the rain&
Treatment focuses on stailizing the patient(s 56Cs and rapidly reducing the temperature&
3arious cooling methods include removal of clothing, covering ,ith ,et sheets, and placing the patient in front
of a large fan! immersion in an ice ,ater ath! and administering cool fluids or lavaging ,ith cool fluids&
Bhivering increases core temperature, complicating cooling efforts, and is treated ,ith .3 chlorpromazine&
5ggressive temperature reduction should continue until core temperature reaches 18"Q @ ($F&EQ C)&
Patients are monitored for signs of rhabdomyolysis, myogloinuria, and disseminated intravascular coagulation&
)6P$,)-M'A
)."othermia is defined as a core temperature ]ECQ @ ($CQ C)&
The elderly are more prone to hypothermia, and certain drugs, alcohol, and diaetes are considered ris' factors
for hypothermia&
1+$1E
Key Points
Core temperature elo, FDQ @ ($8Q C) is a severe and potentially life+threatening situation&
Patients ,ith mild hypothermia (E$&"Q to ED&FQ @ H$%Q to $DQ CI) have shivering, lethargy,
confusion, rational to irrational ehavior, and minor heart rate changes&
Bhivering disappears at temperatures elo, E"Q @ ($$&$Q C)& Moderate hypothermia (FDQ to E$&"Q @
H$8Q to $%Q CI) causes rigidity, radycardia, slo,ed respiratory rate, lood pressure otainale only
y =oppler, metaolic and respiratory acidosis, and hypovolemia&
Coma results ,hen the core temperature falls elo, F"&%Q @ ("FQ C), and death usually occurs
,hen the core temperature is elo, 9FQ @ ("C&DQ C)&
Profound hypothermia (elo, FDQ @ H$8Q CI) ma'es the person appear dead& Profound
radycardia, asystole, or ventricular firillation may e present&
*very effort is made to ,arm the patient to at least E8Q @ ($"&"Q C) efore the person is pronounced dead& The
cause of death is usually refractory ventricular firillation&
Treatment of hypothermia focuses on managing and maintaining 56Cs, re,arming the patient, correcting
dehydration and acidosis, and treating cardiac dysrhythmias&
Passive or active e)ternal re,arming is used for mild hypothermia&
Passive e"ternal rewarming involves moving the patient to a ,arm, dry place,
removing damp clothing, and placing ,arm lan'ets on the patient&
,ctive e"ternal rewarming involves ody+to+ody contact, fluid+ or air+filled
,arming lan'ets, or radiant heat lamps&
,ctive core rewarming is used for moderate to profound hypothermia and refers to the use of
heated, humidified o)ygen! ,armed .3 fluids! and peritoneal, gastric, or colonic lavage ,ith
,armed fluids&
?e,arming places the patient at ris' for afterdrop, a further drop in core temperature, and can result in
hypotension and dysrhythmias&
?e,arming should e discontinued once the core temperature reaches ECQ @ ($CQ C)&
S5/M-S'$N 'NB5-6
Submersion in*ur. results ,hen a person ecomes hypo)ic due to sumersion in a sustance, usually ,ater&
Drowning is death from suffocation after sumersion in ,ater or other fluid medium& 5ear$drowning is defined
as survival from potential dro,ning& -mmersion syndrome occurs ,ith immersion in cold ,ater, ,hich
leads to stimulation of the vagus nerve and potentially fatal dysrhythmias&
5ggressive resuscitation efforts and the mammalian diving refle) improve survival of near+dro,ning victims
even after sumersion in cold ,ater for long periods of time&
Treatment of sumersion in#uries focuses on correcting hypo)ia, acid+ase imalances, and fluid imalances!
supporting asic physiologic functions! and re,arming ,hen hypothermia is present&
.nitial evaluation involves assessment of air,ay, cervical spine, reathing, and circulation&
:echanical ventilation ,ith positive end+e)piratory pressure or continuous positive air,ay
pressure may e used to improve gas e)change across the alveolar+capillary memrane ,hen
1+$"8
Key Points
significant pulmonary edema is present&
=eterioration in neurologic status suggests cereral edema, ,orsening hypo)ia, or profound acidosis&
5ll victims of near+dro,ning should e oserved in a hospital for a minimum of % to D hours& Delayed
pulmonary edema (also 'no,n as secondary dro,ning) can occur and is defined as delayed death from
dro,ning due to pulmonary complications&
AN'MAL /',S
Children are at greatest ris' for animal ites, and the most significant prolems associated ,ith animal ites are
infection and mechanical destruction of the s'in, muscle, tendons, lood vessels, and one&
5nimal ites from dogs and cats are the most common, follo,ed y ites from ,ild or domestic rodents&
Cat ites cause deep puncture ,ounds that can involve tendons and #oint capsules and result in a greater
incidence of infection& Beptic arthritis, osteomyelitis, and tenosynovitis are common&
>uman ites also cause puncture ,ounds or lacerations and carry a high ris' of infection from oral acterial
flora and the hepatitis virus&
>ands, fingers, ears, nose, vagina, and penis are the most common sites of human ites and
are fre<uently a result of violence or se)ual activity&
6o)er(s fracture, fracture of the fourth or fifth metacarpal, is often associated ,ith an open
,ound ,hen the 'nuc'les stri'e teeth&
.nitial treatment for animal and human ites includes cleaning ,ith copious irrigation, deridement, tetanus
prophyla)is, and analgesics as needed&
Prophylactic antiiotics are used for animal and human ites at ris' for infection such as
,ounds over #oints, those more than D to 1" hours old, puncture ,ounds, and ites of the hand
or foot&
Puncture ,ounds are left open, lacerations are loosely sutured, and ,ounds over #oints are
splinted&
Consideration of raies prophyla)is is an essential component in the management of animal
ites& 5n initial in#ection of raies immune gloulin is given, follo,ed y a series of five
in#ections of human diploid cell vaccine on days 8, $, 9, 1%, and "F to provide active
immunity&
P$'S$N'N4S
5 poison is any chemical that harms the ody, and poisoning can e accidental, occupational, recreational, or
intentional&
Beverity of the poisoning depends on type, concentration, and route of e)posure&
Bpecific management of to)ins involves decreasing asorption, enhancing elimination, and implementation of
to)in+specific interventions per the local poison control center
;ptions for decreasing asorption of poisons include gastric lavage, activated charcoal,
dermal cleansing, and eye irrigation&
Patients ,ith an altered level of consciousness or diminished gag refle) must e
1+$"1
Key Points
intuated efore lavage&
2avage must e performed ,ithin " hours of ingestion of most poisons and is
contraindicated in patients ,ho ingested caustic agents, co+ingested sharp o#ects, or
ingested nonto)ic sustances&
The most effective intervention for management of poisonings is administration of
activated charcoal orally or via a gastric tue ,ithin D8 minutes of poison ingestion&

Contraindications to charcoal administration are diminished o,el sounds,
ileus, or ingestion of a sustance poorly asored y charcoal&
Charcoal can asor and neutralize antidotes, and these should not e given
immediately efore, ,ith, or shortly after, charcoal&
B'in and ocular decontamination involves removal of to)ins from eyes and s'in using copious
amounts of ,ater or saline& -ith the e)ception of mustard gas, most to)ins can e safely
removed ,ith ,ater or saline&
-ater mi)es ,ith mustard gas and releases chlorine gas&
=econtamination ta'es priority over all interventions e)cept asic life support
techni<ues&
*limination of poisons is increased through administration of cathartics, ,hole+o,el
irrigation, hemodialysis, hemoperfusion, urine al'alinization, chelating agents, and antidotes&
5 cathartic such as soritol is given ,ith the first dose of activated charcoal to
stimulate intestinal motility and increase elimination&
>emodialysis and hemoperfusion are reserved for patients ,ho develop severe
acidosis from ingestion of to)ic sustances&
2'$LNC
2iolence is the acting out of the emotions of fear or anger to cause harm to someone or something&
.t may e the result of organic disease, psychosis, or antisocial ehavior&
3iolence can ta'e place in a variety of settings, including the home, community, and ,or'place&
*=s have een identified as high+ris' areas for wor7place violence#
Domestic !iolence is a pattern of coercive ehavior in a relationship that involves fear, humiliation,
intimidation, neglect, and1or intentional physical, emotional, financial, or se)ual in#ury&
.t is found in all professions, cultures, socioeconomic groups, ages, and oth genders! although
men can e victims of domestic violence, most victims are ,omen, children, and the elderly&
.t has een reported that 1&C million ,omen and F$%,888 men treated at *=s have een battered
(assaulted) y spouses, significant others, or individuals 'no,n to them&
Bcreening for domestic violence is re<uired for any patient ,ho is found to e a victim of ause&
5ppropriate interventions should e initiated, including ma'ing referrals, providing emotional support, and
informing victims aout their options&
A4N,S $+ ,--$-'SM
Terrorism involves overt actions such as the dispensing of disease pathogens (bioterrorism) or other agents
(e&g&, chemical, radiologic1nuclear, e)plosive devices) as ,eapons for the e)pressed purpose of causing
harm&
The pathogens most li'ely to e used in a ioterrorist attac' are anthra), smallpo), otulism,
plague, tularemia, and hemorrhagic fever&
Those agents that cause anthra), plague, and tularemia can e treated effectively ,ith
commercially availale antiiotics if sufficient supplies are availale and the organisms
are not resistant&
Bmallpo) can e prevented or ameliorated y vaccination even ,hen first given after
1+$""
Key Points
e)posure&
6otulism can e treated ,ith antito)in&
There is no estalished treatment for viruses that cause hemorrhagic fever&
Chemicals used as agents of terrorism are categorized according to their target organ or effect&
Barin is a highly to)ic nerve gas that can cause death ,ithin minutes of e)posure& Barin
enters the ody through the eyes and s'in and acts y paralyzing the respiratory muscles!
antidotes for nerve agent poisoning include atropine and pralido)ime chloride&
Phosgene is a colorless gas normally used in chemical manufacturing& .f inhaled at high
concentrations for a long enough period, it causes severe respiratory distress, pulmonary
edema, and death&
:ustard gas is yello, to ro,n in color and has a garlic+li'e odor& The gas irritates the
eyes and causes s'in urns and listers&
?adiologic1nuclear agents represent another category of agents of terrorism&
!adiologic dispersal devices, %!!D& also 'no,n as /dirty oms,0 consist of a mi) of
e)plosives and radioactive material&
-hen the device is detonated, the last scatters radioactive dust, smo'e, and other
material into the surrounding environment resulting in radioactive contamination&
The main danger from an ??= results from the e)plosion& The radioactive materials used
in an ??= do not usually generate enough radiation to cause immediate serious illness,
e)cept to those casualties ,ho are in close pro)imity to the e)plosion&
Bince radiation cannot e seen, smelled, felt, or tasted, measures to limit contamination
and decontamination should e initiated&
-oni2ing radiation (e&g&, nuclear om, damage to a nuclear reactor) represents a serious threat to
the safety of the casualties and the environment&
*)posure to ionizing radiation may or may not include s'in contamination ,ith
radioactive material! if e)ternal radioactive contaminants are present, decontamination
procedures must e initiated immediately&
5cute radiation syndrome develops after a sustantial e)posure to ionizing radiation and
follo,s a predictale pattern&

*)plosive devices used as agents of terrorism result in one or more of the follo,ing types of
in#uries: last, crush, or penetrating&
6last in#uries result from the supersonic over+pressurization shoc' ,ave that occurs
follo,ing the e)plosion, causing damage to the lungs, middle ear, and gastrointestinal
tract&
Crush in#uries often result from e)plosions that occur in confined spaces and result from
structural collapse&
Bome e)plosive devices contain materials that are pro#ected during the e)plosion, leading
to penetrating in#uries&
M-4NC6 AND MASS CAS5AL,6 'NC'DN, P-PA-DNSS
The term emergenc. usually refers to any e)traordinary event that re<uires a rapid and s'illed response and that
can e managed y a community(s e)isting resources&

5n emergency is differentiated from a mass casualt. incident (:C.) in that an :C. is a manmade (e&g&,
iologic ,arfare) or natural (e&g&, hurricane) event or disaster that over,helms a community(s aility to
respond ,ith e)isting resources&

:C.s usually involve large numers of casualties, involve physical and emotional suffering,
and result in permanent changes ,ithin a community&
:C.s al,ays re<uire assistance from people and resources outside the affected community
(e&g&, 5merican ?ed Cross, @ederal *mergency :anagement 5gency H@*:5I)&
1+$"$
Key Points
-hen an emergency or :C. occurs, first responders (i&e&, police, emergency medical personnel) are dispatched
to the scene&
Triage of casualties of an emergency or :C. differs from the usual triage that occurs in the *=
and must e conducted in less than 1C seconds&
5 system of colored tags is used to designate oth the seriousness of the in#ury and the li'elihood
of survival&
5 green (minor in#ury) or .ellow (nonNlife+threatening in#ury) tag is used to indicate a
non+critical in#ury&
5 red tag indicates a life+threatening in#ury re<uiring immediate intervention&
5 blac0 tag is used to identify those casualties ,ho are deceased or ,ho are e)pected to
die&
Casualties need to e treated and stailized, and if there is 'no,n or suspected contamination,
decontaminated at the scene, and then transported to hospitals&
:any casualties ,ill arrive at hospitals on their o,n (i&e&, ,al'ing ,ounded)&
The total numer of casualties a hospital can e)pect is estimated y douling the numer of
casualties that arrive in the first hour&
Aenerally, $8K of casualties ,ill re<uire admission to the hospital, and C8K of these ,ill need
surgery ,ithin F hours&
:any communities have initiated programs to develop community emergency response teams (C*?Ts)&
C*?Ts have een recognized y @*:5 as important partners in emergency preparedness, and the
training helps citizens to understand their personal responsiility in preparing for a natural or
manmade disaster&
Citizens are taught ,hat to e)pect follo,ing a disaster and ho, to safely help themselves, their
family, and their neighors&
Training includes the teaching of life+saving s'ills, ,ith an emphasis on decision+ma'ing and
rescuer safety&
5ll health care providers have a role in emergency and :C. preparedness, and 'no,ledge of the hospital(s
emergency response plan and participation in emergency1:C. preparedness drills are re<uired&

?esponse to :C.s often re<uires the aid of a federal agency such as the National =isaster :edical Bystem
(N=:B), ,hich is a division ,ithin the 4&B& =epartment of >omeland Becurity that is responsile for the
coordination of the federal medical response to :C.s&
;ne component of the N=:B is to organize and train volunteer disaster medical assistance
teams (=:5Ts)&
=:5Ts are categorized according to their aility to respond to an :C.& 5 2evel+1 =:5T
can e deployed ,ithin F hours of notification and remain self+sufficient for 9" hours
,ith enough food, ,ater, shelter, and medical supplies to treat aout "C8 patients per day&
2evel+" =:5Ts lac' enough e<uipment to e self+sufficient ut are used to replace a
2evel+1 team, using and supplementing the e<uipment left on site&
:any hospitals and =:5Ts have a critical incident stress management unit that arranges
group discussions to allo, participants to veralize and validate their feelings and
emotions aout the e)perience to facilitate psychologic recovery&
1+$"%

Medsurg Nursing KEY POINTS Lecture Notes Ch1 69

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Medsurg Nursing KEY POINTS Lecture Notes Ch1 69

Uploaded by

Copyright:

Available Formats

Lewis et al: Medical-Surgical Nursing: Assessment and Management of

) and secreting e)cess >

You might also like