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ISBN-10 ‏ : ‎ 0323086780
ISBN-13 ‏ : ‎ 978-0323086783
Author: Sharon L. Lewis (Author), Shannon Ruff Dirksen (Author), Margaret McLean Heitkemper (Author), Linda Bucher (Author)

Over the past three decades, more and more nursing educators have turned to Lewis: Medical-Surgical Nursing for its accurate and up-to-date coverage of the latest trends, hot topics, and clinical developments in the field of medical-surgical nursing ― and the new ninth edition is no exception! Written by a dedicated team of expert authors led by Sharon Lewis, Medical-Surgical Nursing, 9th Edition offers the same easy-to-read style that students have come to love, along with the timely and thoroughly accurate content that educators have come to trust. Completely revised and updated content explores patient care in various clinical settings and focuses on key topics such as prioritization, critical thinking, patient safety, and NCLEX^® exam preparation. Best of all ― a complete collection of interactive student resources creates a more engaging learning environment to prepare you for clinical practice.

Table of Content:

Sharon L. Lewis, RN, PhD, FAAN
Shannon Ruff Dirksen, RN, PhD, FAAN
Margaret McLean Heitkemper, RN, PhD, FAAN
Linda Bucher, RN, PhD, CEN, CNE
Contributors
Reviewers
To the Profession of Nursing and to the Important People in Our Lives
Preface
Organization
Classic Features
New Features
Learning Supplements for Students
Teaching Supplements for Instructors
Acknowledgments
Authors of Teaching and Learning Resources
Special Features
Assessment Abnormalities Tables
Case Studies
End-of-Chapter Case Studies
Managing Multiple Patients Case Studies
Assessment Case Studies
Collaborative Care Tables
Complementary & Alternative Therapies Boxes
Cultural & Ethnic Health Disparities Boxes
Delegation Decisions Boxes
Diagnostic Studies Tables
Drug Therapy Tables
Emergency Management Tables
Ethical/Legal Dilemmas Boxes
Evidence-Based Practice
Applying the Evidence Boxes
Evidence-Based Practice
Translating Research Into Practice Boxes
Focused Assessment Boxes
Gender Differences Boxes
Genetics in Clinical Practice Boxes
Gerontologic Assessment Differences Tables
Health History Tables
Healthy People Boxes
Informatics in Practice Boxes
Nursing Assessment Tables
Nursing Care Plans
Nutritional Therapy Tables
Patient & Caregiver Teaching Guide Tables
Pre-Test – Medical-Surgical Nursing
Interactive Review – Medical-Surgical Nursing
Volume 1
Section 1 Concepts in Nursing Practice
Concepts in Nursing Practice
Pre-Test – Section 1
Interactive Review – Section 1
Chapter 1 Professional Nursing Practice
Learning Outcomes
Key Terms
eFigures
eTables
Professional Nursing Practice
Domain of Nursing Practice
FIG. 1-1 Nurses are frontline professionals of health care.
Definitions of Nursing
Nursing’s View of Humanity
Scope of Nursing Practice
Influences on Professional Nursing Practice
Complex Health Care Environments
Expanding Knowledge and Technology.
Diverse Populations.
Consumerism.
Influences on Health Care Systems
Health Care Financing.
Ethical/Legal Dilemmas: Social Networking: HIPAA Violation
Situation
Ethical/Legal Points for Consideration
Discussion Questions
FIG. 1-2 The patient, family, and nurse collaborate as part of coordinating high-quality care.
Healthy People Initiative.
Supporting Professional Practice
Professional Nursing Organizations.
TABLE 1-1 HEALTHY PEOPLE 2020
QSEN.
Patient-Centered Care
Delivery of Nursing Care
Continuum of Patient Care
Critical Thinking
Nursing Process
FIG. 1-3 Nursing process.
Standardized Nursing Terminologies
TABLE 1-2 ANA-RECOGNIZED NURSING TERMINOLOGIES
NANDA-I Nursing Diagnoses.
Nursing Outcomes Classification (NOC).
Nursing Interventions Classification (NIC).
TABLE 1-3 EXAMPLE OF NANDA-NOC-NIC LINKAGE
NANDA-NOC-NIC Linkages.
Nursing Care Plans
FIG. 1-4 Integration of NANDA, NIC, and NOC into the nursing process.
Nursing Care Plan 1-1 Patient with Heart Failure*
Nursing Diagnosis
Patient Goal
FIG. 1-5 Concept map.
Informatics and Technology
Information and Technology in Practice
Clinical Information Systems and Electronic Health Records
Nursing Informatics
Computer Languages
Telehealth
FIG. 1-6 Telemonitoring. A, Remote blood pressure monitoring. B, Videoconference with health care provider.
Evidence-Based Practice
Steps of EBP Process
Step 0 of EBP.
Step 1 of EBP.
Step 2 of EBP.
TABLE 1-4 STEPS OF EVIDENCE-BASED PRACTICE (EBP) PROCESS
Step 3 of EBP.
Step 4 of EBP.
Step 5 of EBP.
Step 6 of EBP.
Implementing EBP
Safety and Quality Improvement
FIG. 1-7 Quality improvement system.
National Patient Safety Goals
Teamwork and Collaboration
Interdisciplinary Team Members
TABLE 1-5 NATIONAL PATIENT SAFETY GOALS*
TABLE 1-6 INTERDISCIPLINARY TEAM MEMBERS
Coordinating Care Among Health Care Team Members
Communication.
Case Management.
TABLE 1-7 GUIDELINES FOR COMMUNICATING USING SBAR
Clinical Pathways.
Delegation and Assignment.
TABLE 1-8 FIVE RIGHTS OF NURSING DELEGATION
Delegation Decisions Delegation Decisions Boxes Throughout Book
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 2 Health Disparities and Culturally Competent Care
Learning Outcomes
Key Terms
eTables
Determinants of Health
FIG. 2-1 Determinants of health.
Healthy People Access to Health Services
Health Disparities and Health Equity
Factors and Conditions Leading to Health Disparities
Ethical/Legal Dilemmas Health Disparities
Situation
Ethical/Legal Points for Consideration
Discussion Questions
TABLE 2-1 FACTORS AND CONDITIONS LEADING TO HEALTH DISPARITIES
Ethnicity and Race.
Cultural & Ethnic Health Disparities Cultural & Ethnic Health Disparities Boxes Throughout Book
Place and Health.
Income, Education, and Occupation.
FIG. 2-2 Percentage of adults ages 18 to 64 years old who skipped or delayed medical care because of cost. The data are displayed by disability and insurance coverage status.
Gender.
Age.
Sexual Orientation.
FIG. 2-3 Older Asian women are especially at risk for health disparities.
Health Care Provider Attitudes.
Culture
TABLE 2-2 BASIC CHARACTERISTICS OF CULTURE
TABLE 2-3 DISTINCT CULTURAL CHARACTERISTICS OF DIFFERENT ETHNIC GROUPS IN THE UNITED STATES
Native American
Hispanic/Latino
African American
European American
Asian American
Pacific Islander American
FIG. 2-4 Members of this family share a common heritage.
Cultural Competence
TABLE 2-4 HOW TO DEVELOP CULTURAL COMPETENCE
Cultural Diversity in the Health Care Workplace
FIG. 2-5 Nurses working together in a multicultural health care environment.
Cultural Factors Affecting Health and Health Care
Folk Healers
Spirituality and Religion
TABLE 2-5 CULTURAL FACTORS AFFECTING HEALTH AND HEALTH CARE
Cross-Cultural Communication
FIG. 2-6 Co-workers from different cultures communicate with verbal and nonverbal cues.
TABLE 2-6 HEALTH-RELATED BELIEFS AND PRACTICES OF SELECTED RELIGIOUS GROUPS
Family Roles and Relationships
FIG. 2-7 Family roles and relationships differ from one culture to another.
Personal Space
Touch
Nutrition
Immigrants and Immigration
FIG. 2-8 Recently arrived immigrants join a neighbor for a barbecue, a common American tradition.
Medications
Psychologic Factors
TABLE 2-7 CULTURAL ASSESSMENT*
Nursing Management Reducing Health Disparities and Increasing Cultural Competency
Nurse’s Self-Assessment
TABLE 2-8 CULTURE-BOUND SYNDROMES
Patient Assessment
Nursing Implementation
Advocacy.
TABLE 2-9 NURSING INTERVENTIONS TO REDUCE HEALTH DISPARITIES
FIG. 2-9 A Navajo nurse instructs a Navajo patient.
Standardized Guidelines.
Communication.
TABLE 2-10 USING A MEDICAL INTERPRETER
TABLE 2-11 GUIDELINES FOR COMMUNICATING WHEN NO INTERPRETER IS AVAILABLE
Informatics in Practice Use of Translation Applications
Case Study Health Disparities
Patient Profile
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 3 Health History and Physical Examination
Learning Outcomes
Key Terms
eTables
Data Collection
Medical Focus
Nursing Focus
Types of Data
FIG. 3-1 Obtaining and recording data from a nursing history and physical examination using a computer.
Interview Considerations
Symptom Investigation
TABLE 3-1 INVESTIGATION OF PATIENT-REPORTED SYMPTOM
Data Organization
Culturally Competent Care
Assessment
Nursing History: Subjective Data
Important Health Information
Delegation Decisions Assessment and Data Collection
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Past Health History.
Medications.
Complementary & Alternative Therapies Assessment of Use of Herbs and Dietary Supplements
Why Assessment Is Important
Nurse’s Role
Allergies.
Surgery or Other Treatments.
Functional Health Patterns
Health Perception–Health Management Pattern.
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
TABLE 3-2 HEALTH HISTORY: Functional Health Pattern Format
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Physical Examination: Objective Data
General Survey
Physical Examination
Techniques.
Inspection.
Palpation.
Percussion.
Auscultation.
FIG. 3-2 Palpation is the examination of the body using touch.
FIG. 3-3 Percussion technique. Tapping the interphalangeal joint. Only the middle finger of the nondominant hand should be in contact with the skin surface.
Equipment.
Organization of Examination.
FIG. 3-4 Auscultation is listening to sounds produced by the body to assess normal conditions and deviations from normal.
TABLE 3-3 EQUIPMENT FOR PHYSICAL EXAMINATION*
Recording Physical Examination.
Types of Assessment
Comprehensive Assessment
TABLE 3-4 OUTLINE FOR PHYSICAL EXAMINATION
TABLE 3-5 GERONTOLOGIC ASSESSMENT DIFFERENCES: Adaptations in Physical Assessment Techniques
Focused Assessment
Emergency Assessment
Using Assessment Approaches
TABLE 3-6 TYPES OF ASSESSMENT
Problem Identification and Nursing Diagnoses
TABLE 3-7 CLINICAL APPLICATION OF VARIOUS TYPES OF ASSESSMENT
Bridge to NCLEX Examination
References
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Videos
Chapter 4 Patient and Caregiver Teaching
Learning Outcomes
Key Terms
eFigures
eTable
Role of Patient and Caregiver Teaching
Teaching-Learning Process
Adult Learner
Adult Learning Principles.
Models to Promote Health.
TABLE 4-1 ADULT LEARNING PRINCIPLES APPLIED TO PATIENT AND CAREGIVER TEACHING
TABLE 4-2 STAGES OF CHANGE IN TRANSTHEORETICAL MODEL
TABLE 4-3 KEY ASPECTS OF MOTIVATIONAL INTERVIEWING
Nurse as Teacher
Required Competencies
Knowledge of Subject Matter.
Communication Skills.
Challenges to Nurse-Teacher Effectiveness.
FIG. 4-1 Open, relaxed positioning of patient, spouse, and nurse at eye level promotes communication in teaching and learning.
Caregiver Support in the Teaching-Learning Process
TABLE 4-4 ASSESSMENT OF CAREGIVER NEEDS
Caregiver Stress.
TABLE 4-5 CAREGIVER STRESSORS
Regulatory Mandates for Patient Teaching
TABLE 4-6 THE JOINT COMMISSION’S SPEAK UP™ INITIATIVE
Process of Patient Teaching
Assessment
Physical Factors.
TABLE 4-7 ASSESSMENT OF FACTORS AFFECTING PATIENT TEACHING: Factors and Key Questions
Psychologic Factors.
Sociocultural Factors
Health Literacy.
Cultural Considerations.
FIG. 4-2 Nurse communicating with a non-English-speaking patient using a translation phone service.
Socioeconomic Considerations.
Learner Factors.
Learning Needs.
Readiness to Learn.
Learning Style.
Planning
Setting Goals.
Evidence-Based Practice Translating Research Into Practice
Are Decision Aids Helpful in Making Decisions About Health Care?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Selecting Teaching Strategies.
Learning Materials.
TABLE 4-8 LEARNER CHARACTERISTICS AND TEACHING STRATEGIES BY GENERATION
TABLE 4-9 COMPARISON OF TEACHING STRATEGIES
FIG. 4-3 Effective teaching using a variety of strategies (written materials, video-based patient education programs).
Implementation
Evaluation
FIG. 4-4 Teaching using demonstration and return demonstration (“show back”) increases successful learning by the patient.
TABLE 4-10 TECHNIQUES TO EVALUATE PATIENT AND CAREGIVER LEARNING
Case Study Patient and Caregiver Teaching
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 5 Chronic Illness and Older Adults
Learning Outcomes
Key Terms
eTable
Chronic Illness
TABLE 5-1 CHARACTERISTICS OF ACUTE AND CHRONIC ILLNESS
TABLE 5-2 IMPACT OF CHRONIC ILLNESSES
TABLE 5-3 CHRONIC ILLNESS TRAJECTORY
Trajectory of Chronic Illness
FIG. 5-1 The Chronic Illness Trajectory is a theoretical model of chronic illness. The trajectory model of chronic illness recognizes that chronic illness will have many phases (see Table 5-3).
TABLE 5-4 SEVEN TASKS OF PEOPLE WITH CHRONIC ILLNESS
TABLE 5-5 CHARACTERISTICS OF TREATMENT REGIMENS
Preventing and Managing a Crisis.
Carrying Out Prescribed Treatment Regimens.
Controlling Symptoms.
Reordering Time.
Adjusting to Changes in Course of Disease.
Preventing Social Isolation.
Attempting to Normalize Interactions With Others.
Prevention of Chronic Illness
Nursing Management Chronic Illness
Older Adults
Demographics of Aging
Evidence-Based Practice Translating Research Into Practice
What Is the Effectiveness of Chronic Illness Strategies for Asian/Pacific Islanders?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Attitudes Toward Aging
FIG. 5-2 The aging process can be viewed as a balance between negative and positive factors.
Biologic Aging
Age-Related Physiologic Changes
TABLE 5-6 GERONTOLOGIC ASSESSMENT DIFFERENCES: Summary of Tables
Special Older Adult Populations
Chronically Ill Older Adults
Older Adult Women
TABLE 5-7 GERONTOLOGIC ASSESSMENT DIFFERENCES: Cognitive Function
Gender Differences
Men
Women
Cognitively Impaired Older Adults
Rural Older Adults
FIG. 5-3 Older adults living in rural areas often enjoy outside activities, such as gardening.
FIG. 5-4 Older adults are using computers more frequently and accessing health care information on the Internet.
Informatics in Practice Older Adults and Internet Use
Homeless Older Adults
Frail Older Adults
TABLE 5-8 SCALES: NUTRITIONAL ASSESSMENT OF OLDER ADULTS
Culturally Competent Care
Older Adults
Social Support for Older Adults
Family Caregivers
Elder Mistreatment or Abuse
Self-Neglect
Social Services for Older Adults
Medicare and Medicaid
TABLE 5-9 TYPES OF ELDER MISTREATMENT
TABLE 5-10 NURSING ASSESSMENT: Mistreatment
Care Alternatives for Older Adults
Adult Day Care and Adult Day Health Care
Home Health Care.
FIG. 5-5 Senior centers offer places for older adults who live independently to meet and gather with friends.
Long-Term Care Facilities
Legal and Ethical Issues
FIG. 5-6 Social interaction and acceptance are important for older adults.
Nursing Management Older Adults
Nursing Assessment
Planning
Nursing Implementation
FIG. 5-7 SPICES.
Health Promotion.
Acute Care.
FIG. 5-8 Water aerobics is an example of a health promotion activity for older adults.
Care Transitions.
Rehabilitation.
TABLE 5-11 CARE OF THE HOSPITALIZED OLDER ADULT
FIG. 5-9 The nurse assists a patient in a geriatric rehabilitation facility.
Assistive Devices.
Safety.
Medication Use.
TABLE 5-12 DRUG THERAPY: Common Causes of Medication Errors by Older Adults
FIG. 5-10 The effects of aging on drug metabolism.
Depression.
TABLE 5-13 DRUG THERAPY: Medication Use by Older Adults
Use of Restraints.
Sleep.
Evaluation
TABLE 5-14 EVALUATING NURSING CARE FOR OLDER ADULTS
Case Study Older Adults
Patient Profile
Subjective Data
Psychosocial Data
Objective Data
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 6 Complementary and Alternative Therapies
Learning Outcomes
Key Terms
TABLE 6-1 COMPARISON OF CONVENTIONAL AND INTEGRATIVE HEALTH CARE MODELS
Complementary and Alternative Therapies
NCCAM Categories
TABLE 6-2 NCCAM CATEGORIES OF COMPLEMENTARY AND ALTERNATIVE THERAPIES
Natural Products
TABLE 6-3 WHOLE MEDICAL SYSTEMS
TABLE 6-4 PATIENT & CAREGIVER TEACHING GUIDE: Herbal Therapies
Complementary & Alternative Therapies
TABLE 6-5 COMMONLY USED HERBS*
Mind-Body Medicine
FIG. 6-1 Yoga is an example of both mind-body medicine and manipulative and body-based practices.
Complementary & Alternative Therapies
Yoga
Scientific Evidence
Nursing Implications
FIG. 6-2 Herbs are most commonly administered as a pill or capsule, but the source is a plant, such as echinacea.
Acupuncture.
FIG. 6-3 Acupuncture showing the placement of acupuncture needles.
Manipulative and Body-Based Practices
Massage.
TABLE 6-6 COMMONLY USED DIETARY SUPPLEMENTS*
Massage Techniques.
FIG. 6-4 Hand massage can be a helpful tool to calm down an agitated or nervous patient.
Other CAT Practices
Energy Therapies.
Gerontologic Considerations
Complementary and Alternative Therapies
Nursing Management Complementary and Alternative Therapies
Professional Practice
Knowledge of Therapies.
Assessment of Complementary and Alternative Therapy Use.
Promoting Safe Use of Therapies.
Incorporating Therapies in Practice.
TABLE 6-7 NURSES CAN USE COMPLEMENTARY AND ALTERNATIVE THERAPIES
Self-Care Practice
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
Glossary
Key Points
Stress-Busting Kit for Nursing Students
Chapter 7 Stress and Stress Management
Learning Outcomes
Key Terms
eTable
Definition of Stress
FIG. 7-1 Stressors can be physiologic or emotional/psychologic. Your perception of these stressors will determine whether they cause stress. Events or circumstances become stressful when you perceive them to be.
FIG. 7-2 During stressful situations, the demands seem to exceed the resources.
Factors Affecting Response to Stress
TABLE 7-1 FACTORS AFFECTING PERSON’S RESPONSE TO STRESS
FIG. 7-3 Neurochemical links among the nervous, endocrine, and immune systems. The communication among these three systems is bidirectional.
Physiologic Response to Stress
Nervous System
Cerebral Cortex.
Limbic System.
Reticular Formation.
Hypothalamus.
Endocrine System
FIG. 7-4 Hypothalamic-pituitary-adrenal axis. ACTH, Adrenocorticotropic hormone; CRH, corticotropin-releasing hormone.
Summary of Stress Response
FIG. 7-5 “Fight-or-flight” reaction. Alarm reaction responses resulting from increased sympathetic nervous system (SNS) activity.
Immune System
FIG. 7-6 The cerebral cortex processes stressful stimuli and relays the information via the limbic system to the hypothalamus. Corticotropin-releasing hormone (CRH) stimulates the release of adrenocorticotropic hormone (ACTH) from the pituitary gland. ACTH stimulates the adrenal cortex to release corticosteroids. The sympathetic nervous system is also stimulated, resulting in the release of epinephrine and norepinephrine from the adrenal medulla. The end result is the inhibition of the immune system.
Effects of Stress on Health
TABLE 7-2 DISORDERS WITH A STRESS COMPONENT*
Coping
TABLE 7-3 PROBLEM- AND EMOTION-FOCUSED COPING
TABLE 7-4 COPING STRATEGIES
Relaxation Strategies
TABLE 7-5 RELAXATION BREATHING TECHNIQUES*
Relaxation Breathing
Meditation
TABLE 7-6 GUIDE TO MEDITATION*
Imagery
TABLE 7-7 IMAGERY: CREATING YOUR SPECIAL PLACE*
Music for Relaxation
FIG. 7-7 In imagery, special places are created involving all the senses, such as a place where one can hear rustling water, smell flowers, feel the wind, and see a colorful landscape.
TABLE 7-8 EXAMPLES OF IMAGERY
Massage
Nursing Management Stress
Nursing Assessment
FIG. 7-8 As a nurse, you have an important role in helping patients deal with stress.
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Nursing Implementation
TABLE 7-9 PERSONAL TIPS FOR HANDLING STRESS
TABLE 7-10 HOW TO IMPLEMENT STRESS MANAGEMENT IN PRACTICE
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Case Study Stress-Induced Complaints
Patient Profile
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Stress-Busting Kit for Nursing Students
Chapter 8 Sleep and Sleep Disorders
Learning Outcomes
Key Terms
eFigure
eTables
Sleep
FIG. 8-1 Sleep disorders are common in our society.
TABLE 8-1 SELECTED SLEEP DISORDERS
Physiologic Sleep Mechanisms
Sleep-Wake Cycle
FIG. 8-2 Excessive daytime sleepiness can occur in people with sleep disorders.
Wake Behavior.
Sleep Behavior.
Circadian Rhythms.
Sleep Architecture
NREM Sleep.
REM Sleep.
Insufficient Sleep and Sleep Disorders
FIG. 8-3 Effects of sleep deprivation and sleep disorders on the body.
Insomnia
Etiology and Pathophysiology
TABLE 8-2 RELATIONSHIP OF SLEEP DISTURBANCES TO DISEASES AND DISORDERS
Clinical Manifestations
Diagnostic Studies
Self-Report.
Actigraphy.
Polysomnography.
Collaborative Care
Cognitive-Behavioral Therapy for Insomnia.
TABLE 8-3 COLLABORATIVE CARE: Insomnia
TABLE 8-4 PATIENT TEACHING GUIDE: Sleep Hygiene
TABLE 8-5 DRUG THERAPY: Insomnia
Benzodiazepines
Benzodiazepine-Receptor–like Agents
Melatonin-Receptor Agonist
Antidepressants
Antihistamines
Drug Therapy.
Benzodiazepines.
Benzodiazepine-Receptor–like Agents.
Melatonin-Receptor Agonist.
Antidepressants.
Antihistamines.
Complementary and Alternative Therapies.
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Nursing Management Insomnia
Nursing Assessment
TABLE 8-6 NURSING ASSESSMENT: Sleep
Nursing Diagnoses
Nursing Implementation
TABLE 8-7 CAFFEINE CONTENT OF SELECTED FOODS AND BEVERAGES
Sleep Disturbances in the Hospital
Narcolepsy
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
TABLE 8-8 DRUG THERAPY: Narcolepsy
Nursing and Collaborative Management
Drug Therapy.
Behavioral Therapy.
Circadian Rhythm Disorders
Sleep-Disordered Breathing
Obstructive Sleep Apnea
FIG. 8-4 How sleep apnea occurs. A, The patient predisposed to obstructive sleep apnea (OSA) has a small pharyngeal airway. B, During sleep, the pharyngeal muscles relax, allowing the airway to close. Lack of airflow results in repeated apneic episodes. C, Continuous positive airway pressure (CPAP) splints the airway open, preventing airflow obstruction.
Informatics in Practice Sleep Apnea Diagnosis and Monitoring
Clinical Manifestations and Diagnostic Studies.
Nursing and Collaborative Management Sleep Apnea
Conservative Treatment
FIG. 8-5 Examples of positive airwave pressure devices for sleep apnea. A, Patient wearing a nasal mask and headgear (positive pressure only through nose). B, Patient wearing nasal pillows (positive pressure only through nose). C, Patient wearing a full face mask (positive pressure to both nose and mouth).
Surgical Treatment
Periodic Limb Movement Disorder
Gerontologic Considerations
Sleep
FIG. 8-6 Many older people have sleep problems.
Parasomnias
Special Sleep Needs of Nurses
Case Study Insomnia
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 9 Pain
Learning Outcomes
Key Terms
eFigures
Magnitude of Pain Problem
TABLE 9-1 HARMFUL EFFECTS OF UNRELIEVED ACUTE PAIN
Definitions and Dimensions of Pain
TABLE 9-2 DIMENSIONS OF PAIN
Gender Differences
Men
Women
Pain Mechanisms
Transduction.
FIG. 9-1 Nociceptive pain originates when the tissue is injured. 1, Transduction occurs when there is release of chemical mediators. 2, Transmission involves the conduct of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. 3, Perception is the conscious awareness of pain. 4, Modulation involves signals from the brain going back down the spinal cord to modify incoming impulses.
Transmission.
Transmission to Spinal Cord.
Dorsal Horn Processing.
Transmission to Thalamus and Cortex.
Perception.
FIG. 9-2 Typical areas of referred pain.
Modulation.
Classification of Pain
TABLE 9-3 COMPARISON OF NOCICEPTIVE AND NEUROPATHIC PAIN
Nociceptive Pain
Neuropathic Pain
TABLE 9-4 DIFFERENCES BETWEEN ACUTE AND CHRONIC PAIN
Acute and Chronic Pain
TABLE 9-5 CORE PRINCIPLES OF PAIN ASSESSMENT
Pain Assessment
Elements of a Pain Assessment
Pain Pattern.
TABLE 9-6 NURSING ASSESSMENT: Pain
Location.
Intensity.
FIG. 9-3 Pain thermometer scale. Ask the patient to circle words next to the thermometer or to mark the area on the thermometer to indicate the intensity of pain.
Quality.
Associated Symptoms.
Management Strategies.
Impact of Pain.
Patient’s Beliefs, Expectations, and Goals.
Documentation
Reassessment
Pain Treatment
Basic Principles
TABLE 9-7 DRUG THERAPY: Managing Side Effects of Pain Medications
Drug Therapy for Pain
Nonopioids.
TABLE 9-8 DRUG THERAPY: Selected Nonopioid Analgesics
FIG. 9-4 Arachidonic acid is oxidized by two different pathways: lipoxygenase and cyclooxygenase. The cyclooxygenase pathway leads to two forms of the enzyme cyclooxygenase: COX-1 and COX-2. COX-1 is known as constitutive (always present), and COX-2 is known as inducible (its expression varies markedly depending on the stimulus). Nonsteroidal antiinflammatory drugs (NSAIDs) differ in their actions, with some having more effects on COX-1 and others more on COX-2. Indomethacin acts primarily on COX-1, whereas ibuprofen is equipotent on COX-1 and COX-2. Celecoxib primarily inhibits COX-2.
Drug Alert
Opioids.
Types of Opioids.
Drug Alert
Drug Alert
Mixed Mu Agonist Opioid and Dual Mechanism Agents.
TABLE 9-9 DRUG THERAPY: Opioid Analgesics
TABLE 9-10 OPIOID EQUIANALGESIC DOSES*
Opioids to Avoid.
Drug Alert
Side Effects of Opioids.
Safety Alert
TABLE 9-11 PASERO OPIOID-INDUCED SEDATION SCALE (POSS) WITH INTERVENTIONS
Adjuvant Analgesic Therapy.
Corticosteroids.
Antidepressants.
Antiseizure Drugs.
GABA Receptor Agonist.
α2-Adrenergic Agonists.
Local Anesthetics.
TABLE 9-12 DRUG THERAPY: Adjuvant Drugs Used for Pain
Cannabinoids.
Administration
Scheduling.
Titration.
Equianalgesic Dosing.
Administration Routes.
Oral.
Transmucosal and Buccal Routes.
Intranasal Route.
Rectal.
Transdermal Route.
Drug Alert
Parenteral Routes.
FIG. 9-5 Spinal anatomy. The spinal cord extends from the foramen magnum to the first or second lumbar vertebral space. The subarachnoid space (intrathecal space) is filled with cerebrospinal fluid that continuously circulates and bathes the spinal cord. The epidural space is a potential space filled with blood vessels, fat, and a network of nerve extensions.
Intraspinal Delivery.
Implantable Pumps.
Patient-Controlled Analgesia.
Interventional Therapy
Therapeutic Nerve Blocks.
Neuroablative Techniques.
Neuroaugmentation.
FIG. 9-6 Sites of neurosurgical procedures for pain relief.
Nondrug Therapies for Pain
Physical Pain Relief Strategies
Massage.
Exercise.
TABLE 9-13 NONDRUG THERAPIES FOR PAIN
Transcutaneous Electrical Nerve Stimulation.
Acupuncture.
Heat Therapy.
FIG. 9-7 Transcutaneous electrical nerve stimulation (TENS) treatment being given for treatment of pain after shoulder surgery.
TABLE 9-14 PATIENT & CAREGIVER TEACHING GUIDE: Heat and Cold Therapy
Cold Therapy.
Cognitive Therapies.
Distraction.
Hypnosis.
Relaxation Strategies.
Nursing and Collaborative Management Pain
Effective Communication
Challenges to Effective Pain Management
Tolerance.
TABLE 9-15 PATIENT & CAREGIVER TEACHING GUIDE: Pain Management
Physical Dependence.
Pseudoaddiction.
Addiction.
TABLE 9-16 MANIFESTATIONS OF OPIOID WITHDRAWAL SYNDROME
Delegation Decisions Pain
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
TABLE 9-17 PATIENT & CAREGIVER TEACHING GUIDE: Reducing Barriers to Pain Management
Institutionalizing Pain Education and Management
Ethical Issues in Pain Management
Fear of Hastening Death by Administering Analgesics
Requests for Assisted Suicide
Use of Placebos in Pain Assessment and Treatment
Gerontologic Considerations
Pain
Managing Pain in Special Populations
Patients Unable to Self-Report Pain
TABLE 9-18 ASSESSING PAIN IN NONVERBAL PATIENTS
Patients With Substance Abuse Problems
Case Study Pain
Patient Profile
Subjective Data
Objective Data
Discussion Questions
Bridge to NCLEX Examination
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eFigures
Glossary
Key Points
Stress-Busting Kit for Nursing Students
Chapter 10 Palliative Care at End of Life
Learning Outcomes
Key Terms
Palliative Care
TABLE 10-1 GOALS OF PALLIATIVE CARE
FIG. 10-1 One goal of palliative care is to improve the quality of the patient’s remaining life.
FIG. 10-2 Integrated model of curative care, palliative and end-of-life care, and bereavement care.
Hospice Care
FIG. 10-3 Relationship of palliative care, end-of-life care, and hospice care.
FIG. 10-4 Hospice care is designed to provide compassion, concern, and support for the dying.
FIG. 10-5 Inpatient hospice settings have been deinstitutionalized to make the atmosphere as relaxed and homelike as possible.
Death
End-of-Life Care
Physical Manifestations at End of Life
TABLE 10-2 PHYSICAL MANIFESTATIONS AT END OF LIFE
Psychosocial Manifestations at End of Life
TABLE 10-3 PSYCHOSOCIAL MANIFESTATIONS AT END OF LIFE
TABLE 10-4 KÜBLER-ROSS MODEL OF GRIEF
Bereavement and Grief
FIG. 10-6 The grief wheel model begins with the normal state at the bottom. After a person goes through the grief process, eventually the grief will resolve. However, because of the loss, the normal state is not the same as before. The challenge is to accept the “new normal.”
Spiritual Needs
TABLE 10-5 SPIRITUAL ASSESSMENT
FIG. 10-7 Spiritual needs are an important consideration in end-of-life care.
Culturally Competent Care
End of Life
Legal and Ethical Issues Affecting End-of-Life Care
Organ and Tissue Donation
Advance Care Planning and Advance Directives
Resuscitation
TABLE 10-6 COMMON DOCUMENTS USED IN END-OF-LIFE CARE
Ethical/Legal Dilemmas End-of-Life Care
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Nursing Management End of Life
Nursing Assessment
Planning
Nursing Implementation
Psychosocial Care.
Anxiety and Depression.
Anger.
TABLE 10-7 NURSING ASSESSMENT: Psychosocial Care at End of Life
Hopelessness and Powerlessness.
Fear.
Fear of Pain.
FIG. 10-8 Dying patients typically want someone whom they know and trust to stay with them.
Fear of Shortness of Breath.
Fear of Loneliness and Abandonment.
Fear of Meaninglessness.
Communication.
Physical Care.
Postmortem Care.
Special Needs of Caregivers and Nurses in End-of-Life Care
Special Needs of Family Caregivers
TABLE 10-8 NURSING MANAGEMENT: Physical Care at End of Life
Special Needs of Nurses
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Chapter 11 Substance Abuse
Learning Outcomes
Key Terms
eTable
TABLE 11-1 TERMINOLOGY OF SUBSTANCE ABUSE
TABLE 11-2 COMMON HEALTH PROBLEMS RELATED TO SUBSTANCE ABUSE
Common Drugs of Abuse
Nicotine
Effects of Use and Complications
TABLE 11-3 CLINICAL PRACTICE GUIDELINE: Treating Tobacco Use and Dependence
Nursing and Collaborative Care Tobacco Use
Tobacco Cessation
FIG. 11-1 Clinical practice guidelines: treating tobacco use and dependence.
TABLE 11-4 INPATIENT TOBACCO CESSATION INTERVENTIONS
TABLE 11-5 PATIENT TEACHING GUIDE: Smoking and Tobacco Use Cessation
TABLE 11-6 DRUG THERAPY: Smoking Cessation*
Drug Alert
Alcohol
Effects of Use and Complications
FIG. 11-2 Alcohol is often used to cope with the stresses of life.
Nursing and Collaborative Care Alcohol Dependence
Alcohol Intoxication
TABLE 11-7 EFFECTS OF CHRONIC ALCOHOL ABUSE
TABLE 11-8 CLINICAL MANIFESTATIONS AND TREATMENT OF ALCOHOL WITHDRAWAL
Alcohol Withdrawal Syndrome
Nursing Care Plan 11-1
Nursing Diagnosis
Patient Goals
Substance Withdrawal Severity
Distorted Thought Self-Control
Substance Use Treatment: Alcohol Withdrawal
Seizure Precautions
Delirium Management
Nursing Diagnosis
Patient Goals
Alcohol Abuse Cessation Behavior
Substance Use Treatment
TABLE 11-9 CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT OF ALCOHOL SCALE, REVISED (CIWA-Ar)*
Other Drugs of Abuse
Stimulants
Nursing and Collaborative Care Stimulant Abuse
Overdose
Withdrawal
Depressants
Sedative-Hypnotics
Opioids
TABLE 11-10 COMMONLY ABUSED ADDICTIVE SUBSTANCES
Nursing and Collaborative Care Depressant Abuse
Overdose
Sedative-Hypnotics.
FIG. 11-3 Use of oxycodone injections has increased rapidly.
Opioids.
TABLE 11-11 EMERGENCY MANAGEMENT: Cocaine and Amphetamine Toxicity
Cardiovascular
Central Nervous System
Other
TABLE 11-12 EMERGENCY MANAGEMENT: Depressant Drug Overdose
Withdrawal
Sedative-Hypnotics.
Opioids.
Cannabis
Nursing Management Substance Abuse
Nursing Assessment
TABLE 11-13 ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)
TABLE 11-14 DRUG ABUSE SCREENING TEST (DAST-10)
TABLE 11-15 SIGNS SUGGESTING SUBSTANCE ABUSE
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Gerontologic Considerations
Substance Abuse
Case Study Substance Misuse and Abuse
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Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Tests
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Managing Multiple Patients
Introduction
Patients
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Case Study Progression
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Section 2 Pathophysiologic Mechanisms of Disease
Pathophysiologic Mechanisms of Disease
Pre-Test – Section 2
Interactive Review – Section 2
Chapter 12 Inflammation and Wound Healing
Learning Outcomes
Key Terms
eFigures
eTables
Inflammatory Response
FIG. 12-1 Vascular and cellular responses to tissue injury.
Vascular Response
Cellular Response
Neutrophils.
Monocytes.
TABLE 12-1 MEDIATORS OF INFLAMMATION
Lymphocytes.
Chemical Mediators
Complement System.
Prostaglandins and Leukotrienes.
FIG. 12-2 Pathway of generation of prostaglandins, thromboxane, and leukotrienes. Corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDs), and acetylsalicylic acid (ASA) act to inhibit various steps in this pathway.
Exudate Formation
Clinical Manifestations
Fever.
TABLE 12-2 TYPES OF INFLAMMATORY EXUDATE
TABLE 12-3 LOCAL MANIFESTATIONS OF INFLAMMATION
FIG. 12-3 Production of fever. When monocytes/macrophages are activated, they secrete cytokines such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor (TNF), which reach the hypothalamic temperature-regulating center. These cytokines promote the synthesis and secretion of prostaglandin E2 (PGE2) in the anterior hypothalamus. PGE2 increases the thermostatic set point, and the autonomic nervous system is stimulated, resulting in shivering, muscle contraction, and peripheral vasoconstriction.
Types of Inflammation
Nursing and Collaborative Management Inflammation
Nursing Implementation
Health Promotion.
Acute Intervention
Observation and Vital Signs.
Fever.
Drug Therapy.
TABLE 12-4 DRUG THERAPY: Inflammation and Healing
RICE.
Rest.
Cold and Heat.
Compression and Immobilization.
Elevation.
Healing Process
Regeneration
Repair
TABLE 12-5 REGENERATIVE ABILITY OF DIFFERENT TYPES OF TISSUES
FIG. 12-4 Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention.
Primary Intention.
Initial Phase.
TABLE 12-6 PHASES IN PRIMARY INTENTION HEALING
Granulation Phase.
Maturation Phase and Scar Contraction.
Secondary Intention.
Tertiary Intention.
Wound Classification
Complications of Healing
Nursing and Collaborative Management Wound Healing
Nursing Assessment
TABLE 12-7 RED-YELLOW-BLACK CONCEPT OF WOUND CARE
Nursing Implementation
TABLE 12-8 COMPLICATIONS OF WOUND HEALING
FIG. 12-5 Dehiscence following a cholecystectomy.
FIG. 12-6 Postoperative deep wound infection following wrist surgery.
FIG. 12-7 Hypertrophic scarring.
FIG. 12-8 Keloid scarring.
Red, Yellow, and Black Wounds.
Red Wounds.
FIG. 12-9 Wound measurements are made in centimeters. The first measurement is oriented from head to toe, the second is from side to side, and the third is the depth (if any). If there is any tunneling (when cotton-tipped applicator is placed in wound, there is movement) or undermining (when cotton-tipped applicator is placed in wound, there is a “lip” around the wound), this is charted in respect to a clock, with 12 o’clock being toward the patient’s head. This wound would be charted as a full-thickness, red wound, 7 × 5 × 3 cm, with a 3-cm tunnel at 7 o’clock and 2 cm undermining from 3 o’clock to 5 o’clock.
FIG. 12-10 Jackson-Pratt drainage device.
TABLE 12-9 FACTORS DELAYING WOUND HEALING
Yellow Wounds.
Black Wounds.
Negative-Pressure Wound Therapy.
Evidence-Based Practice Translating Research Into Practice
What Is the Effect of Tap Water on Wound Cleansing?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
TABLE 12-10 TYPES OF WOUND DRESSINGS
Hyperbaric Oxygen Therapy.
FIG. 12-11 Negative-pressure wound therapy. A, Femoral wound that is not healing. B, Negative-pressure wound therapy in place. C, Granulation tissue formation after therapy.
Delegation Decisions Wound Care
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
TABLE 12-11 TYPES OF DEBRIDEMENT
Drug Therapy.
Nutritional Therapy.
Infection Prevention and Control.
Psychologic Implications.
Patient Teaching.
Pressure Ulcers
Etiology and Pathophysiology
Clinical Manifestations
TABLE 12-12 RISK FACTORS FOR PRESSURE ULCERS
Nursing and Collaborative Management Pressure Ulcers
TABLE 12-13 STAGING OF PRESSURE ULCERS
Nursing Assessment
Safety Alert
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Safety Alert
Acute Intervention.
TABLE 12-14 ASSESSING PATIENTS WITH DARK SKIN
TABLE 12-15 NURSING ASSESSMENT: Pressure Ulcers
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Informatics in Practice Digital Images
TABLE 12-16 PATIENT & CAREGIVER TEACHING GUIDE: Pressure Ulcer
Ambulatory and Home Care.
Evaluation
Case Study Inflammation and Infection
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Patient Profile
Subjective Data
Objective Data
Physical Examination
Laboratory Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
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Care Plans
Case Studies
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eFigures
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Glossary
Key Points
Chapter 13 Genetics and Genomics
Learning Outcomes
Key Terms
eFigure
Genetics and Genomics
Basic Principles of Genetics
Genes.
TABLE 13-1 GLOSSARY OF GENETIC AND GENOMIC TERMS
Chromosomes.
DNA.
FIG. 13-1 The long, stringy DNA that makes up genes is spooled within chromosomes inside the nucleus of a cell. (Note that a gene would actually be a much longer stretch of DNA than what is shown here.)
RNA.
Protein Synthesis.
FIG. 13-2 DNA consists of two long, twisted chains made up of nucleotides. Each nucleotide contains one base, one phosphate molecule (P), and the sugar molecule deoxyribose (S). The bases in DNA nucleotides are adenine (A), thymine (T), cytosine (C), and guanine (G).
Mitosis.
Meiosis.
Genetic Mutations
FIG. 13-3 In sickle cell disease a single gene mutation leads to mutant (incorrect) protein. The substitution of valine (VAL) for glutamic acid on the β-globin chain of hemoglobin produces abnormal hemoglobin, hemoglobin S (Hb S). In response to low O2 levels, the erythrocytes with Hb S stiffen and elongate, taking on a sickle shape (see Fig. 31-3).
Types of Mutations.
Inheritance Patterns
TABLE 13-2 COMPARISON OF GENETIC DISORDERS
FIG. 13-4 Examples of family pedigrees showing inheritance of (A) autosomal dominant, (B) autosomal recessive, and (C) X-linked recessive disorders.
FIG. 13-5 Family pedigrees showing three generations. A, Family pedigree suggestive of an autosomal dominant disorder. B, Family pedigree suggestive of an autosomal recessive disorder. C, Family pedigree suggestive of an X-linked recessive disorder.
Human Genome Project
Genetic Disorders
Classification of Genetic Disorders
Single Gene Disorders.
Multifactorial Genetic Disorders.
Epigenetics.
FIG. 13-6 A, Genetic disorders can be caused by a mutation in a single gene (e.g., sickle cell disease, cystic fibrosis, hemophilia). B, Most genetic disorders are multifactorial genetic disorders caused by a combination of mutations in multiple genes, often interacting with environmental factors. Examples include cancer, diabetes mellitus, obesity, and hypertension.
Chromosome Disorders.
Genetics in Clinical Practice
Genetic Testing
TABLE 13-3 USE OF GENETIC TESTS*
Genetics in Clinical Practice
What Is GINA?
Why Was GINA Needed?
What Is a Genetic Test?
What Is Genetic Information?
What Does GINA Do?
Interpreting Genetic Test Results
Ethical/Legal Dilemmas Genetic Testing
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Direct-to-Consumer Genetic Tests
Genetic Technology
DNA Finger Printing.
DNA Microarray (DNA Chip).
TABLE 13-4 PATIENT & FAMILY TEACHING GUIDE: Genetic Testing
Genome-Wide Association Study (GWAS)
Pharmacogenetics and Pharmacogenomics
TABLE 13-5 EXAMPLES OF PHARMACOGENETICS
FIG. 13-7 Individuals respond differently to the drug warfarin (Coumadin). The diversity of responses is partially due to genetic variants in one of the cytochrome P450 genes.
Gene Therapy
FIG. 13-8 Gene therapy for adenosine deaminase (ADA) deficiency attempts to correct this immunodeficiency state. The viral vector containing the therapeutic ADA gene is inserted into the patient’s lymphocytes. These cells can then make the ADA enzyme.
Stem Cell Therapy
Nursing Management Genetics and Genomics
FIG. 13-9 Punnett squares illustrate inheritance possibilities. A, If the mother and father are both carriers for cystic fibrosis, there is a 25% chance that offspring will have cystic fibrosis. B, If the mother is a carrier for the hemophilia gene and the father has a normal genotype, there is a 50% chance that any male offspring will have hemophilia. There is a 50% chance that any female offspring will be a carrier. C, If the mother has a normal genotype and the father has Huntington’s disease, there is a 50% chance that offspring will have the disease.
Nursing Assessment Family History
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eFigures
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Chapter 14 Altered Immune Responses and Transplantation
Learning Outcomes
Key Terms
eFigures
eTables
Normal Immune Response
Antigens
Types of Immunity
Innate Immunity.
Acquired Immunity.
Active Acquired Immunity.
Passive Acquired Immunity.
Lymphoid Organs
TABLE 14-1 TYPES OF ACQUIRED SPECIFIC IMMUNITY
Healthy People
Cells Involved in Immune Response
Mononuclear Phagocytes.
FIG. 14-1 Organs of the immune system.
Lymphocytes.
B Lymphocytes.
T Lymphocytes.
T Cytotoxic Cells.
T Helper Cells.
Natural Killer Cells.
FIG. 14-2 The immune response to a virus. A, A virus invades the body through a break in the skin or another portal of entry. The virus must make its way inside a cell to replicate itself. B, A macrophage recognizes the antigens on the surface of the virus. The macrophage digests the virus and displays pieces of the virus (antigens) on its surface. C, A T helper cell recognizes the antigen displayed and binds to the macrophage. This binding stimulates the production of cytokines (interleukin-1 [IL-1] and tumor necrosis factor [TNF] ) by the macrophage and interleukin-2 (IL-2) and γ-interferon (γ-IFN) by the T cell. These cytokines are intracellular messengers that provide communication among the cells. D, IL-2 instructs other T helper cells and T cytotoxic cells to proliferate (multiply). T helper cells release cytokines, causing B cells to multiply and produce antibodies. E, T cytotoxic cells and natural killer cells destroy infected body cells. F, The antibodies bind to the virus and mark it for macrophage destruction. G, Memory B and T cells remain behind to respond quickly if the same virus attacks again.
FIG. 14-3 Relationships and functions of macrophages, B lymphocytes, and T lymphocytes in an immune response.
TABLE 14-2 CHARACTERISTICS OF IMMUNOGLOBULINS
Dendritic Cells.
Cytokines
TABLE 14-3 TYPES AND FUNCTIONS OF CYTOKINES*
Comparison of Humoral and Cell-Mediated Immunity
FIG. 14-4 Mechanism of action of interferon (IFN). When a virus attacks a cell, the cell begins to synthesize viral DNA and interferon. Interferon serves as an intercellular messenger and induces the production of antiviral proteins. Then the virus is not able to replicate in the cell.
Humoral Immunity.
TABLE 14-4 CLINICAL USES OF CYTOKINES
TABLE 14-5 COMPARISON OF HUMORAL AND CELL-MEDIATED IMMUNITY
FIG. 14-5 Primary and secondary immune responses. The introduction of antigen induces a response dominated by two classes of immunoglobulins, IgM and IgG. IgM predominates in the primary response, with some IgG appearing later. After the host’s immune system is primed, another challenge with the same antigen induces the secondary response, in which some IgM and large amounts of IgG are produced.
Cell-Mediated Immunity.
Gerontologic Considerations
Effects of Aging on the Immune System
TABLE 14-6 GERONTOLOGIC ASSESSMENT DIFFERENCES: Effects of Aging on the Immune System
Altered Immune Response
Hypersensitivity Reactions
Type I: IgE-Mediated Reactions.
TABLE 14-7 TYPES OF HYPERSENSITIVITY REACTIONS
FIG. 14-6 Steps in a type I allergic reaction.
TABLE 14-8 MEDIATORS OF ALLERGIC RESPONSE*
Anaphylaxis.
Atopic Reactions.
FIG. 14-7 Clinical manifestations of a systemic anaphylactic reaction.
TABLE 14-9 ALLERGENS CAUSING ANAPHYLACTIC SHOCK
Drugs
Foods
Treatment Measures
Insect Venoms
Animal Sera
FIG. 14-8 Atopic dermatitis of the lower leg.
Type II: Cytotoxic and Cytolytic Reactions.
Hemolytic Transfusion Reactions.
Goodpasture Syndrome.
Type III: Immune-Complex Reactions.
Type IV: Delayed Hypersensitivity Reactions.
Contact Dermatitis.
FIG. 14-9 Contact dermatitis to rubber.
Microbial Hypersensitivity Reactions.
Allergic Disorders
Assessment
Diagnostic Studies
Skin Tests.
TABLE 14-10 NURSING ASSESSMENT: Allergies
Procedure.
Results.
Precautions.
Collaborative Care
Anaphylaxis.
Chronic Allergies.
Allergen Recognition and Control.
TABLE 14-11 EMERGENCY MANAGEMENT: Anaphylactic Shock
Drug Therapy.
Antihistamines.
Sympathomimetic/Decongestant Drugs.
Corticosteroids.
Antipruritic Drugs.
Mast Cell–Stabilizing Drug.
Leukotriene Receptor Antagonists.
Immunotherapy.
Mechanism of Action.
Method of Administration.
Subcutaneous Immunotherapy.
Sublingual Immunotherapy.
Nursing Management Immunotherapy
Latex Allergies
Types of Latex Allergies.
Latex-Food Syndrome.
Nursing and Collaborative Management Latex Allergies
Multiple Chemical Sensitivity
TABLE 14-12 GUIDELINES FOR PREVENTING ALLERGIC LATEX REACTIONS
Autoimmunity
TABLE 14-13 EXAMPLES OF AUTOIMMUNE DISEASES*
Autoimmune Diseases
Apheresis
Plasmapheresis.
Immunodeficiency Disorders
Primary Immunodeficiency Disorders
Secondary Immunodeficiency Disorders
TABLE 14-14 PRIMARY IMMUNODEFICIENCY DISORDERS
TABLE 14-15 CAUSES OF SECONDARY IMMUNODEFICIENCY
Drug-Induced Immunodeficiency
Age
Malnutrition
Therapies
Diseases or Disorders
Stress
Human Leukocyte Antigen System
Human Leukocyte Antigen and Disease Associations
FIG. 14-10 Patterns of human leukocyte antigen (HLA) inheritance. A, HLA genes are located on chromosome 6. B, The two haplotypes of the father are labeled P1 and P2, and the haplotypes of the mother are labeled M1 and M2. Each child inherits two haplotypes, one from each parent. C, Therefore only four combinations—P1M1, P1M2, P2M1, and P2M2—are possible, and 25% of the offspring will have identical HLA haplotypes.
Organ Transplantation
FIG. 14-11 Tissues and organs that can be transplanted.
Tissue Typing
HLA Typing.
Panel of Reactive Antibodies.
Crossmatch.
Transplant Rejection
Hyperacute Rejection.
Acute Rejection.
Chronic Rejection.
FIG. 14-12 Mechanism of action of T cytotoxic lymphocyte activation and attack of transplanted tissue. The transplanted organ (e.g., kidney) is recognized as foreign and activates the immune system. T helper cells are activated to produce interleukin-2 (IL-2), and T cytotoxic lymphocytes are sensitized. After the T cytotoxic cells proliferate, they attack the transplanted organ.
Immunosuppressive Therapy
TABLE 14-16 DRUG THERAPY: Immunosuppressive Therapy
Calcineurin Inhibitors.
FIG. 14-13 Sites of action for immunosuppressive agents.
Drug Alert
Sirolimus.
Mycophenolate Mofetil.
Drug Alert
Monoclonal Antibodies.
Polyclonal Antibody.
Graft-Versus-Host Disease
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Chapter 15 Infection and Human Immunodeficiency Virus Infection
Learning Outcomes
Key Terms
eTables
Infections
Types of Pathogens
TABLE 15-1 DISEASE-CAUSING BACTERIA
TABLE 15-2 DISEASE-CAUSING VIRUSES
TABLE 15-3 DISEASE-CAUSING FUNGI
Emerging Infections
TABLE 15-4 EMERGING INFECTIONS
Reemerging Infections
TABLE 15-5 REEMERGING INFECTIONS
Antibiotic-Resistant Organisms
TABLE 15-6 ANTIBIOTIC-RESISTANT ORGANISMS AND TREATMENT
TABLE 15-7 PATIENT & CAREGIVER TEACHING GUIDE: Decrease Risk for Antibiotic-Resistant Infection
Health Care–Associated Infections
TABLE 15-8 OSHA REQUIREMENTS FOR PERSONAL PROTECTIVE EQUIPMENT
Gerontologic Considerations
Infections in Older Adults
Safety Alert
Infection Prevention and Control
Occupational Safety and Health Administration (OSHA) Guidelines
Infection Precautions
Human Immunodeficiency Virus Infection
Significance of Problem
Transmission of HIV
FIG. 15-1 Viral load in the blood in relationship to number of CD4+ T cells over the spectrum of untreated HIV infection.
Sexual Transmission.
Contact With Blood and Blood Products.
FIG. 15-2 HIV is surrounded by an envelope made up of proteins (including gp120) and contains a core of viral RNA and proteins.
Perinatal Transmission.
Pathophysiology
FIG. 15-3 HIV has gp120 glycoproteins that attach to CD4 and chemokine CXCR4 and CCR5 receptors on the surface of CD4+ T cells. Viral RNA then enters the cell, produces viral DNA in the presence of reverse transcriptase, and incorporates itself into the cellular genome in the presence of integrase, causing permanent cellular infection and the production of new virions. New viral RNA develops initially in long strands that are cut in the presence of protease and leave the cell through a budding process that ultimately contributes to cellular destruction.
Clinical Manifestations and Complications
Acute Infection.
FIG. 15-4 Timeline for the spectrum of untreated HIV infection. The timeline represents the course of untreated illness from the time of infection to clinical manifestations of disease.
Chronic HIV Infection
Asymptomatic Infection.
Symptomatic Infection.
FIG. 15-5 Oral thrush involving hard and soft palate.
FIG. 15-6 Kaposi sarcoma (KS). The malignant vascular lesions of KS can appear anywhere on the skin surface or on internal organs. Lesions vary in size from pinpoint to large and may appear in a variety of shades.
AIDS.
FIG. 15-7 Oral hairy leukoplakia on the lateral aspect of the tongue.
TABLE 15-9 DIAGNOSTIC CRITERIA FOR AIDS
Diagnostic Studies
Diagnosis of HIV Infection.
Laboratory Studies in HIV Infection.
Collaborative Care
TABLE 15-10 OPPORTUNISTIC DISEASES ASSOCIATED WITH HIV INFECTION*
TABLE 15-11 HIV-ANTIBODY TESTS
Drug Therapy for HIV Infection.
TABLE 15-12 DRUG THERAPY: HIV Infection
Drug Alert
Drug Therapy for Opportunistic Diseases.
Preventing Transmission of HIV.
Nursing Management HIV Infection
Nursing Assessment
Planning
Nursing Implementation
Health Promotion.
Healthy People
Prevention of HIV Infection.
TABLE 15-13 NURSING ASSESSMENT: HIV-Infected Patient
TABLE 15-14 PATIENT & CAREGIVER TEACHING GUIDE: Antiretroviral Drugs
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Decreasing Risks Related to Sexual Intercourse.
Decreasing Risks Related to Drug Use.
Ethical/Legal Dilemmas Individual Versus Public Health Protection
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Decreasing Risks of Perinatal Transmission.
Decreasing Risks at Work.
HIV Testing.
Acute Intervention
Early Intervention.
Initial Response to Diagnosis of HIV.
Informatics in Practice Use of Internet and Mobile Devices to Manage HIV
Antiretroviral Therapy.
TABLE 15-15 PATIENT & CAREGIVER TEACHING GUIDE: Improving Adherence to Antiretroviral Therapy
Delaying Disease Progression.
Acute Exacerbations.
TABLE 15-16 PATIENT & CAREGIVER TEACHING GUIDE: Signs and Symptoms HIV Patients Need to Report
FIG. 15-8 Chest x-ray showing interstitial infiltrates as the result of Pneumocystis jiroveci pneumonia.
Ambulatory and Home Care.
Stigma of HIV.
Disease and Drug Side Effects.
FIG. 15-9 Lipodystrophy manifestations.
End-of-Life Care.
Evaluation
Gerontologic Considerations
HIV Infection
Case Study HIV Infection
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Patient Profile
Subjective Data
Objective Data
Physical Examination
Laboratory Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
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Resources
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eTables
Glossary
Key Points
Chapter 16 Cancer
Learning Outcomes
Key Terms
eFigure
eTables
TABLE 16-1 CANCER INCIDENCE BY SITE AND GENDER*
TABLE 16-2 CANCER DEATHS BY SITE AND GENDER*
Gender Differences Cancer
Men
Women
Informatics in Practice Managing Cancer Patients’ Symptoms
Biology of Cancer
Defect in Cell Proliferation
FIG. 16-1 Cell life cycle and metabolic activity. Generation time is the period from M phase to M phase. Cells not in the cycle but capable of division are in the resting phase (G0).
Defect in Cell Differentiation
Genetic Link
Development of Cancer
Initiation.
Genetic Link
Carcinogens.
Chemical Carcinogens.
FIG. 16-2 Process of cancer development.
Radiation.
Viral Carcinogens.
Promotion.
FIG. 16-3 Main sites of metastasis.
Progression.
FIG. 16-4 The pathogenesis of cancer metastasis. To produce metastases, tumor cells must detach from the primary tumor and enter the circulation, survive in the circulation to arrest in the capillary bed, adhere to capillary basement membrane, gain entrance into the organ parenchyma, respond to growth factors, proliferate and induce angiogenesis, and evade host defenses.
Role of the Immune System
FIG. 16-5 Tumor-associated antigens appear on the cell surface of malignant cells.
Escape Mechanisms From Immunologic Surveillance.
Oncofetal Antigens and Tumor Markers.
FIG. 16-6 Blocking antibodies prevent T cells from interacting with tumor-associated antigens and from destroying the malignant cell.
Benign Versus Malignant Neoplasms
Classification of Cancer
TABLE 16-3 COMPARISON OF BENIGN AND MALIGNANT NEOPLASMS
Anatomic Site Classification
Histologic Classification
TABLE 16-4 ANATOMIC CLASSIFICATION OF TUMORS
Extent of Disease Classification
Clinical Staging.
TNM Classification System.
TABLE 16-5 TNM CLASSIFICATION SYSTEM
Prevention and Early Detection of Cancer
TABLE 16-6 SEVEN WARNING SIGNS OF CANCER
Healthy People Prevention and Early Detection of Cancer
Diagnosis of Cancer
Biopsy.
FIG. 16-7 Positron emission tomography (PET) scan before treatment (A) indicating metastasis throughout the body. PET scan after treatment (B) indicates the effects of therapy. More radioactive material accumulates in areas that have higher levels of activity. This often corresponds to areas of disease and shows up as brighter spots on the PET scan.
Collaborative Care
Treatment Goals
FIG. 16-8 Goals of cancer treatment.
Cure.
Control.
Palliation.
Surgical Therapy
Prevention
Cure or Control
Supportive and Palliative Care
Chemotherapy
FIG. 16-9 Role of surgery in the treatment of cancer.
FIG. 16-10 Goals of chemotherapy.
Effect on Cells
Classification of Chemotherapy Drugs
TABLE 16-7 DRUG THERAPY Chemotherapy Drugs
Preparation of Chemotherapy
Methods of Administration
TABLE 16-8 DRUG THERAPY: Methods of Chemotherapy Administration
FIG. 16-11 Extravasation injury from infiltration of chemotherapy drug.
Regional Chemotherapy Administration
Intraarterial Chemotherapy.
Intraperitoneal Chemotherapy.
Intrathecal or Intraventricular Chemotherapy.
Intravesical Bladder Chemotherapy.
Effects of Chemotherapy on Normal Tissues
TABLE 16-9 CELLS WITH RAPID RATE OF PROLIFERATION
Treatment Plan
Radiation Therapy
Effects of Radiation
Principles of Radiobiology
TABLE 16-10 TUMOR RADIOSENSITIVITY*
High Radiosensitivity
Moderate Radiosensitivity
Mild Radiosensitivity
Poor Radiosensitivity
Simulation and Treatment Planning
FIG. 16-12 Immobilization device. A head holder and an immobilization mask may be used to ensure accurate positioning for daily treatment of head and neck cancer.
Treatment
External Radiation.
FIG. 16-13 Linear accelerator. Varian Clinac EX linear accelerator with multiple photon and electron energies available for use according to the treatment plan. Patient is positioned on radiation treatment table for treatment of head and neck cancer.
Internal Radiation.
Nursing Management Chemotherapy and Radiation Therapy
Nursing Implementation
Bone Marrow Suppression.
Fatigue.
Gastrointestinal Effects.
TABLE 16-11 NURSING MANAGEMENT OF PROBLEMS CAUSED BY CHEMOTHERAPY AND RADIATION THERAPY
Nausea and Vomiting.
Diarrhea.
Mucositis.
Anorexia.
Skin Reactions
Radiation Skin Changes.
FIG. 16-14 Dry desquamation.
Chemotherapy Skin Changes.
FIG. 16-15 Wet desquamation.
TABLE 16-12 PATIENT & CAREGIVER TEACHING GUIDE: Radiation Skin Reactions
Pulmonary Effects.
Cardiovascular Effects.
Reproductive Effects.
Coping with Therapy.
Late Effects of Radiation and Chemotherapy
Biologic and Targeted Therapy
FIG. 16-16 Sites of action of targeted therapy. EGFR, Epidermal growth factor receptor; HER-2, human epidermal growth factor receptor 2; VEGF, vascular endothelial growth factor.
TABLE 16-13 DRUG THERAPY: Biologic and Targeted Therapy*
Side Effects of Biologic and Targeted Therapy
Nursing Management Biologic and Targeted Therapy
Hematopoietic Growth Factors
TABLE 16-14 DRUG THERAPY: Hematopoietic Growth Factors Used in Cancer Treatment
Hematopoietic Stem Cell Transplantation
TABLE 16-15 INDICATIONS FOR HEMATOPOIETIC STEM CELL TRANSPLANTATION
Malignant Diseases
Nonmalignant Diseases
Types of Hematopoietic Stem Cell Transplants
FIG. 16-17 Autologous stem cell transplant.
Procedures
Harvest Procedures.
Preparative Regimens and Stem Cell Infusions.
Complications.
TABLE 16-16 NUTRITIONAL THERAPY Protein Foods With High Biologic Value
Gene Therapy
Complications Resulting From Cancer
Nutritional Problems
Malnutrition
TABLE 16-17 NUTRITIONAL THERAPY: High-Calorie Foods
Altered Taste Sensation (Dysgeusia)
Infection
Oncologic Emergencies
Obstructive Emergencies
Superior Vena Cava Syndrome.
FIG. 16-18 Superior vena caval obstruction in bronchial carcinoma. Note the swelling of the face and neck and the development of collateral circulation in the veins.
Spinal Cord Compression.
Third Space Syndrome.
Metabolic Emergencies
Syndrome of Inappropriate Antidiuretic Hormone Secretion.
Hypercalcemia.
Tumor Lysis Syndrome.
Infiltrative Emergencies
Cardiac Tamponade.
Carotid Artery Rupture.
Cancer Pain
Pain Assessment
Pain Management
TABLE 16-18 PAIN ASSESSMENT IN CANCER PATIENTS
Psychologic Support
TABLE 16-19 FACTORS AFFECTING HOW PATIENTS COPE WITH CANCER
Ethical/Legal Dilemmas Medical Futility
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Gerontologic Considerations
Cancer
Cancer Survivorship
TABLE 16-20 RESOURCES FOR CANCER SURVIVORS
Culturally Competent Care
Cancer
Cultural & Ethnic Health Disparities Cancer
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eFigures
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Glossary
Key Points
Chapter 17 Fluid, Electrolyte, and Acid-Base Imbalances
Learning Outcomes
Key Terms
Homeostasis
FIG. 17-1 Body water over the life span.
Water Content of the Body
Body Fluid Compartments
FIG. 17-2 Relative volumes of three body fluids. Values represent fluid distribution in a young male adult.
Calculation of Fluid Gain or Loss
Electrolytes
Measurement of Electrolytes
Electrolyte Composition of Fluid Compartments
FIG. 17-3 The relative concentrations of the major cations and anions in the intracellular space and the plasma.
TABLE 17-1 NORMAL SERUM ELECTROLYTE VALUES
Mechanisms Controlling Fluid and Electrolyte Movement
Diffusion
FIG. 17-4 Diffusion is the movement of molecules from an area of high concentration to an area of low concentration. Eventually the sugar molecules are evenly distributed.
Facilitated Diffusion
Active Transport
Osmosis
FIG. 17-5 Sodium-potassium pump. As sodium (Na+) diffuses into the cell and potassium (K +) diffuses out of the cell, an active transport system supplied with energy delivers Na+ back to the extracellular compartment and K+ to the intracellular compartment. ATP, Adenosine triphosphate.
FIG. 17-6 Osmosis is the process of water movement through a semipermeable membrane from an area of low solute concentration to an area of high solute concentration.
Measurement of Osmolality.
Osmotic Movement of Fluids.
FIG. 17-7 Effects of water status on red blood cells. A, Hypotonic solution (H2O excess) results in cellular swelling. B, Isotonic solution (normal H2O balance) results in no change. C, Hypertonic solution (H2O deficit) results in cellular shrinking.
Hydrostatic Pressure
Oncotic Pressure
Fluid Movement in Capillaries
FIG. 17-8 Dynamics of fluid exchange between a capillary and tissue. An equilibrium exists between forces filtering fluid out of the capillary and forces absorbing fluid back into the capillary. Note that the hydrostatic pressure is greater at the arterial end of the capillary than at the venous end. The net effect of pressures at the arterial end of the capillary causes a movement of fluid into the tissue. At the venous end of the capillary, there is net movement of fluid back into the capillary.
Fluid Shifts
Shifts of Plasma to Interstitial Fluid.
Elevation of Venous Hydrostatic Pressure.
Decrease in Plasma Oncotic Pressure.
Elevation of Interstitial Oncotic Pressure.
Shifts of Interstitial Fluid to Plasma.
Fluid Spacing
Regulation of Water Balance
Hypothalamic-Pituitary Regulation
Renal Regulation
Adrenal Cortical Regulation
FIG. 17-9 Factors affecting aldosterone secretion. ACTH, Adrenocorticotropic hormone.
Cardiac Regulation
Gastrointestinal Regulation
TABLE 17-2 NORMAL FLUID BALANCE IN THE ADULT
FIG. 17-10 Effects of stress on fluid and electrolyte balance. ACTH, Adrenocorticotropic hormone; ADH, antidiuretic hormone; CRH, corticotropin-releasing hormone.
Insensible Water Loss
Gerontologic Considerations
Fluid and Electrolytes
Fluid and Electrolyte Imbalances
Extracellular Fluid Volume Imbalances
Fluid Volume Deficit
Collaborative Care
Fluid Volume Excess
Collaborative Care
TABLE 17-3 EXTRACELLULAR FLUID IMBALANCES: CAUSES AND CLINICAL MANIFESTATIONS
Nursing Management Extracellular Fluid Volume Imbalances
Nursing Diagnoses
Nursing Implementation
Intake and Output.
Cardiovascular Changes.
Respiratory Changes.
Neurologic Changes.
Daily Weights.
FIG. 17-11 Assessment of skin turgor. A and B, When normal skin is pinched, it resumes shape in seconds. C, If the skin remains wrinkled for 20 to 30 seconds, the patient has poor skin turgor.
Skin Assessment and Care.
Other Nursing Measures.
Sodium Imbalances
FIG. 17-12 Differential assessment of extracellular fluid (ECF) volume.
Hypernatremia
Clinical Manifestations.
FIG. 17-13 Isotonic gains and losses affect mainly the extracellular fluid (ECF) compartment with little or no water movement into the cells. Hypertonic imbalances cause water to move from inside the cell into ECF to dilute the concentrated sodium, causing cell shrinkage. Hypotonic imbalances cause water to move into the cell, causing cell swelling.
TABLE 17-4 SODIUM IMBALANCES: CAUSES AND CLINICAL MANIFESTATIONS
Nursing and Collaborative Management Hypernatremia
Nursing Diagnoses
Nursing Implementation
Hyponatremia
Clinical Manifestations.
Nursing and Collaborative Management Hyponatremia
Nursing Diagnoses
Nursing Implementation
Potassium Imbalances
Hyperkalemia
TABLE 17-5 POTASSIUM IMBALANCES: CAUSES AND CLINICAL MANIFESTATIONS
FIG. 17-14 Electrocardiographic changes associated with alterations in potassium status.
Clinical Manifestations.
Nursing and Collaborative Management Hyperkalemia
Nursing Diagnoses
Nursing Implementation
Hypokalemia
Clinical Manifestations.
Nursing and Collaborative Management Hypokalemia
Nursing Diagnoses
Nursing Implementation
Safety Alert
TABLE 17-6 PATIENT & CAREGIVER TEACHING GUIDE: Prevention of Hypokalemia
Calcium Imbalances
TABLE 17-7 CALCIUM IMBALANCES: CAUSES AND CLINICAL MANIFESTATIONS
Hypercalcemia
Nursing and Collaborative Management Hypercalcemia
Nursing Diagnoses
Nursing Implementation
Hypocalcemia
FIG. 17-15 Tests for hypocalcemia. A, Chvostek’s sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. B, Trousseau’s sign is a carpal spasm induced by, C, inflating a blood pressure cuff above the systolic pressure for a few minutes.
Nursing and Collaborative Management Hypocalcemia
Nursing Diagnoses
Nursing Implementation
Phosphate Imbalances
Hyperphosphatemia
TABLE 17-8 PHOSPHATE IMBALANCES: CAUSES AND CLINICAL MANIFESTATIONS
Hypophosphatemia
Magnesium Imbalances
Hypermagnesemia
TABLE 17-9 MAGNESIUM IMBALANCES: CAUSES AND CLINICAL MANIFESTATIONS
Hypomagnesemia
FIG. 17-16 The normal range of plasma pH is 7.35 to 7.45. A normal pH is maintained by a ratio of 1 part carbonic acid to 20 parts bicarbonate.
Acid-Base Imbalances
pH and Hydrogen Ion Concentration
Acid-Base Regulation
Buffer System.
Respiratory System.
Renal System.
Alterations in Acid-Base Balance
Respiratory Acidosis.
TABLE 17-10 ACID-BASE IMBALANCES
FIG. 17-17 Kinds of acid-base imbalances. A, Respiratory imbalances caused by carbonic acid (CA) excess and carbonic acid deficit. B, Metabolic imbalances caused by base bicarbonate (BB) deficit and base bicarbonate excess.
Respiratory Alkalosis.
Metabolic Acidosis.
Metabolic Alkalosis.
Mixed Acid-Base Disorders.
Clinical Manifestations
Blood Gas Values.
TABLE 17-11 CLINICAL MANIFESTATIONS OF ACIDOSIS
TABLE 17-12 CLINICAL MANIFESTATIONS OF ALKALOSIS
Assessment of Fluid, Electrolyte, and Acid-Base Imbalances
TABLE 17-13 NORMAL ARTERIAL BLOOD GAS VALUES*
Subjective Data
Important Health Information
Past Health History.
Medications.
Surgery or Other Treatments.
TABLE 17-14 ARTERIAL BLOOD GAS (ABG) ANALYSIS
TABLE 17-15 ROME: MEMORY DEVICE FOR ACID-BASE IMBALANCES
Functional Health Patterns
Health Perception–Health Management Pattern.
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Cognitive-Perceptual Pattern.
Objective Data
Physical Examination.
Laboratory Values.
TABLE 17-16 ASSESSMENT ABNORMALITIES: Fluid and Electrolyte Imbalances
Oral Fluid and Electrolyte Replacement
Intravenous Fluid and Electrolyte Replacement
Solutions
Hypotonic.
Isotonic.
TABLE 17-17 COMMONLY USED CRYSTALLOID SOLUTIONS
Hypertonic.
Intravenous Additives.
Plasma Expanders.
Delegation Decisions Intravenous Therapy
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Central Venous Access Devices
TABLE 17-18 INDICATIONS FOR CENTRAL VENOUS ACCESS DEVICE (CVAD)*
Centrally Inserted Catheters
FIG. 17-18 Tunneled central venous catheter. Note tip of the catheter in the superior vena cava.
Peripherally Inserted Central Catheters
FIG. 17-19 Peripherally inserted central catheter (PICC) can be inserted using the basilic or cephalic vein.
TABLE 17-19 COMPLICATIONS OF CENTRAL VENOUS ACCESS DEVICES (CVADs)
Local
Systemic
Implanted Infusion Ports
Complications
Nursing Management Central Venous Access Devices
FIG. 17-20 A, Cross section of implantable port displaying access of the port with the Huber-point needle. Note the deflected point of the Huber-point needle, which prevents coring of the port’s septum. B, Two Huber-point needles used to enter the implanted port. The 90-degree needle is used for top-entry ports for continuous infusion.
Removal of CVADs
Case Study Fluid and Electrolyte Imbalance
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Patient Profile
Subjective Data
Objective Data
Discussion Questions
Bridge to NCLEX Examination
References
Resource
Case Study Managing Multiple Patients
Patients
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Case Studies
Concept Map Creator
Content Updates
Glossary
Key Points
Tutorials
Section 3 Perioperative Care
Perioperative Care
Pre-Test – Section 3
Interactive Review – Section 3
Chapter 18 Nursing Management: Preoperative Care
Learning Outcomes
Key Terms
TABLE 18-1 SUFFIXES DESCRIBING SURGICAL PROCEDURES
Surgical Settings
Patient Interview
Nursing Assessment of Preoperative Patient
Subjective Data
Psychosocial Assessment.
TABLE 18-2 PSYCHOSOCIAL ASSESSMENT OF PREOPERATIVE PATIENT
Anxiety.
Common Fears.
Hope.
Past Health History.
Medications.
Complementary & Alternative Therapies
Helpful Herbs and Vitamins
Allergies.
Review of Systems.
Cardiovascular System.
Respiratory System.
Neurologic System.
Genitourinary System.
Hepatic System.
Integumentary System.
Musculoskeletal System.
Endocrine System.
Immune System.
Fluid and Electrolyte Status.
Nutritional Status.
Objective Data
Physical Examination.
TABLE 18-3 AMERICAN SOCIETY OF ANESTHESIOLOGISTS’ PHYSICAL CLASSIFICATION SYSTEM
Laboratory and Diagnostic Testing.
Nursing Management Preoperative Patient
Preoperative Teaching
TABLE 18-4 HEALTH ASSESSMENT AND PHYSICAL EXAMINATION OF PREOPERATIVE PATIENT*
General Surgery Information.
TABLE 18-5 COMMON PREOPERATIVE LABORATORY AND DIAGNOSTIC TESTS
Ambulatory Surgery Information.
TABLE 18-6 PATIENT & CAREGIVER TEACHING GUIDE: Preoperative Preparation
Legal Preparation For Surgery
Consent for Surgery.
TABLE 18-7 PREOPERATIVE FASTING RECOMMENDATIONS*
Evidence-Based Practice Applying the Evidence
Your Decision and Action
References for Evidence
Ethical/Legal Dilemmas Informed Consent
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Day-of-Surgery Preparation
Nursing Role.
FIG. 18-1 The nurse performs a safety check by verifying that the patient has an identification band (wristband) as part of the preoperative preparations before she goes to surgery.
Safety Alert
Preoperative Medications.
Informatics in Practice Computer-Based Timing for Antibiotic Administration
TABLE 18-8 PREOPERATIVE CHECKLIST
Transportation to the Operating Room
Culturally Competent Care
Preoperative Patient
TABLE 18-9 DRUG THERAPY: Commonly Used Preoperative Medications
Gerontologic Considerations
Preoperative Patient
Case Study Preoperative Patient
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
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Glossary
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Chapter 19 Nursing Management: Intraoperative Care
Learning Outcomes
Key Terms
eFigures
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Physical Environment of Operating Room
Department Layout
Holding Area
Operating Room
FIG. 19-1 Typical operating room.
Surgical Team
Registered Nurse
TABLE 19-1 INTRAOPERATIVE ACTIVITIES OF PERIOPERATIVE NURSE
FIG. 19-2 The complexity of surgery requires maintaining asepsis.
Licensed Practical/Vocational Nurse and Surgical Technologist
Surgeon and Assistant
TABLE 19-2 NURSING ACTIVITIES DURING SURGICAL EXPERIENCE*
Registered Nurse First Assistant
Anesthesia Care Provider
Nursing Management Patient before Surgery
Psychosocial Assessment
Physical Assessment
Chart Review
Admitting the Patient
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Nursing Management Patient During Surgery
Room Preparation
FIG. 19-3 Surgical attire is worn by all people entering the operating room.
Transferring Patient
Scrubbing, Gowning, and Gloving
FIG. 19-4 A sterile field is created before surgery.
Basic Aseptic Technique
Assisting Anesthesia Care Provider
TABLE 19-3 PRINCIPLES OF ASEPTIC TECHNIQUE IN OPERATING ROOM
Safety Considerations
FIG. 19-5 When an electrosurgical unit is used, the patient must be properly grounded to prevent unintended injury. A well-vascularized muscle mass is an optimal site. Safety can be compromised by excessive hair, adipose tissue, bony prominences, fluid (edema), adhesive failure, and scar tissue.
Safety Alert
Positioning Patient
Preventing Hypothermia
Preparing Surgical Site
Patient After Surgery
Anesthesia
Classification of Anesthesia
TABLE 19-4 CLASSIFICATION OF ANESTHESIA AND PATIENT EFFECTS
General Anesthesia
Intravenous Agents.
Inhalation Agents.
Adjuncts to General Anesthesia.
TABLE 19-5 PHASES OF GENERAL ANESTHESIA
Dissociative Anesthesia.
Local and Regional Anesthesia
TABLE 19-6 DRUG THERAPY: General Anesthesia
TABLE 19-7 DRUG THERAPY: Adjuncts to General Anesthesia
Methods of Administration.
FIG. 19-6 Location of needle point and injected anesthetic relative to dura and spinal cord. A, Spinal anesthesia. B, Single-injection epidural. C, Epidural catheter. (Interspaces most commonly used are L2-3, L4-5, L3-4.)
Spinal and Epidural Anesthesia.
Gerontologic Considerations
Patient during Surgery
Catastrophic Events in Operating Room
Anaphylactic Reactions
Malignant Hyperthermia
Future Considerations
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Chapter 20 Nursing Management: Postoperative Care
Learning Outcomes
Key Terms
eTable
Postoperative Care of the Surgical Patient
Postanesthesia Care Unit Admission
PACU Progression.
TABLE 20-1 PHASES OF POSTANESTHESIA CARE
Phase I Initial Assessment.
TABLE 20-2 PACU ADMISSION REPORT
TABLE 20-3 INITIAL PACU ASSESSMENT
Airway
Breathing
Circulation
Neurologic
Gastrointestinal
Genitourinary
Surgical Site
Pain
TABLE 20-4 MANIFESTATIONS OF INADEQUATE OXYGENATION
Central Nervous System
Cardiovascular System
Integumentary System
Respiratory System
Renal System
FIG. 20-1 Potential problems in the postoperative period.
Respiratory Problems
Etiology
PACU.
TABLE 20-5 POSTOPERATIVE RESPIRATORY COMPLICATIONS
FIG. 20-2 Etiology and relief of airway obstruction.
FIG. 20-3 Postoperative atelectasis. A, Normal bronchiole and alveoli. B, Mucous plug in bronchiole. C, Collapse of alveoli resulting from atelectasis after absorption of air.
Clinical Unit.
Nursing Management Respiratory Problems
Nursing Assessment
Delegation Decisions Postoperative Patient
Nursing Diagnoses
Nursing Implementation
Safety Alert
FIG. 20-4 Position of patient during recovery from general anesthesia.
FIG. 20-5 Proper use of an incentive spirometer.
FIG. 20-6 Techniques for splinting incision when coughing.
Cardiovascular Problems
Etiology
PACU.
Clinical Unit.
Nursing Management Cardiovascular Problems
Nursing Assessment
Nursing Diagnoses
Nursing Implementation
PACU.
Clinical Unit.
Neurologic and Psychologic Problems
Etiology
PACU.
Clinical Unit.
Nursing Management Neurologic and Psychologic Problems
Nursing Assessment
Nursing Diagnoses
Nursing Implementation
PACU.
Clinical Unit.
Pain and Discomfort
Etiology
Nursing Management Pain
Nursing Assessment
Nursing Diagnoses
Nursing Implementation
Alterations in Temperature
Etiology
Hypothermia.
TABLE 20-6 POSTOPERATIVE TEMPERATURE CHANGES
Fever.
Nursing Management Altered Temperature
Nursing Assessment
Nursing Diagnoses
Nursing Implementation
Gastrointestinal Problems
Etiology
Nursing Management Gastrointestinal Problems
Nursing Assessment
Nursing Diagnoses
Nursing Implementation
Urinary Problems
Etiology
Nursing Management Urinary Problems
Nursing Assessment
Nursing Diagnoses
Nursing Implementation
Integumentary Problems
Etiology
Nursing Management Surgical Wounds
Nursing Assessment
Nursing Diagnoses
Nursing Implementation
TABLE 20-7 DRAINAGE FROM TUBES AND CATHETERS
Discharge From the PACU
Discharge to the Clinical Unit
TABLE 20-8 SURGERY DISCHARGE CRITERIA
Ambulatory Surgery
Phase II and Extended Observation
Ambulatory Surgery Discharge
TABLE 20-9 POSTOPERATIVE SBAR HANDOFF COMMUNICATION
TABLE 20-10 NURSING ASSESSMENT: Care of Patient on Admission to Clinical Unit
Informatics in Practice Discharge Teaching
Planning for Discharge and Follow-up Care
Gerontologic Considerations
Postoperative Patient
Case Study Postoperative Patient
Patient Profile
Subjective Data
Objective Data
Collaborative Care
Postoperative Orders
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Patients
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Management Discussion Questions
Case Study Progression
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Care Plans
Case Studies
Concept Map Creator
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Glossary
Key Points
Section 4 Problems Related to Altered Sensory Input
Problems Related to Altered Sensory Input
Pre-Test – Section 4
Interactive Review – Section 4
Chapter 21 Nursing Assessment: Visual and Auditory Systems
Learning Outcomes
Key Terms
eFigures
eTable
Visual System
Structures and Functions of Visual System
FIG. 21-1 The human eye.
Structures and Functions of Vision
Eyeball.
Refractive Media.
Refractive Errors.
Visual Pathways.
External Structures and Functions
FIG. 21-2 The visual pathway. Fibers from the nasal portion of each retina cross over to the opposite side of the optic chiasma, terminating in the lateral geniculate body of the opposite side. Location of a lesion in the visual pathway determines the resulting visual defect.
FIG. 21-3 External eye and lacrimal apparatus. Tears produced in the lacrimal gland pass over the surface of the eye and enter the lacrimal canal.
Internal Structures and Functions
TABLE 21-1 GERONTOLOGIC ASSESSMENT DIFFERENCES: Visual System
Gerontologic Considerations
Effects of Aging on Visual System
Focused Assessment
Assessment of Visual System
Subjective Data
Important Health Information
Past Health History.
FIG. 21-4 Arcus senilis, or age-related degeneration of the cornea.
Case Study Patient Introduction
Jack Hollingsworth/Photodisc/Thinkstock
Critical Thinking
Medications.
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
TABLE 21-2 HEALTH HISTORY: Visual System
Genetic Risk Alert
Glaucoma
Age-Related Macular Degeneration (AMD)
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Case Study Subjective Data
Jack Hollingsworth/Photodisc/Thinkstock
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Objective Data
Physical Examination.
TABLE 21-3 NORMAL PHYSICAL ASSESSMENT OF VISUAL SYSTEM
Initial Observation.
Assessing Functional Status
Visual Acuity.
TABLE 21-4 NURSING ASSESSMENT: Assessment Techniques: Visual System
Extraocular Muscle Functions.
Pupil Function and Intraocular Pressure.
Assessing Structures.
Eyebrows, Eyelashes, and Eyelids.
Conjunctiva and Sclera.
TABLE 21-5 ASSESSMENT ABNORMALITIES: Visual System
FIG. 21-5 Magnified view of retina through the ophthalmoscope.
Cornea.
Iris.
Retina and Optic Nerve.
Special Assessment Techniques
Color Vision.
Stereopsis.
Case Study Objective Data
Jack Hollingsworth/Photodisc/Thinkstock
Physical Examination
Diagnostic Studies
Diagnostic Studies of Visual System
Auditory System
Structures and Functions of Auditory System
External Ear
TABLE 21-6 DIAGNOSTIC STUDIES: Visual System
Middle Ear
Inner Ear
Transmission of Sound.
FIG. 21-6 External, middle, and inner ear.
Gerontologic Considerations
Effects of Aging on Auditory System
Focused Assessment
Assessment of Auditory System
Subjective Data
Important Health Information
Past Health History.
TABLE 21-7 GERONTOLOGIC ASSESSMENT DIFFERENCES: Auditory System
Medications.
TABLE 21-8 HEALTH HISTORY: Auditory System
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Objective Data
Physical Examination.
TABLE 21-9 NORMAL PHYSICAL ASSESSMENT OF AUDITORY SYSTEM
External Ear.
External Auditory Canal and Tympanum.
FIG. 21-7 The tympanic membrane. A, Landmarks of right tympanic membrane. B, Normal-appearing tympanic membrane. C, Perforated tympanic membrane.
Diagnostic Studies of Auditory System
Tests for Hearing Acuity
Tuning Fork Tests.
Audiometry.
TABLE 21-10 ASSESSMENT ABNORMALITIES: Auditory System
TABLE 21-11 DIAGNOSTIC STUDIES: Auditory System
Screening Audiometry.
Specialized Tests
Test for Vestibular Function
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Chapter 22 Nursing Management: Visual and Auditory Problems
Learning Outcomes
Key Terms
eFigures
eTables
Visual Problems
Correctable Refractive Errors
Nonsurgical Corrections
Corrective Glasses.
Contact Lenses.
Surgical Therapy
Laser.
Implant.
Cultural & Ethnic Health Disparities
Uncorrectable Visual Impairment
Nursing Management Visual Impairment
Nursing Assessment
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Optical Devices for Vision Enhancement.
Nonoptical Methods for Vision Enhancement.
Evaluation
Healthy People
Gerontologic Considerations
Visual Impairment
Eye Trauma
Extraocular Disorders
Inflammation and Infection
TABLE 22-1 EMERGENCY MANAGEMENT: Eye Injury
Trauma
Chemical Burn
Thermal Burn
Foreign Bodies
Initial
Ongoing Monitoring
FIG. 22-1 Hordeolum (sty) on the upper eyelid caused by staphylococcal infection.
Conjunctivitis
Bacterial Infections.
Viral Infections.
Chlamydial Infections.
Allergic Conjunctivitis.
Keratitis
Bacterial Infections.
Viral Infections.
Other Causes of Keratitis.
Corneal Ulcer.
FIG. 22-2 Corneal ulcer. Infection associated with poor contact lens care.
Nursing Management Inflammation and Infection
Dry Eye Disorders
Strabismus
Corneal Disorders
Corneal Scars and Opacities
Keratoconus
FIG. 22-3 Sutures on a donated cornea after penetrating keratoplasty (corneal transplant).
Intraocular Disorders
Cataract
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
Collaborative Care
Nonsurgical Therapy.
TABLE 22-2 COLLABORATIVE CARE: Cataract
Surgical Therapy.
Preoperative Phase.
Drug Alert
Intraoperative Phase.
Postoperative Phase.
FIG. 22-4 Intraocular lens implant after cataract surgery.
Nursing Management Cataracts
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 22-3 PATIENT & CAREGIVER TEACHING GUIDE: After Eye Surgery
Ambulatory and Home Care.
Evaluation
Gerontologic Considerations
Cataracts
Retinopathy
FIG. 22-5 Diabetic retinopathy. Intraretinal dot or blot hemorrhages.
Retinal Detachment
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
TABLE 22-4 RISK FACTORS FOR RETINAL DETACHMENT
TABLE 22-5 COLLABORATIVE CARE: Retinal Detachment
Collaborative Care
Surgical Therapy
Laser Photocoagulation and Cryopexy.
Scleral Buckling.
Intraocular Procedures.
FIG. 22-6 Retinal break with detachment and surgical repair by scleral buckling technique.
Postoperative Considerations.
Age-Related Macular Degeneration
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
Collaborative Care
Glaucoma
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Chronic Open-Angle Glaucoma
FIG. 22-7 A, In the normal eye the optic cup is pink with little cupping. B, In glaucoma the optic cup is bleached and optic cupping is present. (Note the appearance of the retinal vessels, which travel over the edge of the optic cup and appear to dip into it.)
TABLE 22-6 COLLABORATIVE CARE: Glaucoma
Acute Angle-Closure Glaucoma.
TABLE 22-7 DRUG THERAPY: Acute and Chronic Glaucoma
Drug Alert
Nursing Management Glaucoma
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Gerontologic Considerations
Glaucoma
Intraocular Inflammation and Infection
Ocular Tumors
FIG. 22-8 Uveal melanoma. A large tumor in the choroid, the most common location in the eye for melanoma.
Enucleation
Ocular Manifestations of Systemic Diseases
Auditory Problems External Ear and Canal
Trauma
External Otitis
Nursing and Collaborative Management External Otitis
TABLE 22-8 PATIENT & CAREGIVER TEACHING GUIDE: Prevention of External Otitis
Cerumen and Foreign Bodies in External Ear Canal
Malignancy of External Ear
Middle Ear and Mastoid
Otitis Media
Acute Otitis Media
Otitis Media With Effusion
Chronic Otitis Media and Mastoiditis
Nursing and Collaborative Management Chronic Otitis Media
TABLE 22-9 COLLABORATIVE CARE: Chronic Otitis Media
Diagnostic
Collaborative Therapy
FIG. 22-9 Perforation of the tympanic membrane (TM).
Otosclerosis
TABLE 22-10 COLLABORATIVE CARE: Otosclerosis
Diagnostic
Collaborative Therapy
Inner Ear Problems
Ménière’s Disease
Nursing and Collaborative Management Ménière’s Disease
TABLE 22-11 COLLABORATIVE CARE: Ménière’s Disease
Benign Paroxysmal Positional Vertigo
Acoustic Neuroma
Hearing Loss and Deafness
Types of Hearing Loss
Conductive Hearing Loss.
FIG. 22-10 Causes of hearing loss.
Sensorineural Hearing Loss.
Mixed Hearing Loss.
Central and Functional Hearing Loss.
TABLE 22-12 CLASSIFICATION OF HEARING LOSS
Classification of Hearing Loss.
Clinical Manifestations
Tinnitus and Hearing Loss.
Nursing and Collaborative Management Hearing Loss and Deafness
Health Promotion
Environmental Noise Control.
Healthy People
Immunizations.
FIG. 22-11 Range of common environmental sounds.
Ototoxic Substances.
Assistive Devices and Techniques
Hearing Aids.
TABLE 22-13 TYPES OF HEARING AIDS
TABLE 22-14 COMMUNICATION WITH HEARING-IMPAIRED PATIENT
Nonverbal Aids
Verbal Aids
Speech Reading.
Sign Language.
Cochlear Implant.
FIG. 22-12 Cochlear implant.
Assisted Listening Devices.
Gerontologic Considerations
Hearing Loss
TABLE 22-15 CLASSIFICATION OF PRESBYCUSIS
Delegation Decisions Corrective Lenses and Hearing Aids
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Case Study Glaucoma and Diabetic Retinopathy
Kevin Peterson/Stockbyte/Thinkstock
Patient Profile
Subjective Data
Objective Data
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 23 Nursing Assessment: Integumentary System
Learning Outcomes
Key Terms
Structures and Functions of Skin and Appendages
Structures
Epidermis.
FIG. 23-1 Microscopic view of the skin in longitudinal section.
Dermis.
Subcutaneous Tissue.
Skin Appendages.
FIG. 23-2 Structure of a nail.
FIG. 23-3 Pigmented nail bed normally seen with dark skin color.
Functions of Integumentary System
Gerontologic Considerations
Effects of Aging on Integumentary System
TABLE 23-1 GERONTOLOGIC ASSESSMENT DIFFERENCES: Integumentary System
FIG. 23-4 Photoaging. Irregular pigmentation and keratoses occur on sun-damaged skin on forehead.
TABLE 23-2 NORMAL PHYSICAL ASSESSMENT OF INTEGUMENTARY SYSTEM
Assessment of Integumentary System
Subjective Data
Important Health Information
Past Health History.
Case Study Patient Introduction
Critical Thinking
Medications.
Surgery or Other Treatments.
Functional Health Patterns
Health Perception–Health Management Pattern.
Genetic Risk Alert
TABLE 23-3 HEALTH HISTORY: Integumentary System
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Case Study—cont’d
Objective Data
Physical Examination.
Inspection.
TABLE 23-4 PRIMARY SKIN LESIONS
TABLE 23-5 SECONDARY SKIN LESIONS
TABLE 23-6 NURSING ASSESSMENT: Assessment Variations in Light- and Dark-Skinned Individuals
TABLE 23-7 LESION DISTRIBUTION TERMINOLOGY
FIG. 23-5 Intertrigo. Rash in body folds with Candida infection.
TABLE 23-8 ASSESSMENT ABNORMALITIES: Integumentary System
Palpation.
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Inspect
Palpate
Assessment of Dark Skin
FIG. 23-6 Keloid. Hypertrophic scarring after skin injury, which is more common in dark-skinned individuals.
FIG. 23-7 Vitiligo. Total loss of pigment in the affected area.
FIG. 23-8 Nevus of Ota. Flat gray to blue pigmentation in the upper trigeminal area, which is more common in dark-skinned individuals.
FIG. 23-9 Traction alopecia. Hair loss in scalp because of prolonged tension from hair rollers, braiding, or straightening combs.
FIG. 23-10 Patch test. Results from an application of possible allergens to the skin shows positive reactions in the sites labeled “standard” and “shoe.”
Case Study—cont’d
Physical Examination
Diagnostic Studies
Diagnostic Studies of Integumentary System
TABLE 23-9 DIAGNOSTIC STUDIES: Integumentary System
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
Glossary
Key Points
Videos
Chapter 24 Nursing Management: Integumentary Problems
Learning Outcomes
Key Terms
eFigures
eTable
Health Promotion
Environmental Hazards
Sun Exposure.
TABLE 24-1 WAVELENGTHS OF SUN AND EFFECTS ON SKIN
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Evidence-Based Practice Translating Research Into Practice
Is Sun-Protective Counseling Effective?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Cultural & Ethnic Health Disparities
Irritants and Allergens.
TABLE 24-2 DRUG THERAPY: Drugs That May Cause Photosensitivity
FIG. 24-1 Intense eruption in areas exposed to sunlight after patient started on hydrochlorothiazide.
Radiation.
Rest and Sleep
Exercise
Hygiene
Nutrition
Self-Treatment
Malignant Skin Neoplasms
FIG. 24-2 The ABCDEs of melanoma. A, Asymmetry: one half unlike the other half. B, Border irregularity: edges are ragged, notched, or blurred. C, Color: varied pigmentation; shades of tan, brown, and black. D, Diameter: greater than 6 mm (diameter of a pencil eraser). E, (not pictured) Evolving; changing appearance (change in shape, size, color, or other characteristic is noted over time).
Risk Factors
Nonmelanoma Skin Cancers
Actinic Keratosis
Basal Cell Carcinoma
Squamous Cell Carcinoma
TABLE 24-3 PREMALIGNANT AND MALIGNANT CONDITIONS OF THE SKIN
Malignant Melanoma
FIG. 24-3 Dysplastic nevus. Irregular border and color.
FIG. 24-4 Basal cell carcinoma. Rolled, well-defined border and central erosion.
Clinical Manifestations
FIG. 24-5 Breslow measurement of tumor thickness. A, Thin (0.08 mm) superficial spreading melanoma, good prognosis. B, Thick nodular melanoma with lymph node involvement, poor prognosis.
Collaborative Care
Atypical or Dysplastic Nevus
TABLE 24-4 COMMON BACTERIAL INFECTIONS OF THE SKIN
Skin Infections and Infestations
Bacterial Infections
Viral Infections
FIG. 24-6 Cellulitis with characteristic erythema, tenderness, and edema.
FIG. 24-7 Herpes zoster (shingles) on the anterior chest, classic dermatomal distribution.
FIG. 24-8 Plantar wart. A, Keratotic lesion. B, After excision.
Fungal Infections
FIG. 24-9 Tinea unguium (onychomycosis). Fungal infection of toenails. Crumbly, discolored, and thickened nails.
TABLE 24-5 COMMON VIRAL INFECTIONS OF THE SKIN
TABLE 24-6 COMMON FUNGAL INFECTIONS OF THE SKIN
TABLE 24-7 COMMON INFESTATIONS AND INSECT BITES
Infestations and Insect Bites
Allergic Dermatologic Problems
Benign Dermatologic Problems
TABLE 24-8 COMMON ALLERGIC CONDITIONS OF THE SKIN
FIG. 24-10 Acne vulgaris. Papules and pustules.
Drug Alert
Diseases with Dermatologic Manifestations
FIG. 24-11 Psoriasis. Characteristic inflammation and scaling.
TABLE 24-9 COMMON BENIGN CONDITIONS OF THE SKIN
Collaborative Care Dermatologic Problems
Diagnostic Studies
Collaborative Therapy
Phototherapy.
TABLE 24-10 DRUG THERAPY: Common Bases for Topical Medications
Radiation Therapy.
Laser Technology.
TABLE 24-11 SKIN CONDITIONS TREATED BY LASER
Drug Therapy
Antibiotics.
Corticosteroids.
Antihistamines.
Topical Fluorouracil.
Immunomodulators.
Diagnostic and Surgical Therapy
Skin Scraping.
Electrodesiccation and Electrocoagulation.
Curettage.
Punch Biopsy.
FIG. 24-12 Punch biopsy. A, Removal of skin for diagnostic purposes. B, Specimen obtained.
Cryosurgery.
Excision.
FIG. 24-13 A, Removal of melanoma by Mohs’ surgery. B, After plastic surgery using a skin flap to repair defect.
Nursing Management Dermatologic Problems
Ambulatory and Home Care
Wet Dressings.
Baths.
Topical Medications.
Control of Pruritus.
Prevention of Spread.
Prevention of Secondary Infections.
Specific Skin Care.
Psychologic Effects of Chronic Dermatologic Problems.
Physiologic Effects of Chronic Dermatologic Problems.
TABLE 24-12 COMMON COSMETIC TOPICAL PROCEDURES
Cosmetic Procedures
Elective Surgery
Laser Surgery.
Face-Lift.
FIG. 24-14 Face-lift. A, Preoperative. B, Postoperative.
Liposuction.
Delegation Decisions Skin Care
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Nursing Management Cosmetic Surgery
Preoperative Management
Postoperative Management
Skin Grafts
Uses
Types
Case Study Malignant Melanoma and Dysplastic Nevi
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 25 Nursing Management: Burns
Learning Outcomes
Key Terms
eFigure
TABLE 25-1 SOURCES OF BURN INJURY*
Kitchen and Bathroom
General Household
TABLE 25-2 STRATEGIES TO REDUCE BURN INJURY
Types of Burn Injury
Thermal Burns
FIG. 25-1 Types of burn injury. A, Partial-thickness thermal hand burn. B, Full-thickness thermal hand burn. C, Full-thickness scald burn to the buttock and lower back secondary to immersion in hot water.
Chemical Burns
Smoke and Inhalation Injury
TABLE 25-3 MANIFESTATIONS OF LUNG INJURY ASSOCIATED WITH BURNS
Metabolic Asphyxiation.
Upper Airway Injury.
Lower Airway Injury.
Electrical Burns
FIG. 25-2 Electrical injury produces heat coagulation of blood supply and contact area as electric current passes through the skin. A, Back and buttock (arrows). B, Leg (arrow).
Cold Thermal Injury
TABLE 25-4 BURN CENTER REFERRAL CRITERIA
Classification of Burn Injury
Depth of Burn
FIG. 25-3 Cross section of skin indicating the depth of burn and structures involved.
Extent of Burn
Location of Burn
TABLE 25-5 CLASSIFICATION OF BURN INJURY DEPTH
FIG. 25-4 A, Lund-Browder chart. By convention, areas of partial-thickness injury are colored in blue and areas of full-thickness injury in red. Superficial partial-thickness burns are not calculated. B, Rule of Nines chart.
Patient Risk Factors
Phases of Burn Management
Prehospital Care
TABLE 25-6 EMERGENCY MANAGEMENT: Thermal Burns
Partial-Thickness (superficial; first-degree) Burn
Partial-Thickness (deep; second-degree) Burn
Full-Thickness (third- and fourth-degree) Burns
Initial
Ongoing Monitoring
Emergent Phase
TABLE 25-7 EMERGENCY MANAGEMENT: Inhalation Injury
Initial
Ongoing Monitoring
TABLE 25-8 EMERGENCY MANAGEMENT Electrical Burns
Alternating Current
Direct Current
Initial
Ongoing Monitoring
TABLE 25-9 EMERGENCY MANAGEMENT Chemical Burns
Initial
Ongoing Monitoring
Pathophysiology
Fluid and Electrolyte Shifts.
FIG. 25-5 At the time of major burn injury, there is increased capillary permeability. All fluid components of the blood begin to leak into the interstitium, causing edema and a decreased blood volume. Hematocrit increases, and the blood becomes more viscous. The combination of decreased blood volume and increased viscosity produces increased peripheral resistance. Burn shock, a type of hypovolemic shock, rapidly ensues and, if not corrected, can result in death.
Inflammation and Healing.
Immunologic Changes.
FIG. 25-6 A, Facial edema before fluid resuscitation. B, Facial edema after 24 hours.
FIG. 25-7 The effects of burn shock are shown above the blue line. As the capillary seal is lost, interstitial edema develops. The cellular integrity is also altered, with sodium (Na) moving into the cell in abnormal amounts and potassium (K) leaving the cell. The shifts after the resolution of burn shock are shown below the blue line. The water and sodium move back into the circulating volume through the capillary. The albumin remains in the interstitium. Potassium is transported into the cell and sodium is transported out as the cellular integrity returns.
Clinical Manifestations
Complications
Cardiovascular System.
FIG. 25-8 Escharotomies of the chest and arm (indicated by arrows).
Respiratory System.
Other Cardiopulmonary Problems.
Urinary System.
Nursing and Collaborative Management Emergent Phase
Airway Management
Fluid Therapy
TABLE 25-10 COLLABORATIVE CARE: Burn Injury
Fluid Therapy (see Table 25-11)
Wound Care
Pain and Anxiety
Physical and Occupational Therapy
Nutritional Therapy
Respiratory Therapy
Psychosocial Care
Fluid Therapy
Wound Care
Early Excision and Grafting
Pain and Anxiety
Physical and Occupational Therapy
Nutritional Therapy
Respiratory Therapy
Psychosocial Care
Drug Therapy (see Table 25-13)
TABLE 25-11 FLUID RESUSCITATION
Wound Care
FIG. 25-9 Cart shower. Showering presents an opportunity for physical therapy and wound care.
FIG. 25-10 Surgical debridement of full-thickness burns is necessary to prepare the wound for grafting.
FIG. 25-11 Application of silver sulfadiazine cream to saline-moistened gauze.
TABLE 25-12 SOURCES OF GRAFTS
Other Care Measures
Drug Therapy
Analgesics and Sedatives.
Tetanus Immunization.
Antimicrobial Agents.
Safety Alert
TABLE 25-13 DRUG THERAPY: Burn Care
Venous Thromboembolism Prophylaxis.
Evidence-Based Practice Translating Research Into Practice
Does the Type of Enteral Feeding Affect Outcomes in Burn Patients?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Nutritional Therapy
Acute Phase
Pathophysiology
Clinical Manifestations
Laboratory Values
Sodium.
Potassium.
Complications
Infection.
Cardiovascular and Respiratory Systems.
Neurologic System.
Musculoskeletal System.
Gastrointestinal System.
Endocrine System.
Nursing and Collaborative Management Acute Phase
Wound Care
Excision and Grafting
FIG. 25-12 A, Freshly applied split-thickness sheet skin graft to the hand. B, Split-thickness skin graft is harvested from a patient’s thigh using a dermatome. C, Donor site is covered with a hydrophilic foam dressing after harvesting. D, Healed donor site.
Cultured Epithelial Autografts.
Artificial Skin.
FIG. 25-13 Patient with cultured epithelial autograft (CEA). A, Intraoperative application of CEA. B, Appearance of healed CEA.
Pain Management
Physical and Occupational Therapy
Nutritional Therapy
Rehabilitation Phase
Pathophysiologic Changes and Clinical Manifestations
FIG. 25-14 Neck contractures.
Complications
Nursing and Collaborative Management Rehabilitation Phase
Gerontologic Considerations
Burns
Emotional/Psychologic Needs of Patients and Caregivers
TABLE 25-14 EMOTIONAL RESPONSES OF BURN PATIENTS*
Special Needs of Nurses
Case Study Burn Injury
Patient Profile
Subjective Data
Objective Data
Physical Examination
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Introduction
Patients
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Section 5 Problems of Oxygenation: Ventilation
Problems of Oxygenation: Ventilation
Pre-Test – Section 5
Interactive Review – Section 5
Chapter 26 Nursing Assessment: Respiratory System
Learning Outcomes
Key Terms
eFigures
eTable
Structures and Functions of Respiratory System
Upper Respiratory Tract
FIG. 26-1 Structures of the respiratory tract. A, Pulmonary functional unit. B, Ciliated mucous membrane.
FIG. 26-2 Landmarks and structures of the chest wall. A, Anterior view. B, Posterior view.
Lower Respiratory Tract
FIG. 26-3 Structures of lower airways.
Surfactant.
FIG. 26-4 Scanning electron micrograph of lung parenchyma. A, Alveoli (A) and alveolar-capillary membrane (arrow). B, Effects of atelectasis. Alveoli (A) are partially or totally collapsed.
FIG. 26-5 Partial pressure of respiratory gases in normal respiration. The pressures are shown in inhaled and exhaled air from the lungs and at the level of the alveoli and pulmonary venous and arterial blood vessels.
Blood Supply.
Chest Wall
Physiology of Respiration
Ventilation.
Compliance.
Diffusion.
Arterial Blood Gases.
TABLE 26-1 NORMAL ARTERIAL AND VENOUS BLOOD GAS VALUES*
TABLE 26-2 MANIFESTATIONS OF INADEQUATE OXYGENATION
Mixed Venous Blood Gases.
Oximetry.
Carbon Dioxide Monitoring.
TABLE 26-3 CRITICAL VALUES FOR PaO2 AND SpO2 *
Control of Respiration
Chemoreceptors.
Mechanical Receptors.
Respiratory Defense Mechanisms
Filtration of Air.
Mucociliary Clearance System.
Cough Reflex.
Reflex Bronchoconstriction.
Alveolar Macrophages.
Gerontologic Considerations
Effects of Aging on Respiratory System
TABLE 26-4 GERONTOLOGIC ASSESSMENT DIFFERENCES: Respiratory System
Assessment of Respiratory System
Case Study Patient Introduction
Critical Thinking
Subjective Data
Important Health Information
Past Health History.
Medications.
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
TABLE 26-5 HEALTH HISTORY: Respiratory System
Genetic Risk Alert
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Case Study—cont’d
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Objective Data
Physical Examination.
Nose.
Mouth and Pharynx.
Neck.
Thorax and Lungs.
Inspection.
Palpation.
FIG. 26-6 Estimation of thoracic expansion. A, Exhalation. B, Maximal inhalation.
Case Study—cont’d
Percussion.
FIG. 26-7 Sequence for examination of the chest. A, Anterior sequence. B, Lateral sequence. C, Posterior sequence. For palpation, place the palms of the hands in the position designated as “1” on the right and left sides of the chest. Compare the intensity of vibrations. Continue for all positions in each sequence. For percussion, tap the chest at each designated position, moving downward from side to side. Compare percussion sounds at all positions. For auscultation, place the stethoscope at each position and listen to at least one complete inspiratory and expiratory cycle. Keep in mind that, with a female patient, the breast tissue will modify the completeness of the anterior examination.
TABLE 26-6 PERCUSSION SOUNDS
FIG. 26-8 Diagram of percussion areas and sounds in the anterior side of the chest.
FIG. 26-9 Diagram of percussion areas and sounds in the posterior side of the chest. Percussion proceeds from the lung apices to the lung bases while comparing sounds in opposite areas of the chest.
Auscultation.
FIG. 26-10 Normal auscultatory sounds.
TABLE 26-7 NORMAL PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Observe
Inspect
Palpate
Auscultate
TABLE 26-8 ASSESSMENT ABNORMALITIES: Respiratory System
TABLE 26-9 CHEST EXAMINATION FINDINGS IN PULMONARY PROBLEMS
Diagnostic Studies of Respiratory System
Sputum Studies
Skin Tests
Endoscopic Examinations
Bronchoscopy.
TABLE 26-10 DIAGNOSTIC STUDIES: Respiratory System
FIG. 26-11 Fiberoptic bronchoscope. A, The transbronchoscopic balloon-tipped catheter and the flexible fiberoptic bronchoscope. B, The catheter is introduced into a small airway and the balloon inflated with 1.5 to 2 mL of air to occlude the airway. Bronchoalveolar lavage is performed by injecting and withdrawing 30-mL aliquots of sterile saline solution, gently aspirating after each instillation. Specimens are sent to the laboratory for analysis.
Lung Biopsy
TABLE 26-11 INTERPRETING RESPONSES TO TUBERCULIN SKIN TESTING
Case Study—cont’d
FIG. 26-12 Transbronchial biopsy needle penetrating the bronchial wall and entering a mass of subcarinal lymph nodes or tumor.
FIG. 26-13 Thoracentesis. A catheter is positioned in the pleural space to remove accumulated fluid.
Thoracentesis
Pulmonary Function Tests
TABLE 26-12 LUNG VOLUMES AND CAPACITIES
TABLE 26-13 COMMON MEASURES OF PULMONARY FUNCTION AIRFLOW
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Glossary
Key Points
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Chapter 27 Nursing Management: Upper Respiratory Problems
Learning Outcomes
Key Terms
eFigure
Problems of Nose and Paranasal Sinuses
Deviated Septum
Nasal Fracture
Rhinoplasty
Nursing Management Nasal Surgery
Epistaxis
Nursing and Collaborative Management Epistaxis
Allergic Rhinitis
FIG. 27-1 A, Epistaxis balloon. The balloon is inflated after insertion. B, Epistaxis balloon in proper position in nares.
Clinical Manifestations
Nursing and Collaborative Management Allergic Rhinitis
TABLE 27-1 PATIENT & CAREGIVER TEACHING GUIDE: Avoiding Allergens in Allergic Rhinitis
Drug Alert
Drug Alert
Acute Viral Rhinitis
TABLE 27-2 DRUG THERAPY: Rhinitis and Sinusitis
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Nursing and Collaborative Management Acute Viral Rhinitis
Evidence-Based Practice Translating Research Into Practice
Do Probiotics Prevent Upper Respiratory Tract Infections?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Influenza
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Nursing and Collaborative Management Influenza
TABLE 27-3 TYPES OF INFLUENZA IMMUNIZATION
Safety Alert
Sinusitis
Cultural & Ethnic Health Disparities
FIG. 27-2 Location of the sinuses.
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Clinical Manifestations
Nursing and Collaborative Management Sinusitis
TABLE 27-4 PATIENT & CAREGIVER TEACHING GUIDE: Acute or Chronic Sinusitis
Obstruction of Nose and Sinuses
Nasal Polyps
Foreign Bodies
Problems of Pharynx
Acute Pharyngitis
Clinical Manifestations
Nursing and Collaborative Management Acute Pharyngitis
Peritonsillar Abscess
Problems of Trachea and Larynx
Airway Obstruction
Tracheostomy
FIG. 27-3 Tracheostomy tube. A, Parts of a tracheostomy tube. B, Tracheostomy tube inserted in airway with inflated cuff. (See Table 27-5 and eNursing Care Plan 27-1 [on the website for this chapter] for related nursing management.)
Nursing Management Tracheostomy
Providing Tracheostomy Care
TABLE 27-5 NURSING MANAGEMENT OF TRACHEOSTOMIES
TABLE 27-6 SUCTIONING A TRACHEOSTOMY TUBE
FIG. 27-4 Suctioning tracheostomy with closed system suction catheter.
FIG. 27-5 Changing tracheostomy ties. A, A slit is cut about 1 in (2.5 cm) from the end. The slit end is put into the opening of the cannula. B, A loop is made with the other end of the tape. C, The tapes are tied together with a double knot on the side of the neck. D, A Velcro tracheostomy tube holder can be used instead of twill ties to make tracheostomy tube stabilization more secure.
TABLE 27-7 TRACHEOSTOMY CARE
Swallowing Dysfunction
FIG. 27-6 Changing the tracheostomy tube at home. When a tracheostomy has been in place for several months, the tract will be well formed. The patient can be taught to change the tube using a clean technique at home.
TABLE 27-8 COMPLICATIONS OF TRACHEOSTOMY
Speech With a Tracheostomy Tube
FIG. 27-7 Speaking tracheostomy tubes. A, Fenestrated tracheostomy tube with cuff deflated, inner cannula removed, and tracheostomy tube capped to allow air to pass over the vocal cords. B, Speaking tracheostomy tube. One tube is used for cuff inflation. The second tube is connected to a source of compressed air or O2. When the port on the second tube is occluded, air flows up over the vocal cords, allowing speech with an inflated cuff. (See Table 27-5 and eNursing Care Plan 27-1 for related nursing management.)
FIG. 27-8 Passy-Muir speaking tracheostomy valve. The valve is placed over the hub of the tracheostomy tube after the cuff is deflated. Multiple options are available and can be used for ventilated and nonventilated patients. The one-way valve allows air to enter the lungs during inspiration and redirects air upward over the vocal cords into the mouth during expiration.
Informatics in Practice Communication Devices for Patient With Laryngectomy
Decannulation
Laryngeal Polyps
Head and Neck Cancer
Clinical Manifestations
Diagnostic Studies
Collaborative Care
FIG. 27-9 Excision of laryngeal cancer. This cancer of the right vocal cord meets criteria for resection by transoral cordectomy. The cord is fully mobile, and the lesion can be fully exposed. It does not approach or cross the anterior commissure.
FIG. 27-10 A, Normal airflow in and out of the lungs. B, Airflow in and out of the lungs after total laryngectomy. Patients using esophageal speech trap air in the esophagus and release it to create sound.
FIG. 27-11 Reconstructive surgery involving skin grafts may be needed after a radical neck dissection.
Nutritional Therapy.
Nursing Management Head and Neck Cancer
Nursing Assessment
TABLE 27-9 PATIENT TEACHING GUIDE: Supraglottic Swallow
TABLE 27-10 NURSING ASSESSMENT: Head and Neck Cancer
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Radiation Therapy.
Surgical Therapy.
Voice Rehabilitation.
FIG. 27-12 Artificial larynx. A, Battery-powered electronic artificial larynx for patient who has had a total laryngectomy. B, The sound waves created by the electrolarynx allow the person to speak.
FIG. 27-13 Blom-Singer voice prosthesis and tracheostoma valve. With this prosthesis and valve, patients with a laryngectomy can speak normally. Inset shows laryngectomy stoma and voice prosthesis with tracheostoma valve removed.
Stoma Care.
Depression.
Sexuality.
Delegation Decisions Suctioning and Tracheostomy Care
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Ambulatory and Home Care.
Evaluation
Case Study Laryngeal Cancer
Patient Profile
Subjective Data
Objective Data
Laryngoscopy
Physical Examination
Computed Tomography Scan
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Animations
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Chapter 28 Nursing Management: Lower Respiratory Problems
Learning Outcomes
Key Terms
eTables
Healthy People
Lower Respiratory Tract Infections
Acute Bronchitis
Pertussis
Pneumonia
Etiology
TABLE 28-1 RISK FACTORS FOR PNEUMONIA
Types of Pneumonia
Community-Acquired Pneumonia.
TABLE 28-2 ORGANISMS CAUSING PNEUMONIA
TABLE 28-3 ASSESSING PNEUMONIA USING CURB-65
Medical Care–Associated Pneumonia.
Aspiration Pneumonia.
Opportunistic Pneumonia.
FIG. 28-1 Pathophysiologic course of pneumonia.
Pathophysiology
Clinical Manifestations
Complications
Diagnostic Studies
TABLE 28-4 COLLABORATIVE CARE: Pneumonia
Diagnostic
Collaborative Therapy
Collaborative Care
TABLE 28-5 PNEUMOVAX VACCINATION
Drug Therapy.
TABLE 28-6 DRUG THERAPY: Bacterial Community-Acquired Pneumonia
Nutritional Therapy.
Nursing Management Pneumonia
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
TABLE 28-7 NURSING ASSESSMENT: Pneumonia
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Tuberculosis
Cultural & Ethnic Health Disparities
Etiology and Pathophysiology
TABLE 28-8 CLASSIFICATION OF TUBERCULOSIS (TB)
Classification
TABLE 28-9 LATENT TUBERCULOSIS (TB) INFECTION COMPARED WITH TB DISEASE
Clinical Manifestations
Complications
Diagnostic Studies
Tuberculin Skin Test.
Interferon-γ Release Assays.
Chest X-Ray.
Bacteriologic Studies.
Collaborative Care
TABLE 28-10 COLLABORATIVE CARE: Pulmonary Tuberculosis
Diagnostic
Collaborative Therapy
TABLE 28-11 DRUG THERAPY: Tuberculosis (TB)
Drug Therapy
Active TB Disease.
TABLE 28-12 DRUG THERAPY: Tuberculosis Disease Regimens
Drug Alert
Ethical/Legal Dilemmas Patient Adherence
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Latent Tuberculosis Infection.
TABLE 28-13 DRUG THERAPY: Latent Tuberculosis Infection Regimens
Vaccine.
Nursing Management Tuberculosis
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Atypical Mycobacteria
Pulmonary Fungal Infections
TABLE 28-14 FUNGAL INFECTIONS OF THE LUNG
Lung Abscess
Etiology and Pathophysiology
Clinical Manifestations and Complications
Diagnostic Studies
Nursing and Collaborative Management Lung Abscess
Environmental Lung Diseases
Clinical Manifestations
Collaborative Care
Lung Cancer
Etiology
Cultural & Ethnic Health Disparities
African Americans
Whites
Asian/Pacific Islanders and Hispanics
Other
Gender Differences
FIG. 28-2 Lung cancer (peripheral adenocarcinoma). The tumor shows prominent black pigmentation, suggestive of having evolved in an anthracotic scar.
Pathophysiology
Paraneoplastic Syndrome.
TABLE 28-15 TYPES OF PRIMARY LUNG CANCER
FIG. 28-3 Lung carcinoma. The gray-white tumor tissue is infiltrating the lung. Histologically this tumor is identified as a squamous cell carcinoma.
Evidence-Based Practice Translating Research Into Practice
Which Interventions Improve Well-Being in Lung Cancer?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Clinical Manifestations
TABLE 28-16 COLLABORATIVE CARE: Lung Cancer
Diagnostic
Collaborative Therapy
Diagnostic Studies
TABLE 28-17 STAGING OF NON–SMALL CELL LUNG CANCER
Staging.
Screening for Lung Cancer.
Collaborative Care
Surgical Therapy.
Radiation Therapy.
Stereotactic Body Radiotherapy.
Chemotherapy.
Targeted Therapy.
Other Therapies
Prophylactic Cranial Radiation.
Bronchoscopic Laser Therapy.
Photodynamic Therapy.
Airway Stenting.
Radiofrequency Ablation.
Nursing Management Lung Cancer
Nursing Assessment
Nursing Diagnoses
TABLE 28-18 NURSING ASSESSMENT: Lung Cancer
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Other Types of Lung Tumors
Chest Trauma and Thoracic Injuries
TABLE 28-19 EMERGENCY MANAGEMENT: Chest Trauma
Blunt
Penetrating
Respiratory
Cardiovascular
Surface Findings
Initial
Ongoing Monitoring
TABLE 28-20 EMERGENCY MANAGEMENT: Thoracic Injuries
Pneumothorax
Types of Pneumothorax
Spontaneous Pneumothorax.
Iatrogenic Pneumothorax.
FIG. 28-4 Open pneumothorax resulting from collapse of lung due to disruption of chest wall and outside air entering.
Traumatic Pneumothorax.
FIG. 28-5 Tension pneumothorax. As pleural pressure on the affected side increases, mediastinal displacement ensues with resultant respiratory and cardiovascular compromise. Tracheal deviation is an external manifestation of the mediastinal shift.
Tension Pneumothorax.
Hemothorax.
Chylothorax.
Collaborative Care
Fractured Ribs
Flail Chest
FIG. 28-6 Flail chest produces paradoxic respiration. On inspiration, the flail section sinks in with mediastinal shift to the uninjured side. On expiration, the flail section bulges outward with mediastinal shift to the injured side.
Chest Tubes and Pleural Drainage
FIG. 28-7 Placement of chest tubes.
Chest Tube Insertion
FIG. 28-8 Chest drainage unit. Both units have three chambers: (1) collection chamber; (2) water-seal chamber; and (3) suction control chamber. Suction control chamber requires a connection to a wall suction source that is dialed up higher than the prescribed suction for the suction to work. A, Water suction. This unit uses water in the suction control chamber to control the wall suction pressure. B, Dry suction. This unit controls wall suction by using a regulator control dial.
Flutter or Heimlich Valve
FIG. 28-9 A, Heimlich chest drain valve is a specially designed flutter valve that is used in place of a chest drainage unit for small uncomplicated pneumothorax with little or no drainage and no need for suction. The valve allows for escape of air but prevents the reentry of air into the pleural space. B, Placement of valve between chest tube and vented drainage bag, which can be worn under a person’s clothes.
Pleural Drainage
TABLE 28-21 CHEST TUBES AND WATER-SEAL DRAINAGE
Informatics in Practice Chest Drainage System
Nursing Management Chest Drainage
Chest Tube Removal
Chest Surgery
Preoperative Care
TABLE 28-22 CHEST SURGERIES
Surgical Procedures
Thoracotomy.
Video-Assisted Thoracic Surgery.
Postoperative Care
Restrictive Respiratory Disorders
TABLE 28-23 EXTRAPULMONARY CAUSES OF RESTRICTIVE LUNG DISEASE*
TABLE 28-24 INTRAPULMONARY CAUSES OF RESTRICTIVE LUNG DISEASE*
Pleural Effusion
Types
FIG. 28-10 Fibrothorax resulting from an organization of inflammatory exudate and pleural effusion.
Clinical Manifestations
Thoracentesis
Collaborative Care
Pleurisy
Atelectasis
Interstitial Lung Diseases
Idiopathic Pulmonary Fibrosis
Sarcoidosis
Vascular Lung Disorders
Pulmonary Edema
TABLE 28-25 CAUSES OF PULMONARY EDEMA
Pulmonary Embolism
Etiology and Pathophysiology
FIG. 28-11 Large embolus from the femoral vein lying in the main left and right pulmonary arteries.
Clinical Manifestations
Complications
Diagnostic Studies
TABLE 28-26 COLLABORATIVE CARE: Acute Pulmonary Embolism
Diagnostic
Collaborative Therapy
Collaborative Care
Drug Therapy.
Surgical Therapy.
Nursing Management Pulmonary Embolism
Nursing Implementation
Evaluation
Pulmonary Hypertension
Idiopathic Pulmonary Arterial Hypertension
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
FIG. 28-12 Pathogenesis of pulmonary hypertension and cor pulmonale.
Nursing and Collaborative Management Pulmonary Hypertension
Secondary Pulmonary Arterial Hypertension
TABLE 28-27 DRUG THERAPY: Pulmonary Hypertension
FIG. 28-13 A patient with pulmonary hypertension who is on continuous epoprostenol infusion is being taught how to use the portable infusion pump.
Cor Pulmonale
Clinical Manifestations and Diagnostic Studies
Collaborative Care
TABLE 28-28 COLLABORATIVE CARE: Cor Pulmonale
Diagnostic
Collaborative Therapy
Lung Transplantation
Preoperative Care
TABLE 28-29 INDICATIONS FOR LUNG TRANSPLANTATION*
Surgical Procedure
Postoperative Care
Case Study Pneumonia and Lung Cancer
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 29 Nursing Management: Obstructive Pulmonary Diseases
Learning Outcomes
Key Terms
eFigures
eTables
Cultural & Ethnic Health Disparities
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Cystic Fibrosis
Gender Differences
Asthma
Risk Factors for Asthma and Triggers of Asthma Attacks
Genetics.
TABLE 29-1 TRIGGERS OF ASTHMA ATTACKS
Immune Response.
Allergens.
Exercise.
Air Pollutants.
Occupational Factors.
Respiratory Tract Infections.
Nose and Sinus Problems.
Drugs and Food Additives.
Gastroesophageal Reflux Disease.
Psychologic Factors.
Pathophysiology
FIG. 29-1 Pathophysiology of asthma. IL, Interleukin.
FIG. 29-2 Allergic asthma is triggered when an allergen cross-links IgE receptors on mast cells, which are then activated to release histamine and other inflammatory mediators (early-phase response). A late-phase response may occur due to further inflammation.
FIG. 29-3 Factors causing obstruction (especially expiratory obstruction) in asthma. A, Cross section of a bronchiole occluded by muscle spasm, swollen mucosa, and mucus in the lumen. B, Longitudinal section of a bronchiole.
Clinical Manifestations
TABLE 29-2 CLASSIFICATION OF ASTHMA SEVERITY
Classification of Asthma
Complications
Severe and Life-Threatening Asthma Exacerbations.
Safety Alert
Diagnostic Studies
TABLE 29-3 COMPARISON OF ASTHMA AND COPD*
TABLE 29-4 COLLABORATIVE CARE: Asthma
TABLE 29-5 COMPONENTS OF ASTHMA CONTROL
Collaborative Care
FIG. 29-4 Drug therapy: stepwise approach for managing asthma.
TABLE 29-6 DRUG THERAPY: Long-Term Control Versus Quick Relief of Asthma
Intermittent and Persistent Asthma.
Acute Asthma Exacerbations.
Severe and Life-Threatening Asthma Exacerbations.
Drug Therapy
Antiinflammatory Drugs
Corticosteroids.
TABLE 29-7 DRUG THERAPY Asthma and Chronic Obstructive Pulmonary Disease (COPD)*
FIG. 29-5 Example of an AeroChamber spacer used with a metered-dose inhaler.
Leukotriene Modifiers.
Anti-IgE.
Bronchodilators.
β2-Adrenergic Agonist Drugs.
Drug Alert
Drug Alert
Methylxanthines.
Drug Alert
Anticholinergic Drugs.
Inhalation Devices for Drug Delivery.
Inhalers.
FIG. 29-6 How to use your metered-dose inhaler correctly.
TABLE 29-8 PROBLEMS USING A METERED-DOSE INHALER (MDI)
FIG. 29-7 Example of a dry powder inhaler (DPI).
TABLE 29-9 PATIENT TEACHING GUIDE: How to Use a Dry Powder Inhaler (DPI)
TABLE 29-10 COMPARISON OF METERED-DOSE AND DRY POWDER INHALERS
Nebulizers.
Informatics in Practice Home Monitoring of Asthma
Patient Teaching Related to Drug Therapy.
Nonprescription Combination Drugs.
Nursing Management Asthma
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Care Plan 29-1
Patient With Asthma
Nursing Diagnosis*
Patient Goals
Respiratory Status: Airway Patency
Asthma Management
Nursing Diagnosis
Patient Goals
Anxiety Level
Anxiety Reduction
Nursing Diagnosis
Patient Goals
Asthma Self-Management
Asthma Management
TABLE 29-11 NURSING ASSESSMENT: Asthma
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
TABLE 29-12 ASTHMA ACTION PLAN*
TABLE 29-13 PATIENT TEACHING GUIDE: Pursed-Lip Breathing (PLB)
TABLE 29-14 PATIENT TEACHING GUIDE: How to Use Your Peak Flow Meter
Evaluation
Chronic Obstructive Pulmonary Disease
Etiology
Cigarette Smoking.
Gender Differences
TABLE 29-15 PATIENT & CAREGIVER TEACHING GUIDE: Asthma
Occupational Chemicals and Dusts.
Air Pollution.
TABLE 29-16 EFFECTS OF TOBACCO SMOKE ON RESPIRATORY SYSTEM
Infection.
Genetics.
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
α1-Antitrypsin (AAT) Deficiency.
Genetic Link
Aging.
Pathophysiology
FIG. 29-8 Pathophysiology of chronic obstructive pulmonary disease (COPD).
FIG. 29-9 A, Normal lungs showing bronchioles and alveoli. B, Changes in the bronchioles and alveoli in the lungs of a patient with chronic obstructive pulmonary disease (COPD).
Clinical Manifestations
Classification of COPD.
Complications
Cor Pulmonale.
TABLE 29-17 CLASSIFICATION OF COPD SEVERITY*
FIG. 29-10 Mechanisms involved in the pathophysiology of pulmonary hypertension and cor pulmonale secondary to chronic obstructive pulmonary disease.
COPD Exacerbations.
Acute Respiratory Failure.
Depression and Anxiety.
Diagnostic Studies
TABLE 29-18 COLLABORATIVE CARE: Chronic Obstructive Pulmonary Disease (COPD)
Collaborative Care
FIG. 29-11 Rubric for chronic obstructive pulmonary disease (COPD) showing the association between symptoms, spirometric classification, and future risk of exacerbations. The following factors are considered in the rubric: (1) current level of patient’s symptoms as measured by one of two validated questionnaires (modified Medical Research Council [mMRC] Dyspnea Scale [see eTable 29-4] or the COPD Assessment Test [CAT] [see eTable 29-3]); (2) severity of the disease as measured by the FEV1; (3) exacerbation risk as reflected in the spirometric classification or patient’s history of exacerbations; and (4) presence of co-morbidities.
Smoking Cessation.
Drug Therapy.
TABLE 29-19 DRUG THERAPY: Medication Guidelines for Stable COPD
Oxygen Therapy.
Indications for Use.
Methods of Administration.
TABLE 29-20 METHODS OF OXYGEN ADMINISTRATION
FIG. 29-12 Golfer uses Helios liquid portable O2 system.
Humidification and Nebulization.
Complications
Combustion.
Carbon Dioxide Narcosis.
Oxygen Toxicity.
Absorption Atelectasis.
Infection.
Delegation Decisions Oxygen Administration
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Chronic Oxygen Therapy at Home.
TABLE 29-21 HOME OXYGEN DELIVERY SYSTEMS*
FIG. 29-13 A portable liquid O2 unit can be refilled from a liquid O2 reservoir unit.
TABLE 29-22 PATIENT & CAREGIVER TEACHING GUIDE: Home Oxygen Use
Breathing Retraining.
Airway Clearance Techniques.
Effective Coughing.
Chest Physiotherapy.
TABLE 29-23 PATIENT & CAREGIVER TEACHING GUIDE: Effective Huff Coughing
Postural Drainage.
Percussion.
Vibration.
FIG. 29-14 Cupped-hand position for percussion. The hand should be cupped as though scooping up water.
FIG. 29-15 Acapella airway clearance device.
Airway Clearance Devices.
High-Frequency Chest Wall Oscillation.
Nutritional Therapy.
TABLE 29-24 NUTRITIONAL THERAPY: Maximizing Food Intake in COPD
Surgical Therapy for COPD.
Nursing Management Chronic Obstructive Pulmonary Disease
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 29-25 NURSING ASSESSMENT: Chronic Obstructive Pulmonary Disease
Ambulatory and Home Care.
Pulmonary Rehabilitation.
Informatics in Practice Texting for Chronic Obstructive Pulmonary Disease (COPD) Patients
Activity Considerations.
Nursing Care Plan 29-2
Patient With Chronic Obstructive Pulmonary Disease
Nursing Diagnosis*
Patient Goals
Respiratory Status: Ventilation
Measurement Scale
Ventilation Assistance
Nursing Diagnosis
Patient Goals
Respiratory Status: Airway Patency
Cough Enhancement
Airway Management
Nursing Diagnosis
Patient Goals
Respiratory Status: Gas Exchange
Oxygen Therapy
TABLE 29-26 PATIENT & CAREGIVER TEACHING GUIDE: Chronic Obstructive Pulmonary Disease
Sexuality and Sexual Activity.
Sleep.
Ethical/Legal Dilemmas Advance Directives
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Psychosocial Considerations.
Evaluation
Cystic Fibrosis
Etiology and Pathophysiology
Genetic Link
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
FIG. 29-16 People with cystic fibrosis inherit a defective gene on chromosome 7 called cystic fibrosis transmembrane regulator (CFTR). The protein produced by this gene normally helps sodium and chloride move in and out of cells. If the protein does not work correctly, then the movement of sodium and chloride is blocked and an abnormally thick sticky mucus is produced on the outside of the cell.
FIG. 29-17 Pathologic changes in bronchiectasis. A, Longitudinal section of bronchial wall where chronic infection has caused damage. B, Collection of purulent material in dilated bronchioles, leading to persistent infection. C, Bronchiectasis in a patient with cystic fibrosis who underwent lung transplantation. Cut surfaces of lung show markedly distended peripheral bronchi filled with mucopurulent secretions.
Clinical Manifestations
Complications
Diagnostic Studies
Collaborative Care
Nursing Management Cystic Fibrosis
Nursing Assessment
Nursing Diagnoses
TABLE 29-27 NURSING ASSESSMENT: Cystic Fibrosis
Planning
Nursing Implementation
Bronchiectasis
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Nursing Management Bronchiectasis
Case Study Chronic Obstructive Pulmonary Disease
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Introduction
Patients
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Section 6 Problems of Oxygenation: Transport
Problems of Oxygenation: Transport
Pre-Test – Section 6
Interactive Review – Section 6
Chapter 30 Nursing Assessment: Hematologic System
Learning Outcomes
Key Terms
eFigure
eTable
Structures and Functions of Hematologic System
Bone Marrow
FIG. 30-1 Development of blood cells. RBCs, Red blood cells; WBCs, white blood cells.
Blood
Plasma.
TABLE 30-1 FUNCTIONS OF BLOOD
Blood Cells.
FIG. 30-2 Approximate values for the components of blood in the adult. Normally, 45% of the blood is composed of blood cells and 55% is composed of plasma.
Erythrocytes.
Leukocytes.
Granulocytes.
Lymphocytes.
Monocytes.
Thrombocytes.
Normal Iron Metabolism
Normal Clotting Mechanisms
Vascular Response.
FIG. 30-3 Normal iron metabolism. Iron is ingested in the diet or from supplements. Macrophages break down ingested red blood cells (RBCs). Iron is returned to blood bound to transferrin or stored as ferritin or hemosiderin.
Platelet Plug Formation.
Plasma Clotting Factors.
FIG. 30-4 Coagulation mechanism showing steps in the intrinsic pathway and extrinsic pathway as they would occur in the test tube.
TABLE 30-2 COAGULATION FACTORS
Lysis of Clot.
FIG. 30-5 Fibrinolytic system.
Spleen
Lymph System
Liver
Gerontologic Considerations
Hematologic System
TABLE 30-3 GERONTOLOGIC ASSESSMENT DIFFERENCES: Effects of Aging on Hematologic Studies
Assessment of Hematologic System
Subjective Data
Important Health Information
Past Health History.
Medications.
Case Study Patient Introduction
Critical Thinking
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
Genetic Risk Alert
Nutritional-Metabolic Pattern.
TABLE 30-4 HEALTH HISTORY: Hematologic System
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Case Study Subjective Data
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Objective Data
Physical Examination.
Lymph Node Assessment.
FIG. 30-6 Palpable superficial lymph nodes.
TABLE 30-5 ASSESSMENT ABNORMALITIES: Hematologic System
Palpation of Liver or Spleen.
Skin Assessment.
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Inspect
Auscultate
Palpate
Case Study Objective Data: Physical Examination
Diagnostic Studies of Hematologic System
Laboratory Studies
Complete Blood Count.
Red Blood Cells.
White Blood Cells.
TABLE 30-6 DIAGNOSTIC STUDIES: Complete Blood Count Studies
Platelet Count.
Blood Typing and Rh Factor.
TABLE 30-7 DIAGNOSTIC STUDIES: Clotting Studies
Iron Metabolism.
TABLE 30-8 ABO BLOOD GROUPS AND COMPATIBILITIES*
TABLE 30-9 DIAGNOSTIC STUDIES: Miscellaneous Blood Studies
Radiologic Studies
Biopsies
Bone Marrow Examination.
TABLE 30-10 DIAGNOSTIC STUDIES: Hematologic System
FIG. 30-7 Bone marrow aspiration from the posterior iliac crest.
Lymph Node Biopsy.
Case Study Objective Data: Diagnostic Studies
Molecular Cytogenetics and Gene Analysis
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Videos
Chapter 31 Nursing Management: Hematologic Problems
Learning Outcomes
Key Terms
Cultural & Ethnic Health Disparities
Anemia
Definition and Classification
FIG. 31-1 Causes of anemia.
Clinical Manifestations
Integumentary Changes.
Cardiopulmonary Manifestations.
TABLE 31-1 MORPHOLOGY AND ETIOLOGY OF ANEMIA
TABLE 31-2 CLASSIFICATION OF ANEMIA
Nursing Management Anemia
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Gerontologic Considerations
Anemia
TABLE 31-3 MANIFESTATIONS OF ANEMIA
TABLE 31-4 NURSING ASSESSMENT: Anemia
Nursing Care Plan 31-1
Patient With Anemia
Nursing Diagnosis*
Patient Goals
Fatigue Level
Energy Conservation
Energy Management
Nursing Diagnosis
Patient Goals
Nutritional Status
Nutritional Status: Biochemical Measures
Nutrition Management
Nursing Diagnosis
Patient Goal
Knowledge: Diet
Knowledge: Medication
Nutritional Counseling
Teaching: Prescribed Medication
Anemia Caused by Decreased Erythrocyte Production
Iron-Deficiency Anemia
Etiology
Clinical Manifestations
TABLE 31-5 NUTRITIONAL THERAPY: Nutrients for Erythropoiesis
Diagnostic Studies
TABLE 31-6 LABORATORY STUDY FINDINGS IN ANEMIAS
TABLE 31-7 COLLABORATIVE CARE: Iron-Deficiency Anemia
Diagnostic
Collaborative Therapy
Collaborative Care
Drug Therapy.
Drug Alert
Nursing Management Iron-Deficiency Anemia
Evidence-Based Practice Translating Research Into Practice
Does Intermittent Iron Supplementation Improve Anemia?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Thalassemia
Etiology
Genetic Link
Clinical Manifestations
Collaborative Care
Megaloblastic Anemias
Cobalamin (Vitamin B12) Deficiency
Etiology
Pernicious Anemia.
TABLE 31-8 CLASSIFICATION OF MEGALOBLASTIC ANEMIA
Other Causes of Cobalamin Deficiency.
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Folic Acid Deficiency
Nursing Management Megaloblastic Anemia
Anemia of Chronic Disease
Aplastic Anemia
Etiology
Clinical Manifestations
Diagnostic Studies
TABLE 31-9 CAUSES OF APLASTIC ANEMIA
Nursing and Collaborative Management Aplastic Anemia
Anemia Caused by Blood Loss
Acute Blood Loss
Clinical Manifestations
TABLE 31-10 MANIFESTATIONS OF ACUTE BLOOD LOSS
Diagnostic Studies
Collaborative Care
Nursing Management Acute Blood Loss
Chronic Blood Loss
Anemia Caused by Increased Erythrocyte Destruction
FIG. 31-2 Sequence of events in extravascular hemolysis.
Sickle Cell Disease
Etiology and Pathophysiology
Genetic Link
FIG. 31-3 In sickle cell, the hemoglobin forms long inflexible chains and alters the shape of the red blood cells (RBCs). The sickled RBCs can become stuck in the capillaries and occlude the blood flow.
Sickling Episodes.
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
Clinical Manifestations
Complications
Diagnostic Studies
Nursing and Collaborative Management Sickle Cell Disease
FIG. 31-4 Clinical manifestations and complications of sickle cell disease.
Ethical/Legal Dilemmas Pain Management
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Acquired Hemolytic Anemia
Other Red Blood Cell Disorders
Hemochromatosis
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
Genetic Link
Polycythemia
Etiology and Pathophysiology
Primary Polycythemia.
Genetic Link
Secondary Polycythemia.
FIG. 31-5 Differentiating between primary and secondary polycythemia. EPO, Erythropoietin; N, normal.
Clinical Manifestations and Complications
Diagnostic Studies
Collaborative Care
Nursing Management Polycythemia Vera
Problems of Hemostasis
Thrombocytopenia
Etiology and Pathophysiology
Immune Thrombocytopenic Purpura.
TABLE 31-11 CAUSES OF THROMBOCYTOPENIA
TABLE 31-12 DRUG AND HERBAL CAUSES OF THROMBOCYTOPENIA*
Thrombotic Thrombocytopenic Purpura.
Heparin-Induced Thrombocytopenia.
FIG. 31-6 Acute idiopathic thrombocytopenic purpura commonly manifests with purpuric lesions of this kind, although they may often be widespread by the time medical attention is sought.
Clinical Manifestations
Diagnostic Studies
TABLE 31-13 LABORATORY RESULTS IN THROMBOCYTOPENIA
Collaborative Care
Immune Thrombocytopenic Purpura.
TABLE 31-14 COLLABORATIVE CARE: Thrombocytopenia
Thrombotic Thrombocytopenic Purpura.
Heparin-lnduced Thrombocytopenia.
Acquired Thrombocytopenia From Decreased Platelet Production.
Nursing Management Thrombocytopenia
Nursing Assessment
Nursing Diagnoses
TABLE 31-15 NURSING ASSESSMENT: Thrombocytopenia
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 31-16 PATIENT & CAREGIVER TEACHING GUIDE: Thrombocytopenia
Ambulatory and Home Care.
Evaluation
Hemophilia and Von Willebrand Disease
Genetic Link
Clinical Manifestations and Complications
TABLE 31-17 TYPES OF HEMOPHILIA
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
FIG. 31-7 Severe ecchymoses in a person with hemophilia after a fall.
FIG. 31-8 Acute hemarthrosis of the knee is a common complication of hemophilia.
Diagnostic Studies
Collaborative Care
TABLE 31-18 LABORATORY RESULTS IN HEMOPHILIA
TABLE 31-19 DRUG THERAPY: Replacement Factors for Hemophilia
Nursing Management Hemophilia
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Disseminated Intravascular Coagulation
Etiology and Pathophysiology
FIG. 31-9 The sequence of events that occur during disseminated intravascular coagulation (DIC).
TABLE 31-20 RISK FACTORS FOR DIC
Clinical Manifestations
FIG. 31-10 Disseminated intravascular coagulation (DIC) resulting from staphylococcal septicemia. Note the characteristic skin hemorrhage ranging from small purpuric lesions to larger ecchymoses.
Diagnostic Studies
TABLE 31-21 LABORATORY RESULTS IN ACUTE DIC
Collaborative Care
Nursing Management Disseminated Intravascular Coagulation
Nursing Diagnoses
Nursing Implementation
FIG. 31-11 Intended sites of action for therapies in disseminated intravascular coagulation (DIC). AT III, Antithrombin III; FSPs, fibrin split products.
Neutropenia
Clinical Manifestations
TABLE 31-22 CAUSES OF NEUTROPENIA
Safety Alert
Delegation Decisions Caring for the Patient With Neutropenia
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Diagnostic Studies
TABLE 31-23 COLLABORATIVE CARE: Neutropenia
Nursing and Collaborative Management Neutropenia
TABLE 31-24 PATIENT & CAREGIVER TEACHING GUIDE: Neutropenia
Myelodysplastic Syndrome
Informatics in Practice Use of Internet to Access Information on Unfamiliar Diseases
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Nursing and Collaborative Management Myelodysplastic Syndrome
Leukemia
Etiology and Pathophysiology
Classification
Acute Myelogenous Leukemia.
Acute Lymphocytic Leukemia.
Chronic Myelogenous Leukemia.
TABLE 31-25 TYPES OF LEUKEMIA
Genetic Link
Chronic Lymphocytic Leukemia.
Other Leukemias.
Overlap Between Leukemia and Lymphoma.
Clinical Manifestations
FIG. 31-12 Pathophysiology of leukemia.
Diagnostic Studies
Collaborative Care
Stages of Chemotherapy.
Induction Therapy.
Postinduction or Postremission Therapy.
Maintenance Therapy.
Drug Therapy Regimens.
TABLE 31-26 DRUG THERAPY: Leukemia*
Other Treatments.
Hematopoietic Stem Cell Transplantation.
Nursing Management Leukemia
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Acute Intervention.
TABLE 31-27 NURSING ASSESSMENT: Leukemia
Ambulatory and Home Care.
Evaluation
TABLE 31-28 COMPARISON OF HODGKIN’S AND NON-HODGKIN’S LYMPHOMA
Lymphomas
Hodgkin’s Lymphoma
Etiology and Pathophysiology
FIG. 31-13 Hodgkin’s lymphoma (stage IIA). This patient has enlargement of the cervical lymph nodes.
Clinical Manifestations
Diagnostic and Staging Studies
Nursing and Collaborative Management Hodgkin’S Lymphoma
FIG. 31-14 Staging system for Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Stage I, involvement of single lymph node (e.g., cervical node). Stage II, involvement of two or more lymph nodes on one side of diaphragm. Stage III, lymph node involvement above and below the diaphragm. Stage IV, involvement outside of diaphragm (e.g., liver, bone marrow). The stage is followed by the letter A (absence) or B (presence) to indicate significant systemic symptoms (e.g., fever, night sweats, weight loss).
Non-Hodgkin’s Lymphoma
Etiology and Pathophysiology
FIG. 31-15 Non-Hodgkin’s lymphoma involving the spleen. The presence of an isolated mass is typical.
Clinical Manifestations
Diagnostic and Staging Studies
TABLE 31-29 CLASSIFICATION OF NON-HODGKIN’S LYMPHOMA*
Nursing and Collaborative Management Non-Hodgkin’s Lymphoma
Drug Alert
TABLE 31-30 TREATMENT OF NON-HODGKIN’S LYMPHOMA*
Multiple Myeloma
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Drug Alert
Nursing Management Multiple Myeloma
Disorders of the Spleen
TABLE 31-31 CAUSES OF SPLENOMEGALY
Blood Component Therapy
Ethical/Legal Dilemmas Religious Beliefs
Situation
Ethical/Legal Points for Consideration
Discussion Questions
TABLE 31-32 BLOOD PRODUCTS*
Administration Procedure
Safety Alert
Delegation Decisions Blood Transfusions
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Blood Transfusion Reactions
TABLE 31-33 ACUTE TRANSFUSION REACTIONS
TABLE 31-34 DELAYED TRANSFUSION REACTIONS
Acute Transfusion Reactions.
Delayed Transfusion Reactions.
Autotransfusion
Case Study Leukemia
Patient Profile
Subjective Data
Objective Data
Physical Examination
Laboratory Results
Bone Marrow Biopsy
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Introduction
Patients
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
Glossary
Key Points
Section 7 Problems of Oxygenation: Perfusion
Problems of Oxygenation: Perfusion
Pre-Test – Section 7
Interactive Review – Section 7
Chapter 32 Nursing Assessment: Cardiovascular System
Learning Outcomes
Key Terms
eFigures
Structures and Functions of Cardiovascular System
Heart
Structure.
Blood Flow Through Heart.
Cardiac Valves.
FIG. 32-1 Schematic representation of blood flow through the heart. Arrows indicate direction of flow. 1, The right atrium receives venous blood from the inferior and superior venae cavae and the coronary sinus. The blood then passes through the tricuspid valve into the right ventricle. 2, With each contraction, the right ventricle pumps blood through the pulmonic valve into the pulmonary artery and to the lungs. 3, Oxygenated blood flows from the lungs to the left atrium by way of the pulmonary veins. 4, It then passes through the mitral valve and into the left ventricle. 5, As the heart contracts, blood is ejected through the aortic valve into the aorta and thus enters the systemic circulation.
Blood Supply to Myocardium.
Conduction System.
FIG. 32-2 Anatomic structures of the heart and heart valves.
FIG. 32-3 Coronary arteries and veins.
Electrocardiogram.
FIG. 32-4 A, Conduction system of the heart. AV, Atrioventricular; SA, sinoatrial. B, The normal electrocardiogram (ECG) pattern. The P wave represents depolarization of the atria. The QRS complex indicates depolarization of the ventricles. The T wave represents repolarization of the ventricles. The U wave, if present, may represent repolarization of the Purkinje fibers, or it may be associated with hypokalemia. The PR, QRS, and QT intervals reflect the time it takes for the impulse to travel from one area of the heart to another.
Mechanical System.
Factors Affecting Cardiac Output.
Cardiac Reserve.
Vascular System
Blood Vessels.
FIG. 32-5 Comparative thickness of layers of the artery, vein, and capillary.
Arteries and Arterioles.
Capillaries.
Veins and Venules.
Regulation of Cardiovascular System
Autonomic Nervous System.
Effect on Heart.
Effect on Blood Vessels.
Baroreceptors.
Chemoreceptors.
Blood Pressure
Measurement of Arterial Blood Pressure.
Pulse Pressure and Mean Arterial Pressure.
Gerontologic Considerations
Effects of Aging on the Cardiovascular System
TABLE 32-1 GERONTOLOGIC ASSESSMENT DIFFERENCES: Cardiovascular System
Assessment of Cardiovascular System
Subjective Data
Important Health Information
History of Present Illness.
Case Study Patient Introduction
Critical Thinking
Past Health History.
Medications.
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
TABLE 32-2 CARDIOVASCULAR EFFECTS OF NONCARDIAC DRUGS*
Genetic Risk Alert
Coronary Artery Disease
Cardiomyopathy
Hypertension
TABLE 32-3 HEALTH HISTORY: Cardiovascular System
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Values-Belief Pattern.
Case Study cont’d
Objective Data
Physical Examination
Vital Signs.
Peripheral Vascular System
Inspection.
Palpation.
FIG. 32-6 Common sites for palpating arteries.
Auscultation.
Thorax
Inspection and Palpation.
FIG. 32-7 Orientation of the heart within the thorax and cardiac auscultatory areas. Red lines indicate the midsternal line (MSL), midclavicular line (MCL), and anterior axillary line (AAL). ICS, Intercostal space; PMI, point of maximal impulse.
TABLE 32-4 ASSESSMENT ABNORMALITIES: Cardiovascular System
Auscultation.
FIG. 32-8 Relationship of electrocardiogram, cardiac cycle, and heart sounds.
Case Study cont’d
TABLE 32-5 NORMAL PHYSICAL ASSESSMENT OF CARDIOVASCULAR SYSTEM
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Inspect and Palpate
Auscultate
Diagnostic Studies of Cardiovascular System
Blood Studies
Cardiac Biomarkers.
C-Reactive Protein.
Homocysteine.
Cardiac Natriuretic Peptide Markers.
Serum Lipids.
TABLE 32-6 DIAGNOSTIC STUDIES: Cardiovascular System
Lipoprotein-Associated Phospholipase A2.
Chest X-Ray
FIG. 32-9 Chest x-ray: standard posterior-anterior view.
Electrocardiogram
Event Monitor or Loop Recorder.
Exercise or Stress Testing
Echocardiogram
FIG. 32-10 Long-axis images of the aortic and mitral valve with the depth adjusted to optimize evaluation of valve anatomy and motion. The 2-D images (left) in diastole (top) and systole (bottom) show normal aortic and mitral opening and closure. The color flow images (right) show normal left ventricular inflow with no aortic regurgitation in diastole (top) and normal antegrade flow in the left ventricular outflow tract and no mitral regurgitation in systole (bottom).
Nuclear Cardiology
Cardiovascular Magnetic Resonance Imaging
Cardiac Computed Tomography
Cardiac Catheterization
FIG. 32-11 Examples of coronary calcification of the left anterior descending coronary artery (large arrow) and left circumflex artery (small arrow) as seen on electron beam computed tomography.
FIG. 32-12 Normal left coronary artery angiogram.
Intracoronary Ultrasound.
Fractional Flow Reserve.
Case Study cont’d
Electrophysiology Study
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Animations
Answer Keys
Audio
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Videos
Chapter 33 Nursing Management: Hypertension
Learning Outcomes
Key Terms
eTables
Cultural & Ethnic Health Disparities
African Americans
Mexican Americans
Gender Differences
Men
Women
Normal Regulation of Blood Pressure
Sympathetic Nervous System
FIG. 33-1 Factors influencing blood pressure (BP). Hypertension develops when one or more of the BP-regulating mechanisms are defective.
Baroreceptors.
TABLE 33-1 SYMPATHETIC NERVOUS SYSTEM RECEPTORS AFFECTING BLOOD PRESSURE
Vascular Endothelium
Renal System
Endocrine System
TABLE 33-2 CLASSIFICATION OF HYPERTENSION
Hypertension
Classification of Hypertension
Etiology
Primary Hypertension.
Secondary Hypertension.
TABLE 33-3 CAUSES OF SECONDARY HYPERTENSION*
Pathophysiology of Primary Hypertension
Genetic Link
Water and Sodium Retention.
TABLE 33-4 RISK FACTORS FOR PRIMARY HYPERTENSION
Altered Renin-Angiotensin-Aldosterone Mechanism.
Stress and Increased Sympathetic Nervous System Activity.
Insulin Resistance and Hyperinsulinemia.
Endothelium Dysfunction.
Clinical Manifestations
Complications
Hypertensive Heart Disease
Coronary Artery Disease.
TABLE 33-5 MANIFESTATIONS OF TARGET ORGAN DISEASE
Left Ventricular Hypertrophy.
Heart Failure.
Cerebrovascular Disease.
FIG. 33-2 A, Massively enlarged heart caused by hypertrophy of the muscle in the left ventricle. B, Compare with the thickness of the normal left ventricle. The patient suffered from severe hypertension.
Peripheral Vascular Disease.
Nephrosclerosis.
Retinal Damage.
TABLE 33-6 COLLABORATIVE CARE: Hypertension
Diagnostic Studies
Ambulatory Blood Pressure Monitoring.
Collaborative Care
Lifestyle Modifications.
Weight Reduction.
DASH Eating Plan.
Dietary Sodium Reduction.
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Moderation of Alcohol Consumption.
Physical Activity.
Avoidance of Tobacco Products.
Management of Psychosocial Risk Factors.
Drug Therapy.
TABLE 33-7 DRUG THERAPY*Hypertension
FIG. 33-3 Site and method of action of various antihypertensive drugs (bold type). ACE, Angiotensin-converting enzyme.
Patient and Caregiver Teaching Related to Drug Therapy.
TABLE 33-8 DRUG THERAPY: Combination Therapy for Hypertension
Evidence-Based Practice Applying the Evidence
Your Decision and Actions
Reference for Evidence
TABLE 33-9 CAUSES OF RESISTANT HYPERTENSION
Resistant Hypertension.
Nursing Management Primary Hypertension
Nursing Assessment
Nursing Diagnoses
TABLE 33-10 NURSING ASSESSMENT: Hypertension
Planning
Nursing Implementation
Health Promotion.
Individual Patient Evaluation.
Blood Pressure Measurement.
Safety Alert
TABLE 33-11 BLOOD PRESSURE MEASUREMENT
Drug Alert
Screening Programs.
Delegation Decisions Caring for the Patient With Hypertension
Role of Registered Nurse (RN)
Role of Licensed Practical Nurse (LPN)
Role of Unlicensed Assistive Personnel (UAP)
Cardiovascular Risk Factor Modification.
Ambulatory and Home Care
TABLE 33-12 PATIENT & CAREGIVER TEACHING GUIDE: Hypertension
Home BP Monitoring.
Informatics in Practice Monitoring Blood Pressure
Patient Adherence.
Evaluation
Gerontologic Considerations
Hypertension
TABLE 33-13 CAUSES OF HYPERTENSIVE CRISIS
Hypertensive Crisis
Clinical Manifestations
FIG. 33-4 Massive retinal exudates (indicated by arrows) from hypertensive retinopathy. To see what a normal retina looks like on ophthalmoscopic examination, see Fig. 21-5 on p. 377.
Nursing and Collaborative Management Hypertensive Crisis
Drug Alert
Drug Alert
Case Study Primary Hypertension
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Case Studies
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome
Learning Outcomes
Key Terms
eFigures
eTable
Coronary Artery Disease
Etiology and Pathophysiology
Developmental Stages.
Fatty Streak.
FIG. 34-1 Pathogenesis of atherosclerosis. A, Damaged endothelium. B, Fatty streak and lipid core formation. C, Fibrous plaque. Raised plaques are visible: some are yellow; others are white. D, Complicated lesion: thrombus is red; collagen is blue. Plaque is complicated by red thrombus deposition.
Fibrous Plaque.
Complicated Lesion.
Collateral Circulation.
Risk Factors for Coronary Artery Disease
Nonmodifiable Risk Factors
Age, Gender, and Ethnicity.
FIG. 34-2 Vessel occlusion with collateral circulation. A, Open, functioning coronary artery. B, Partial coronary artery closure with collateral circulation being established. C, Total coronary artery occlusion with collateral circulation bypassing the occlusion to supply blood to the myocardium.
Cultural & Ethnic Health Disparities
Whites
African Americans
Native Americans
Hispanics
TABLE 34-1 RISK FACTORS FOR CORONARY ARTERY DISEASE
Gender Differences
Genetic Link
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
Major Modifiable Risk Factors
Elevated Serum Lipids.
Hypertension.
Tobacco Use.
Physical Inactivity.
Obesity.
Contributing Modifiable Risk Factors
Diabetes Mellitus.
Metabolic Syndrome.
Psychologic States.
Homocysteine.
Substance Abuse.
Nursing and Collaborative Management Coronary Artery Disease
Health Promotion
Identification of High-Risk People.
Management of High-Risk People.
TABLE 34-2 PATIENT & CAREGIVER TEACHING GUIDE: Reducing Risk Factors for Coronary Artery Disease
Physical Activity
Nutritional Therapy
TABLE 34-3 NUTRITIONAL THERAPY: Therapeutic Lifestyle Changes Diet
Lipid-Lowering Drug Therapy
TABLE 34-4 NUTRITIONAL THERAPY: Tips to Implement Diet and Lifestyle Recommendations
FIG. 34-3 Types of dietary fat.
Evidence-Based Practice Translating Research into Practice
Does Dietary Fat Modification Improve Cardiovascular Disease Outcomes?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Complementary & Alternative Therapies: Lipid-Lowering Agents*
Drugs That Restrict Lipoprotein Production.
TABLE 34-5 DRUG THERAPY: Hyperlipidemia
Drug Alert
Drug Alert
Drug Alert
Drugs That Increase Lipoprotein Removal.
Drugs That Decrease Cholesterol Absorption.
Antiplatelet Therapy
Gerontologic Considerations
Coronary Artery Disease
Chronic Stable Angina
TABLE 34-6 FACTORS INFLUENCING MYOCARDIAL OXYGEN NEEDS*
TABLE 34-7 PQRST ASSESSMENT OF ANGINA
FIG. 34-4 Common locations and patterns of pain during angina or myocardial infarction.
TABLE 34-8 PRECIPITATING FACTORS OF ANGINA
TABLE 34-9 COMPARISON OF MAJOR TYPES OF ANGINA
Silent Ischemia
Nocturnal Angina and Angina Decubitus
Prinzmetal’s Angina
TABLE 34-10 TREATMENT OF CHRONIC STABLE ANGINA
Microvascular Angina
Collaborative Care Chronic Stable Angina
FIG. 34-5 Collaborative care: chronic stable angina and acute coronary syndrome. ACE, Angiotensin-converting enzyme; ARBs, angiotensin II receptor blockers; CK, creatine kinase, see Table 34-11.†, see Table 34-5.‡, see Tables 34-2, 34-3, and 34-4.
Drug Therapy
Short-Acting Nitrates.
Sublingual Nitroglycerin.
Long-Acting Nitrates.
TABLE 34-11 DRUG THERAPY: Chronic Stable Angina and Acute Coronary Syndrome
Nitroglycerin Ointment.
Transdermal Controlled-Release Nitrates.
Drug Alert
Angiotensin-Converting Enzyme Inhibitors.
β-Adrenergic Blockers.
Calcium Channel Blockers.
Sodium Current Inhibitor.
Diagnostic Studies
Cardiac Catheterization.
Evidence-Based Practice Translating Research into Practice
Does Timing of Ambulation Affect Patient Safety After Percutaneous Coronary Intervention?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
FIG. 34-6 Placement of a coronary artery stent. A, The stent is positioned at the site of the lesion. B, The balloon is inflated, expanding the stent. The balloon is then deflated and removed. C, The implanted stent is left in place.
FIG. 34-7 A, A thrombotic occlusion of the right coronary artery is noted (arrows). B, Right coronary artery is opened and blood flow restored following angioplasty and placement of a 4-mm stent.
Acute Coronary Syndrome
FIG. 34-8 Relationships among coronary artery disease, chronic stable angina, and acute coronary syndrome.
Unstable Angina
Myocardial Infarction
FIG. 34-9 Occlusion of the left anterior descending coronary artery, resulting in a myocardial infarction.
FIG. 34-10 Acute myocardial infarction in the posterolateral wall of the left ventricle. This is demonstrated by the absence of staining in the areas of necrosis (white arrow). Note the scarring from a previous anterior wall myocardial infarction (black arrow).
Clinical Manifestations of Myocardial Infarction
Pain.
Sympathetic Nervous System Stimulation.
Cardiovascular Manifestations.
Nausea and Vomiting.
Fever.
Healing Process
Complications of Myocardial Infarction
Dysrhythmias.
Heart Failure.
Cardiogenic Shock.
Papillary Muscle Dysfunction.
Ventricular Aneurysm.
Pericarditis.
Dressler Syndrome.
Diagnostic Studies Acute Coronary Syndrome
Electrocardiogram Findings
Serum Cardiac Markers
FIG. 34-11 Serum cardiac markers found in the blood after myocardial infarction.
TABLE 34-12 EMERGENCY MANAGEMENT: Chest Pain
Cardiovascular
Respiratory
Chest Trauma
Gastrointestinal
Others
Initial
Ongoing Monitoring
Coronary Angiography
Other Measures
Collaborative Care Acute Coronary Syndrome
Emergent PCI
Thrombolytic Therapy
Indications and Contraindications.
Procedure.
TABLE 34-13 CONTRAINDICATIONS FOR THROMBOLYTIC THERAPY
Safety Alert
Coronary Surgical Revascularization
Coronary Artery Bypass Graft Surgery.
FIG. 34-12 Distal end of the left internal mammary artery is grafted below the area of blockage in the left anterior descending artery. Proximal end of the saphenous vein is grafted to the aorta, and the distal end is grafted below the area of blockage in the right coronary artery.
Minimally Invasive Direct Coronary Artery Bypass.
Off-Pump Coronary Artery Bypass.
Robot-Assisted Cardiothoracic Surgery.
Transmyocardial Laser Revascularization.
Drug Therapy
IV Nitroglycerin.
Morphine Sulfate.
β-Adrenergic Blockers.
Angiotensin-Converting Enzyme Inhibitors.
Antidysrhythmic Drugs.
Lipid-Lowering Drugs.
Stool Softeners.
Nutritional Therapy
Nursing Management Chronic Stable Angina and Acute Coronary Syndrome
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation: Chronic Stable Angina
Health Promotion.
TABLE 34-14 NURSING ASSESSMENT: Acute Coronary Syndrome
Acute Intervention.
Ambulatory and Home Care.
Nursing Implementation Acute Coronary Syndrome
Acute Intervention.
Pain.
Nursing Care Plan 34-1
Nursing Diagnosis*
Patient Goal
Nursing Diagnosis
Patient Goal
Pain Management
Nursing Diagnosis
Patient Goal
Nursing Diagnosis
Patient Goal
Energy Management
Nursing Diagnosis
Patient Goal
Monitoring.
Rest and Comfort.
TABLE 34-15 PHASES OF REHABILITATION AFTER ACUTE CORONARY SYNDROME
Anxiety.
Emotional and Behavioral Reactions.
TABLE 34-16 PSYCHOSOCIAL RESPONSES TO ACUTE CORONARY SYNDROME
Coronary Revascularization.
Delegation Decisions Cardiac Catheterization and Percutaneous Coronary Intervention (PCI)
Role of Registered Nurse (RN)
Preprocedure
Postprocedure
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Ambulatory and Home Care.
Evidence-Based Practice Translating Research into Practice
Do Exercise-Based Cardiac Rehabilitation Programs Improve Outcomes?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Evidence-Based Practice Applying the Evidence
Your Decision and Action
References for Evidence
Patient Teaching.
TABLE 34-17 PATIENT & CAREGIVER TEACHING GUIDE: Acute Coronary Syndrome
Physical Activity.
TABLE 34-18 ENERGY EXPENDITURE IN METABOLIC EQUIVALENTS
TABLE 34-19 BORG RATING OF PERCEIVED EXERTION SCALE® *
INSTRUCTIONS TO THE BORG RATING OF PERCEIVED EXERTION SCALE
TABLE 34-20 PATIENT & CAREGIVER TEACHING GUIDE: FITT Activity Guidelines After Acute Coronary Syndrome
Resumption of Sexual Activity.
TABLE 34-21 PATIENT TEACHING GUIDE: Sexual Activity After Acute Coronary Syndrome
Evaluation
Sudden Cardiac Death
Etiology and Pathophysiology
Clinical Manifestations and Complications
Nursing and Collaborative Management Sudden Cardiac Death
Case Study Myocardial Infarction
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Emergency Department
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 35 Nursing Management: Heart Failure
Learning Outcomes
Key Terms
eTable
Heart Failure
Cultural & Ethnic Health Disparities
Etiology and Pathophysiology
Genetic Link
Pathophysiology of Ventricular Failure.
Systolic Failure.
Diastolic Failure.
TABLE 35-1 PRIMARY CAUSES OF HEART FAILURE
TABLE 35-2 PRECIPITATING CAUSES OF HEART FAILURE*
Mixed Systolic and Diastolic Failure.
Gender Differences
Compensatory Mechanisms.
Sympathetic Nervous System Activation.
Neurohormonal Response.
Dilation.
Hypertrophy.
Counterregulatory Mechanisms.
FIG. 35-1 A, Dilated heart chambers. B, Hypertrophied heart chambers.
Types of Heart Failure
Left-Sided Heart Failure.
Right-Sided Heart Failure.
Clinical Manifestations Acute Decompensated Heart Failure
FIG. 35-2 Pathophysiology of heart failure. Elevated systemic vascular resistance results in left-sided heart failure that leads to right-sided heart failure. Systemic vascular resistance and preload are exacerbated by the renin-angiotensin-aldosterone system. ADH, Antidiuretic hormone; LA, left atrium; LV, left ventricle; LVEDP, left ventricular end-diastolic pressure; RV, right ventricle.
TABLE 35-3 CLINICAL PROFILE IN ACUTE DECOMPENSATED HEART FAILURE
Clinical Manifestations Chronic Heart Failure
Fatigue.
Dyspnea.
FIG. 35-3 As pulmonary edema progresses, it inhibits oxygen and carbon dioxide exchange at the alveolar-capillary interface. A, Normal relationship. B, Increased pulmonary capillary hydrostatic pressure causes fluid to move from the vascular space into the pulmonary interstitial space. C, Lymphatic flow increases in an attempt to pull fluid back into the vascular or lymphatic space. D, Failure of lymphatic flow and worsening of left-sided heart failure result in further movement of fluid into the interstitial space and into the alveoli.
TABLE 35-4 MANIFESTATIONS OF HEART FAILURE
Tachycardia.
Edema.
Nocturia.
Skin Changes.
Behavioral Changes.
Chest Pain.
Weight Changes.
Complications of Heart Failure
Pleural Effusion.
Dysrhythmias.
Left Ventricular Thrombus.
Hepatomegaly.
Renal Failure.
Classification of Heart Failure
Diagnostic Studies
TABLE 35-5 NYHA FUNCTIONAL CLASSIFICATION OF HEART DISEASE AND ACCF/AHA STAGES OF HEART FAILURE
Collaborative Care Acute Decompensated Heart Failure
TABLE 35-6 COLLABORATIVE CARE: Heart Failure
Drug Therapy.
Diuretics.
TABLE 35-7 DRUG THERAPY: Heart Failure
Vasodilators.
Drug Alert
Morphine.
Positive Inotropes.
Drug Alert
Collaborative Care Chronic Heart Failure
Evidence-Based Practice Translating Research Into Practice
Can Exercise Help Depression in Heart Failure Patients?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
FIG. 35-4 Placement of pacing leads in cardiac resynchronization therapy.
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Drug Therapy.
Diuretics.
Renin-Angiotensin-Aldosterone System Inhibitors
Angiotensin-Converting Enzyme Inhibitors.
Drug Alert
Angiotensin II Receptor Blockers.
Aldosterone Antagonists.
Drug Alert
β-Adrenergic Blockers.
Complementary & Alternative Therapies
Scientific Evidence*
Nursing Implications
Drug Alert
Vasodilators
Nitrates.
BiDil.
Positive Inotropes.
Drug Alert
Nutritional Therapy
TABLE 35-8 NUTRITIONAL THERAPY: Low-Sodium Diets
FIG. 35-5 Typical nutrition label. Note that a single serving (½ cup) provides more than one third of the daily recommended intake of sodium.
Nursing Management Heart Failure
Nursing Assessment
TABLE 35-9 NURSING ASSESSMENT: Heart Failure
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Nursing Care Plan 35-1
Patient With Heart Failure
Nursing Diagnosis*
Patient Goal
Respiratory Status: Gas Exchange
Measurement Scale
Respiratory Monitoring
Oxygen Therapy
Positioning
Nursing Diagnosis
Patient Goal
Cardiac Pump Effectiveness
Measurement Scale
Cardiac Care
Nursing Diagnosis
Patient Goal
Fluid Balance
Measurement Scale
Hypervolemia Management
Nursing Diagnosis
Patient Goal
Activity Tolerance
Energy Management
Activity Therapy
TABLE 35-10 PATIENT & CAREGIVER TEACHING GUIDE: Heart Failure
FIG. 35-6 Home-based telehealth monitoring unit.
Palliative and End-of-Life Care.
Evaluation
Cardiac Transplantation
TABLE 35-11 INDICATIONS AND CONTRAINDICATIONS FOR CARDIAC TRANSPLANTATION*
Criteria for Selection
Ethical/Legal Dilemmas Competence
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Bridge to Transplantation
Surgical Procedure
Posttransplantation
Case Study Heart Failure
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 36 Nursing Management: Dysrhythmias
Learning Outcomes
Key Terms
eFigure
eTable
Rhythm Identification and Treatment
Conduction System
Nervous Control of the Heart
TABLE 36-1 PROPERTIES OF CARDIAC CELLS
FIG. 36-1 Phases of the cardiac action potential. The electrical potential, measured in millivolts (mV), is indicated along the vertical axis of the graph. Time, measured in seconds (sec), is indicated along the horizontal axis. The action potential has five phases, labeled 0 through 4. Each phase represents a particular electrical event or combination of electrical events. Phase 0 is the upstroke of rapid depolarization and corresponds with ventricular contraction. Phases 1, 2, and 3 represent repolarization. Phase 4 is known as complete repolarization (or the polarized state) and corresponds to diastole. RP, Resting membrane potential; TP, threshold membrane potential.
FIG. 36-2 A, Limb leads I, II, and III. These bipolar leads are located on the extremities. Illustrated are the angles from which these leads view the heart. B, Limb leads aVR, aVL, and aVF. These unipolar leads use the center of the heart as their negative electrode. C, Placement for the unipolar chest leads: V1, fourth intercostal space at the right sternal border; V2, fourth intercostal space at the left sternal border; V3, halfway between V2 and V4; V4, fifth intercostal space at the left midclavicular line; V5, fifth intercostal space at the left anterior axillary line; V6, fifth intercostal space at the left midaxillary line.
Electrocardiographic Monitoring
FIG. 36-3 Twelve-lead electrocardiogram showing a normal sinus rhythm.
FIG. 36-4 A, Lead placement for V1 or V6 using a five-lead system. B, Typical ECG tracing in lead V1. C, Chest; LA, left arm; LL, left leg; RA, right arm; RL, right leg.
FIG. 36-5 Time and voltage on the electrocardiogram; 6-sec strip.
Telemetry Monitoring.
FIG. 36-6 When the rhythm is regular, heart rate can be easily determined. The estimated heart rate is 70 beats/min. NOTE: Recorded from lead II.
FIG. 36-7 Artifact. A, Muscle tremor. B, Loose electrodes.
Informatics in Practice Wireless ECG Monitoring
Assessment of Cardiac Rhythm
Electrophysiologic Mechanisms of Dysrhythmias
FIG. 36-8 Normal sinus rhythm. NOTE: Recorded from lead II.
FIG. 36-9 The ECG tracing as seen in normal sinus rhythm. 1, P wave; 2, PR interval; 3, QRS complex: Q wave, R wave, S wave; 4, ST segment; 5, T wave; 6, QT interval. Isoelectric (flat) line or baseline represents the absence of electrical activity in the cardiac cells. (See Table 36-2 for timing of intervals.)
TABLE 36-2 ECG WAVEFORMS AND INTERVALS*
TABLE 36-3 INTRINSIC RATES OF THE CONDUCTION SYSTEM
FIG. 36-10 Absolute and relative refractory periods correlated with the cardiac muscle’s action potential and with an ECG tracing.
Evaluation of Dysrhythmias
TABLE 36-4 COMMON CAUSES OF DYSRHYTHMIAS*
TABLE 36-5 APPROACH TO ASSESSING HEART RHYTHM
TABLE 36-6 EMERGENCY MANAGEMENT: Dysrhythmias
Initial
Ongoing Monitoring
Types of Dysrhythmias
Sinus Bradycardia.
Clinical Associations.
ECG Characteristics.
Clinical Significance.
FIG. 36-11 A, Sinus bradycardia. B, Sinus tachycardia.
Treatment.
Sinus Tachycardia.
Clinical Associations.
TABLE 36-7 CHARACTERISTICS OF COMMON DYSRHYTHMIAS
ECG Characteristics.
Clinical Significance.
Treatment.
Premature Atrial Contraction.
Clinical Associations.
FIG. 36-12 Premature atrial contractions (arrows).
ECG Characteristics.
Clinical Significance.
Treatment.
Paroxysmal Supraventricular Tachycardia.
Clinical Associations.
FIG. 36-13 Paroxysmal supraventricular tachycardia (PSVT). Arrows indicate beginning and ending of PSVT.
ECG Characteristics.
Clinical Significance.
Treatment.
Drug Alert
Atrial Flutter.
Clinical Associations.
FIG. 36-14 A, Atrial flutter with a 4:1 conduction (four flutter [F] waves to each QRS complex). B, Atrial fibrillation with a controlled ventricular response. Note the chaotic fibrillatory (f) waves (arrows) between the RS complexes. NOTE: Recorded from lead V1.
ECG Characteristics.
Clinical Significance.
Treatment.
Atrial Fibrillation.
Clinical Associations.
ECG Characteristics.
Clinical Significance.
Treatment.
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
TABLE 36-8 DRUG THERAPY: Anticoagulant Therapy for Atrial Fibrillation
FIG. 36-15 Junctional escape rhythm. P wave is hidden in the RS complex. NOTE: Recorded from lead V1.
Junctional Dysrhythmias.
Clinical Associations.
ECG Characteristics.
Clinical Significance.
Treatment.
First-Degree AV Block.
Clinical Associations.
FIG. 36-16 Heart block. A, First-degree atrioventricular (AV) block with a PR interval of 0.40 sec. B, Second-degree AV block, type I, with progressive lengthening of the PR interval until a QRS complex is blocked. C, Second-degree AV block, type II, with constant PR intervals and variable blocked QRS complexes. D, Third-degree AV block. Note that there is no relationship between P waves and QRS complexes.
ECG Characteristics.
Clinical Significance.
Treatment.
Second-Degree AV Block, Type I.
Clinical Associations.
ECG Characteristics.
Clinical Significance.
Treatment.
Second-Degree AV Block, Type II.
Clinical Associations.
ECG Characteristics.
Clinical Significance.
Treatment.
Third-Degree AV Block.
Clinical Associations.
ECG Characteristics.
FIG. 36-17 Various forms of premature ventricular contractions (PVCs).
FIG. 36-18 Ventricular tachycardia. A, Monomorphic. B, Torsades de pointes (polymorphic).
Clinical Significance.
Treatment.
Premature Ventricular Contractions.
Clinical Associations.
ECG Characteristics.
Clinical Significance.
Treatment.
Ventricular Tachycardia.
Ethical/Legal Dilemmas Scope and Standards of Practice
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Clinical Associations.
ECG Characteristics.
Clinical Significance.
Treatment.
Ventricular Fibrillation.
Clinical Associations.
FIG. 36-19 Ventricular fibrillation.
ECG Characteristics.
Clinical Significance.
Treatment.
Asystole.
Clinical Associations.
Clinical Significance.
Treatment.
Pulseless Electrical Activity.
Sudden Cardiac Death.
Prodysrhythmia.
Antidysrhythmia Drugs
TABLE 36-9 DRUG THERAPY: Antidysrhythmia Drugs
Defibrillation
FIG. 36-20 Paddle placement and current flow in monophasic defibrillation (A) and biphasic defibrillation (B).
FIG. 36-21 LifePak contains a monitor, defibrillator, and transcutaneous pacemaker.
Synchronized Cardioversion.
Safety Alert
FIG. 36-22 A, The implantable cardioverter-defibrillator (ICD) pulse generator from Medtronic, Inc. B, The ICD is placed in a subcutaneous pocket over the pectoral muscle. A single-lead system is placed transvenously from the pulse generator to the endocardium. The single lead detects dysrhythmias and delivers an electric shock to the heart muscle.
Implantable Cardioverter-Defibrillator.
Pacemakers
FIG. 36-23 Ventricular capture (depolarization) secondary to signal (pacemaker spike) from pacemaker lead in the right ventricle.
TABLE 36-10 PATIENT & CAREGIVER TEACHING GUIDE: Implantable Cardioverter-Defibrillator (ICD)
FIG. 36-24 A, A dual-chamber rate-responsive pacemaker from Medtronic, Inc., is designed to treat patients with chronic heart problems in which the heart beats too slowly to adequately support the body’s circulation needs. B, Pacing leads in both the atrium and the ventricle enable a dual-chamber pacemaker to sense and pace in both heart chambers.
Permanent Pacemaker.
Cardiac Resynchronization Therapy.
TABLE 36-11 INDICATIONS FOR PERMANENT PACEMAKERS
FIG. 36-25 Temporary external, dual-chamber demand pacemaker.
Temporary Pacemaker.
TABLE 36-12 INDICATIONS FOR TEMPORARY PACEMAKERS*
FIG. 36-26 Temporary transvenous pacemaker catheter insertion. A single lead is positioned in the right ventricle through the brachial, subclavian, jugular, or femoral vein.
Monitoring of Patients With Pacemakers.
FIG. 36-27 Transcutaneous pacemaker. Pacing electrodes are placed on the patient’s anterior (A) and posterior (B) chest walls and attached to an external pacing unit (C).
Radiofrequency Catheter Ablation Therapy
TABLE 36-13 PATIENT & CAREGIVER TEACHING GUIDE: Pacemaker
ECG Changes Associated with Acute Coronary Syndrome
Ischemia
FIG. 36-28 Definitive ECG changes occur in leads that face the area of ischemia, injury, or infarction. Reciprocal changes may occur in leads facing opposite the area of ischemia, injury, or infarction.
FIG. 36-29 ST segment, T wave, and Q wave changes associated with myocardial ischemia (A), injury (B), and infarction (C).
TABLE 36-14 ECG EVIDENCE IN ACUTE CORONARY SYNDROME
FIG. 36-30 ECG findings with anteroseptal lateral wall myocardial infarction. Normally, leads I, aVL, and V1 to V3 have a positive R wave. Note the pathologic Q waves in these leads and the ST segment elevation in leads V2 to V5 (arrows).
Injury and Infarction
Patient Monitoring
Syncope
Case Study Dysrhythmia
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Case Studies
Concept Map Creator
Content Updates
ECG Exercises
eFigures
eTables
Glossary
Key Points
Chapter 37 Nursing Management: Inflammatory and Structural Heart Disorders
Learning Outcomes
Key Terms
eFigures
FIG. 37-1 Layers of the heart muscle and pericardium. The section of the heart wall shows the fibrous pericardium, the parietal and visceral layers of the serous pericardium (with the pericardial sac between them), the myocardium, and the endocardium.
Inflammatory Disorders of Heart
Infective Endocarditis
Classification
Etiology and Pathophysiology
FIG. 37-2 Bacterial endocarditis of the mitral valve. The valve is covered with large, irregular vegetations (arrow).
TABLE 37-1 RISK FACTORS FOR ENDOCARDITIS*
FIG. 37-3 Pathogenesis of infective endocarditis.
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Prophylactic Treatment.
Drug Therapy.
TABLE 37-2 ANTIBIOTIC PROPHYLAXIS TO PREVENT ENDOCARDITIS
Nursing Management Infective Endocarditis
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
TABLE 37-3 NURSING ASSESSMENT: Infective Endocarditis
Ambulatory and Home Care.
Evaluation
Acute Pericarditis
TABLE 37-4 COMMON CAUSES OF PERICARDITIS
Etiology and Pathophysiology
Clinical Manifestations
FIG. 37-4 Acute pericarditis. Note shaggy coat of fibers covering surface of heart.
Complications
Diagnostic Studies
FIG. 37-5 A, X-ray of a normal chest. B, Pericardial effusion is present, and the cardiac silhouette is enlarged with a globular shape (arrows).
TABLE 37-5 MEASUREMENT OF PULSUS PARADOXUS
TABLE 37-6 COLLABORATIVE CARE: Acute Pericarditis
Diagnostic
Collaborative Therapy
Collaborative Care
FIG. 37-6 Pericardiocentesis performed under sterile conditions in conjunction with electrocardiogram (ECG) and hemodynamic measurements.
Nursing Management Acute Pericarditis
Chronic Constrictive Pericarditis
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
Nursing and Collaborative Management Chronic Constrictive Pericarditis
Myocarditis
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies and Collaborative Care
Drug Alert
Nursing Management Myocarditis
Rheumatic Fever and Rheumatic Heart Disease
Etiology and Pathophysiology
Cardiac Lesions and Valve Deformities.
TABLE 37-7 MODIFIED JONES CRITERIA FOR DIAGNOSING RHEUMATIC FEVER
Extracardiac Lesions.
Clinical Manifestations
Major Criteria.
TABLE 37-8 COLLABORATIVE CARE: Rheumatic Fever
Diagnostic
Collaborative Therapy
Minor Criteria.
Evidence of Infection.
Complications
Diagnostic Studies and Collaborative Care
Nursing Management Rheumatic Fever and Rheumatic Heart Disease
Nursing Assessment
TABLE 37-9 NURSING ASSESSMENT: Rheumatic Fever and Rheumatic Heart Disease
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Valvular Heart Disease
FIG. 37-7 Valvular stenosis and regurgitation. A, Normal position of the valve leaflets, or cusps, when the valve is open and closed. B, Open position of a stenosed valve (left) and closed position of regurgitant valve (right). C, Hemodynamic effect of mitral stenosis. The stenosed valve is unable to open sufficiently during left atrial systole, inhibiting left ventricular filling. D, Hemodynamic effect of mitral regurgitation. The mitral valve does not close completely during left ventricular systole, permitting blood to reenter the left atrium. At the same time, blood is moving forward through the aortic valve.
Mitral Valve Stenosis
Etiology and Pathophysiology
TABLE 37-10 MANIFESTATIONS OF VALVULAR HEART DISEASE
Clinical Manifestations
Mitral Valve Regurgitation
Etiology and Pathophysiology
Clinical Manifestations
Mitral Valve Prolapse
Etiology and Pathophysiology
FIG. 37-8 Mitral valve prolapse. In this valvular abnormality, the mitral leaflets have prolapsed back into the left atrium. They also demonstrate hooding (arrow). The left ventricle is on the right.
Genetic Link
Clinical Manifestations
Aortic Valve Stenosis
Etiology and Pathophysiology
TABLE 37-11 PATIENT & CAREGIVER TEACHING GUIDE: Mitral Valve Prolapse
Clinical Manifestations
Drug Alert
Aortic Valve Regurgitation
Etiology and Pathophysiology
Clinical Manifestations
Tricuspid and Pulmonic Valve Disease
Etiology and Pathophysiology
Diagnostic Studies for Valvular Heart Disease
TABLE 37-12 COLLABORATIVE CARE: Valvular Heart Disease
Nonsurgical
Surgical
Collaborative Care of Valvular Heart Disease
Conservative Therapy
Percutaneous Transluminal Balloon Valvuloplasty.
Surgical Therapy.
Valve Repair.
FIG. 37-9 Mitral valvuloplasty performed by the Inoue technique. The catheter is placed in the mitral valve and the distal part of the Inoue balloon inflated (A). The balloon is then pulled back in the mitral valve and inflated for 10 to 15 sec under fluoroscopic control (B) until the waist of the balloon is no longer visible (C) and the balloon falls back into the left atrium.
Informatics in Practice Heart Surgery DVD or CD
FIG. 37-10 Types of prosthetic heart valves. A, Starr-Edwards caged ball valve. B, St. Jude bi-leaflet valve. C, Carpentier-Edwards porcine valve.
Ethical/Legal Dilemmas Do Not Resuscitate
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Valve Replacement.
Nursing Management Valvular Disorders
Nursing Assessment
Nursing Diagnoses
TABLE 37-13 NURSING ASSESSMENT: Valvular Heart Disease
Planning
Nursing Implementation
Health Promotion.
Acute Intervention and Ambulatory and Home Care.
Evaluation
Cardiomyopathy
TABLE 37-14 CAUSES OF CARDIOMYOPATHY
Dilated
Hypertrophic
Restrictive
TABLE 37-15 COMPARISON OF TYPES OF CARDIOMYOPATHY
Dilated Cardiomyopathy
Etiology and Pathophysiology
TABLE 37-16 COLLABORATIVE CARE: Cardiomyopathy
Diagnostic
Collaborative Therapy
Clinical Manifestations
Diagnostic Studies
FIG. 37-11 Dilated cardiomyopathy. The dilated left ventricular wall has thinned (arrow), and the chamber size and volume are increased.
Nursing and Collaborative Management Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Etiology and Pathophysiology
FIG. 37-12 Hypertrophic cardiomyopathy. There is marked left ventricular hypertrophy (arrow), and the chamber size and volume are decreased.
Clinical Manifestations
Diagnostic Studies
Nursing and Collaborative Management Hypertrophic Cardiomyopathy
Restrictive Cardiomyopathy
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
Nursing and Collaborative Management Restrictive Cardiomyopathy
TABLE 37-17 PATIENT & CAREGIVER TEACHING GUIDE: Cardiomyopathy
Case Study Valvular Heart Disease
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Audio
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Chapter 38 Nursing Management: Vascular Disorders
Learning Outcomes
Key Terms
eTables
Peripheral Artery Disease
Gender Differences
Men
Women
Etiology and Pathophysiology
FIG. 38-1 Common anatomic locations of atherosclerotic lesions (shown in yellow) of the abdominal aorta and lower extremities.
Peripheral Artery Disease of the Lower Extremities
Clinical Manifestations
TABLE 38-1 COMPARISON OF PERIPHERAL ARTERY AND VENOUS DISEASE
Complications
Diagnostic Studies
Collaborative Care
Risk Factor Modification.
TABLE 38-2 COLLABORATIVE CARE: Peripheral Artery Disease
Diagnostic
Collaborative Therapy
TABLE 38-3 INTERPRETATION OF ANKLE-BRACHIAL INDEX RESULTS
Drug Therapy.
Drug Alert
Drug Alert
Exercise Therapy.
Nutritional Therapy.
Complementary and Alternative Therapies.
Care of the Leg With Critical Limb Ischemia.
Interventional Radiology Catheter-Based Procedures.
Surgical Therapy.
Nursing Management Lower Extremity Peripheral Artery Disease
Nursing Assessment
FIG. 38-2 A, Femoral-popliteal bypass graft around an occluded superficial femoral artery. B, Femoral–posterior tibial bypass graft around occluded superficial femoral, popliteal, and proximal tibial arteries.
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 38-4 NURSING ASSESSMENT: Peripheral Artery Disease
Ambulatory and Home Care.
Evaluation
Acute Arterial Ischemic Disorders
Etiology and Pathophysiology
TABLE 38-5 PATIENT & CAREGIVER TEACHING GUIDE: Peripheral Artery Bypass Surgery
Clinical Manifestations
Collaborative Care
Thromboangiitis Obliterans
Raynaud’s Phenomenon
FIG. 38-3 Raynaud’s phenomenon.
Aortic Aneurysms
Etiology and Pathophysiology
FIG. 38-4 Angiography demonstrating fusiform abdominal aortic aneurysm. Note calcification of the aortic wall (arrows) and extension of the aneurysm into the common iliac arteries.
Genetic Link
Classification
FIG. 38-5 A, True fusiform abdominal aortic aneurysm. B, True saccular aortic aneurysm. C, False aneurysm, or pseudoaneurysm. D, Aortic dissection.
Clinical Manifestations
Complications
Diagnostic Studies
Collaborative Care
Surgical Therapy.
FIG. 38-6 Surgical repair of an abdominal aortic aneurysm. A, Incising the aneurysmal sac. B, Insertion of synthetic graft. C, Suturing native aortic wall over synthetic graft.
Endovascular Graft Procedure.
Complications.
FIG. 38-7 Bifurcated (two-branched) endovascular stent grafting of an aneurysm. A, Insertion of a woven polyester tube (graft) covered by a tubular metal web (stent). B, The stent graft is inserted through a large blood vessel (e.g., femoral artery) using a delivery catheter. The catheter is positioned below the renal arteries in the area of the aneurysm. C, The stent graft is slowly released (deployed) into the blood vessel. When the stent comes in contact with the blood vessel, it expands to a preset size. D, A second stent graft can be inserted in the contralateral (opposite) vessel if necessary. E, Fully deployed bifurcated stent graft.
Nursing Management Aortic Aneurysms
Nursing Assessment
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Graft Patency.
Cardiovascular Status.
Infection.
Gastrointestinal Status.
Neurologic Status.
Peripheral Perfusion Status.
Renal Perfusion Status.
Ambulatory and Home Care
Evaluation
Aortic Dissection
Etiology and Pathophysiology
FIG. 38-8 Aortic dissection of the thoracic aorta.
Clinical Manifestations
Complications
Diagnostic Studies
TABLE 38-6 COLLABORATIVE CARE: Aortic Dissection
Diagnostic
Collaborative Therapy
Collaborative Care
Conservative Therapy.
Endovascular Dissection Repair.
Surgical Therapy.
Nursing Management Aortic Dissection
Venous Disorders
Phlebitis
Venous Thrombosis
TABLE 38-7 COMPARISON OF SUPERFICIAL VEIN THROMBOSIS AND VENOUS THROMBOEMBOLISM
Etiology
Venous Stasis.
FIG. 38-9 Pathophysiology of venous thromboembolism.
TABLE 38-8 RISK FACTORS FOR VENOUS THROMBOEMBOLISM
Venous Stasis
Endothelial Damage
Hypercoagulability of Blood
Endothelial Damage.
Hypercoagulability of Blood.
Pathophysiology
Superficial Vein Thrombosis
Clinical Manifestations.
Collaborative Care.
Venous Thromboembolism
Clinical Manifestations.
Complications.
FIG. 38-10 Lipodermatosclerosis. Skin on lower leg becomes scarred, and the leg becomes tapered like an “inverted bottle.” Hallmark signs of lipodermatosclerosis are leathery skin, brown discoloration, hyperpigmentation and hypopigmentation, and circumferential or near circumferential scarring and shrinking of the extremity.
Diagnostic Studies.
Collaborative Care
Prevention and Prophylaxis.
TABLE 38-9 DIAGNOSTIC STUDIES: Venous Thromboembolism*
Drug Therapy.
Vitamin K Antagonists.
TABLE 38-10 DRUG THERAPY: Anticoagulant Therapy
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Thrombin Inhibitors: Indirect.
TABLE 38-11 TESTS OF BLOOD COAGULATION
Thrombin Inhibitors: Direct.
Factor Xa Inhibitors.
Anticoagulant Therapy for VTE Prophylaxis.
Anticoagulant Therapy for VTE Treatment.
FIG. 38-11 Inferior vena caval interruption technique using Greenfield stainless steel filter to prevent pulmonary embolism. As blood travels up the vena cava, clots are trapped in the filter.
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Thrombolytic Therapy for VTE Treatment.
Surgical Therapy.
TABLE 38-12 NURSING ASSESSMENT: Venous Thromboembolism
Nursing Management Venous Thromboembolism
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Acute Intervention.
Drug Alert
Safety Alert
TABLE 38-13 NURSING INTERVENTIONS FOR PATIENTS TAKING ANTICOAGULANTS
Ambulatory and Home Care.
Delegation Decisions Caring for the Patient With Venous Thromboembolism (VTE)
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
TABLE 38-14 PATIENT & CAREGIVER TEACHING GUIDE: Anticoagulant Therapy
Evaluation
Varicose Veins
Etiology and Pathophysiology
Clinical Manifestations and Complications
FIG. 38-12 A, Lateral aspect of varicose veins before treatment. B, Lateral aspect of varicose veins 2 years after initial treatment with sclerotherapy.
Diagnostic Studies and Collaborative Care
Nursing Management Varicose Veins
Chronic Venous Insufficiency and Venous Leg Ulcers
Etiology and Pathophysiology
FIG. 38-13 Venous leg ulcer.
Clinical Manifestations and Complications
Collaborative Care
Delegation Decisions Caring for the Patient With Chronic Venous Insufficiency
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Nursing Management Chronic Venous Insufficiency and Venous Leg Ulcers
Case Study Peripheral Artery Disease
Patient Profile
Subjective Data
Current Medications
Objective Data
Physical Examination
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Introduction
Patients
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Volume 2
Section 8 Problems of Ingestion, Digestion, Absorption, and Elimination
Problems of Ingestion, Digestion, Absorption, and Elimination
Pre-Test – Section 8
Interactive Review – Section 8
Chapter 39 Nursing Assessment: Gastrointestinal System
Learning Outcomes
Key Terms
eFigures
FIG. 39-1 A, Location of organs of the gastrointestinal system. B, Parts of the stomach.
Structures and Functions of Gastrointestinal System
Ingestion
Mouth.
Pharynx.
Esophagus.
Digestion and Absorption
Stomach.
Small Intestine.
Physiology of Digestion.
TABLE 39-1 GASTROINTESTINAL SECRETIONS
Elimination
Large Intestine.
TABLE 39-2 PHASES OF GASTRIC SECRETION
TABLE 39-3 HORMONES CONTROLLING GI SECRETION AND MOTILITY
FIG. 39-2 Anatomic locations of the large intestine.
FIG. 39-3 Gross structure of the liver, gallbladder, pancreas, and duct system.
Liver, Biliary Tract, and Pancreas
Liver.
Biliary Tract.
TABLE 39-4 FUNCTIONS OF THE LIVER
Bilirubin Metabolism.
Pancreas.
FIG. 39-4 Bilirubin metabolism and conjugation.
Gerontologic Considerations
Effects of Aging on Gastrointestinal System
TABLE 39-5 GERONTOLOGIC ASSESSMENT DIFFERENCES: Gastrointestinal System
Assessment of Gastrointestinal System
Subjective Data
Important Health Information
Past Health History.
Medications.
Case Study Patient Introduction
Patient Profile
Critical Thinking
TABLE 39-6 HEPATOTOXIC CHEMICALS AND DRUGS
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
TABLE 39-7 SURGERIES OF THE GASTROINTESTINAL SYSTEM
Genetic Risk Alert
Colorectal Cancer
Genetic Risk Alert
Inflammatory Bowel Disease (IBD)
TABLE 39-8 HEALTH HISTORY: Gastrointestinal System
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Case Study—cont’d
Value-Belief Pattern.
Objective Data
Physical Examination
Mouth
Inspection.
Palpation.
Abdomen.
TABLE 39-9 STRUCTURES LOCATED IN ABDOMINAL REGIONS
FIG. 39-5 A, Abdominal quadrants. B, Abdominal regions. LLQ, Left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
Inspection.
Auscultation.
FIG. 39-6 Technique for percussion of the abdomen. Moving clockwise, percuss lightly in all four quadrants.
Percussion.
FIG. 39-7 A, Technique for light palpation of the abdomen. B, Technique for deep palpation.
Palpation.
FIG. 39-8 A, Technique for liver palpation. B, Alternative technique to palpate liver with fingers hooked over the costal region.
TABLE 39-10 NORMAL PHYSICAL ASSESSMENT OF GASTROINTESTINAL SYSTEM
Case Study—cont’d
Rectum and Anus.
Focused Assessment
Diagnostic Studies of Gastrointestinal System
TABLE 39-11 ASSESSMENT ABNORMALITIES: Gastrointestinal System
FIG. 39-9 Barium enema x-ray showing the large intestine.
Radiologic Studies
Upper Gastrointestinal Series.
Lower Gastrointestinal Series.
TABLE 39-12 DIAGNOSTIC STUDIES: Gastrointestinal System
Virtual Colonoscopy.
Endoscopy
FIG. 39-10 A, Illustration showing the ileocecal junction and the ileocecal fold. B, Endoscopic image of the ileocecal fold.
Case Study—cont’d
FIG. 39-11 Capsule endoscopy. A, The video capsule has its own camera and light source. After it is swallowed, it travels through the GI tract and allows visualization of the small intestine. It sends messages to a monitoring device that is worn on a waist belt (B). During the 8-hour examination, the patient is free to move about. After the test, the images are viewed on a video monitor.
Liver Biopsy
Liver Function Studies
TABLE 39-13 DIAGNOSTIC STUDIES: Liver Function Tests
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Animations
Answer Keys
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Videos
Chapter 40 Nursing Management: Nutritional Problems
Learning Outcomes
Key Terms
eTables
Nutritional Problems
Normal Nutrition
FIG. 40-1 MyPlate is the primary food group symbol that serves as a reminder to make healthy food choices and to build a healthy plate at mealtimes. It is a visual cue that identifies the five basic food groups from which to select healthy foods. The plate is divided into four slightly different-sized quadrants, with fruits and vegetables taking up half the space and grains and protein making up the other half. The vegetables and grains portions are the largest of the four. Next to the plate is a blue circle for dairy, which could be a glass of milk or a food such as cheese or yogurt. For more information, see www.choosemyplate.gov
TABLE 40-1 NUTRITIONAL THERAPY: MyPlate Tips for a Healthy Lifestyle
FIG. 40-2 Sample of a Nutrition Facts label.
TABLE 40-2 ESTIMATING DAILY ENERGY (CALORIE) REQUIREMENTS
TABLE 40-3 GOOD SOURCES OF PROTEIN
TABLE 40-4 MAJOR MINERALS AND TRACE ELEMENTS
Special Diet: Vegetarian Diet
TABLE 40-5 NUTRITIONAL THERAPY: Foods High in Iron*
Culturally Competent Care
Nutrition
Malnutrition
Etiology of Malnutrition
FIG. 40-3 Patient with malnutrition.
Contributing Factors to Malnutrition
Socioeconomic Factors.
Physical Illnesses.
TABLE 40-6 CONDITIONS THAT INCREASE THE RISK FOR MALNUTRITION
Incomplete Diets.
Food-Drug Interactions.
TABLE 40-7 RECOMMENDED DAILY VITAMIN AND CALCIUM INTAKE*
Pathophysiology of Starvation
Impact of Inflammation.
Clinical Manifestations
FIG. 40-4 Severe malnutrition that results in wasting and extensive loss of adipose tissue.
Diagnostic Studies
History and Physical Examination.
Laboratory Studies.
TABLE 40-8 NURSING ASSESSMENT: Malnutrition
Anthropometric Measurements.
Functional Measurements.
Nursing and Collaborative Management Malnutrition
Nursing Assessment
TABLE 40-9 COMPONENTS OF NUTRITIONAL ASSESSMENT
Anthropometric Measurements
Physical Examination
Health History
Diet History
Laboratory Data
Functional Status
Healthy People
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Evidence-Based Practice Translating Research Into Practice
Does Nutritional Education Improve Functional Outcomes in Older Adults?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Acute Intervention.
TABLE 40-10 NUTRITIONAL THERAPY*High-Calorie, High-Protein Diet
Breads and Cereals
Vegetables
Fruits
Meat
Milk and Milk Products
Ambulatory and Home Care.
Evaluation
Gerontologic Considerations
Malnutrition
Types of Specialized Nutritional Support
Oral Feeding
FIG. 40-5 Nutritional support algorithm.
Enteral Nutrition
Orogastric, Nasogastric, and Nasointestinal Tubes.
FIG. 40-6 Common enteral feeding tube placement locations.
Gastrostomy and Jejunostomy Tubes.
FIG. 40-7 Percutaneous endoscopic gastrostomy. A, Gastrostomy tube placement via percutaneous endoscopy. With use of endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through a stab wound made in the abdominal wall. B, A retention disk and bumper secure the tube.
TABLE 40-11 PROBLEMS RELATED TO TUBE FEEDINGS
Tube Feedings and Safety.
Patient Position.
Aspiration Risk.
Residual Volumes.
Tube Position.
Complications Related to Tubes and Feedings.
Delegation Decisions Nasogastric and Gastric Tubes and Enteral Feedings
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Gerontologic Considerations
Enteral Nutrition
TABLE 40-12 DECREASING RISK OF ENTERAL FEEDING MISCONNECTIONS
Parenteral Nutrition
TABLE 40-13 INDICATIONS FOR PARENTERAL NUTRITION*
Composition.
Calories.
Protein.
Electrolytes.
Trace Elements and Vitamins.
Methods of Administration.
Central Parenteral Nutrition.
Peripheral Parenteral Nutrition.
Comparison of Central and Peripheral Parenteral Nutrition.
TABLE 40-14 COMPLICATIONS OF PARENTERAL NUTRITION
Infection
Metabolic Problems
Catheter-Related Problems
Nursing Management Parenteral Nutrition
Complications
Home Nutritional Support
Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Case Study Undernutrition
Patient Profile
Subjective Data
Objective Data
Physical Examination
Laboratory Results
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 41 Nursing Management: Obesity
Learning Outcomes
Key Terms
eFigure
eTables
Obesity
Classifications of Body Weight and Obesity
Body Mass Index.
FIG. 41-1 Obesity is an epidemic in the United States.
Waist Circumference.
Waist-to-Hip Ratio.
FIG. 41-2 Body mass index (BMI) chart. Healthy weight: BMI 18 to 24.9 kg/m2; overweight: BMI 25 to 29.9 kg/m2; obesity: BMI 30 kg/m2. BMI = weight (kg)/height (m2).
Body Shape.
Epidemiology of Obesity
TABLE 41-1 CLASSIFICATION OF OVERWEIGHT AND OBESITY
TABLE 41-2 RELATIONSHIP BETWEEN BODY SHAPE AND HEALTH RISKS
Cultural & Ethnic Health Disparities
Healthy People
Etiology and Pathophysiology
Genetic Link
FIG. 41-3 Some of the common hormones and peptides that interact with the hypothalamus to control and influence eating patterns, metabolic activities, and digestion. Obesity disrupts this balance (see Table 41-3).
TABLE 41-3 HORMONES AND PEPTIDES IN OBESITY
Physiologic Regulatory Mechanisms in Obesity.
Environmental Factors.
TABLE 41-4 PORTION SIZES: YESTERDAY VS TODAY
Psychosocial Factors.
Health Risks Associated with Obesity
Cardiovascular Problems
Diabetes Mellitus
FIG. 41-4 Health risks associated with obesity.
Gastrointestinal and Liver Problems
Respiratory and Sleep Problems
Musculoskeletal Problems
Cancer
Metabolic Syndrome
Psychosocial Problems
Nursing and Collaborative Management Obesity
Nursing Assessment
TABLE 41-5 NURSING ASSESSMENT: Obese Patient
Planning
TABLE 41-6 ASSESSING PATIENTS WITH OBESITY
Nursing Implementation
TABLE 41-7 COLLABORATIVE CARE: Obesity
Diagnostic
Collaborative Therapy
Nutritional Therapy.
TABLE 41-8 NUTRITIONAL THERAPY 1200-Calorie–Restricted Weight-Reduction Diet*
Exercise.
Behavior Modification.
Support Groups.
Drug Therapy
Appetite-Suppressing Drugs
Nutrient Absorption–Blocking Drugs
Serotonin Agonist
Phentermine and Topiramate (Qsymia)
Nursing Interventions Related to Drug Therapy
Surgical Therapy
Restrictive Surgeries
Adjustable Gastric Banding.
Vertical Sleeve Gastrectomy.
Combination of Restrictive and Malabsorptive Surgery
Roux-en-Y Gastric Bypass.
TABLE 41-9 SURGICAL INTERVENTIONS FOR OBESITY*
Cosmetic Surgeries to Reduce Fatty Tissue and Skinfolds
Lipectomy.
Liposuction.
FIG. 41-5 Bariatric surgical procedures. A, Adjustable gastric banding (AGB) uses a band to create a gastric pouch. B, Vertical sleeve gastrectomy involves creating a sleeve-shaped stomach by removing about 80% of the stomach. C, Vertical banded gastroplasty (VBG) involves creating a small gastric pouch. D, Biliopancreatic diversion (BPD) with duodenal switch procedure creates an anastomosis between the stomach and the intestine. E, Roux-en-Y gastric bypass procedure involves constructing a gastric pouch whose outlet is a Y-shaped limb of small intestine.
FIG. 41-6 A, Preoperative view of a 37-year-old woman with massive weight loss who had gastric bypass surgery. B, Postoperative view 2½ years after abdominoplasty. She also underwent breast surgery, thighlift, backlift with excision of excess skin of the lower back and upper buttocks, and upper arm surgery.
Nursing Management Perioperative Care of the Obese Patient
Nursing Implementation
Preoperative Care.
Special Considerations for Bariatric Surgery.
Postoperative Care.
Special Considerations for Bariatric Surgery.
Ambulatory and Home Care
Special Considerations for Bariatric Surgery.
Evaluation
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Gerontologic Considerations
Obesity in Older Adults
TABLE 41-10 CRITERIA FOR METABOLIC SYNDROME*
Metabolic Syndrome
Etiology and Pathophysiology
FIG. 41-7 Relationship among insulin resistance, obesity, diabetes mellitus, and cardiovascular disease. HDL, High-density lipoprotein.
Clinical Manifestations and Diagnostic Studies
Nursing and Collaborative Management Metabolic Syndrome
Case Study Obesity
Patient Profile
Subjective Data
Objective Data
Physical Examination
Laboratory Results
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Case Studies
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 42 Nursing Management: Upper Gastrointestinal Problems
Learning Outcomes
Key Terms
eFigures
Nausea and Vomiting
Etiology and Pathophysiology
FIG. 42-1 Stimuli involved in the act of vomiting. CTZ, Chemoreceptor trigger zone.
Clinical Manifestations
Collaborative Care
Drug Therapy.
Drug Alert
Drug Alert
TABLE 42-1 DRUG THERAPY: Nausea and Vomiting
Nutritional Therapy.
Nondrug Therapy.
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Nursing Management Nausea and Vomiting
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Acute Intervention.
TABLE 42-2 NURSING ASSESSMENT: Nausea and Vomiting
Ambulatory and Home Care.
Evaluation
Gerontologic Considerations
Nausea and Vomiting
Oral Inflammation and Infections
TABLE 42-3 INFECTIONS AND INFLAMMATION OF THE MOUTH
Oral Cancer
Cultural & Ethnic Health Disparities
Nausea and Vomiting
Cancers of Oral Cavity and Pharynx
Esophageal Cancer
Stomach Cancer
Etiology and Pathophysiology
Clinical Manifestations
TABLE 42-4 TYPES AND CHARACTERISTICS OF ORAL CANCER
TABLE 42-5 COLLABORATIVE CARE: Oral Cancer
Diagnostic
Collaborative Therapy*
Diagnostic Studies
Collaborative Care
Surgical Therapy.
Nonsurgical Therapy.
Nutritional Therapy.
Nursing Management Oral Cancer
Nursing Assessment
TABLE 42-6 NURSING ASSESSMENT: Oral Cancer
Nursing Diagnoses
Planning
Nursing Implementation
Healthy People
Evaluation
Esophageal Disorders
Gastroesophageal Reflux Disease
FIG. 42-2 Factors involved in the pathogenesis of gastroesophageal reflux disease (GERD). LES, Lower esophageal sphincter.
Etiology and Pathophysiology
Clinical Manifestations
TABLE 42-7 FACTORS AFFECTING LOWER ESOPHAGEAL SPHINCTER PRESSURE
Increase Pressure
Decrease Pressure
Complications
FIG. 42-3 Esophagitis with esophageal ulcerations.
Diagnostic Studies
Collaborative Care
Lifestyle Modifications.
Nutritional Therapy.
TABLE 42-8 COLLABORATIVE CARE: Gastroesophageal Reflux Disease (GERD) and Hiatal Hernia
TABLE 42-9 PATIENT & CAREGIVER TEACHING GUIDE: Gastroesophageal Reflux Disease (GERD)
Drug Therapy.
Evidence-Based Practice Translating Research Into Practice
Are Proton Pump Inhibitors Associated With Increased Risk of Diarrhea?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
TABLE 42-10 DRUG THERAPY: Gastroesophageal Reflux Disease (GERD) and Peptic Ulcer Disease (PUD)
Drug Alert
FIG. 42-4 Nissen fundoplication for repair of hiatal hernia. A, Fundus of stomach is wrapped around distal esophagus. B, The fundus is then sutured to itself.
Surgical Therapy.
Endoscopic Therapy.
Nursing Management Gastroesophageal Reflux Disease
Hiatal Hernia
FIG. 42-5 A, Sliding hiatal hernia. B, Rolling or paraesophageal hernia.
Etiology and Pathophysiology
Clinical Manifestations and Complications
Diagnostic Studies
Ethical/Legal Dilemmas Guardianship
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Nursing and Collaborative Management Hiatal Hernia
Gerontologic Considerations
Gastroesophageal Reflux Disease and Hiatal Hernia
Esophageal Cancer
Etiology and Pathophysiology
Clinical Manifestations and Complications
Diagnostic Studies
Collaborative Care
TABLE 42-11 COLLABORATIVE CARE: Esophageal Cancer
Diagnostic
Collaborative Therapy
Surgery.
Endoscopic Procedures.
Radiation and Chemotherapy.
Nutritional Therapy.
Nursing Management Esophageal Cancer
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention
Preoperative Care.
Postoperative Care.
Ambulatory and Home Care.
Evaluation
Other Esophageal Disorders
Eosinophilic Esophagitis
Esophageal Diverticula
FIG. 42-6 Possible sites for esophageal diverticula. These hollow outpouchings may occur just above the upper esophageal sphincter (Zenker’s, the most common type of pulsion diverticulum), near the midpoint of the esophagus (traction), and just above the lower esophageal sphincter (epiphrenic).
FIG. 42-7 Esophageal achalasia. A, Early stage, showing tapering of lower esophagus. B, Advanced stage, showing dilated, tortuous esophagus.
Esophageal Strictures
Achalasia
FIG. 42-8 Pneumatic dilation attempts to treat achalasia by maintaining an adequate lumen and decreasing lower esophageal sphincter (LES) tone.
Esophageal Varices
Disorders of the Stomach and Upper Small Intestine
Gastritis
TABLE 42-12 CAUSES OF GASTRITIS
Drugs
Diet
Microorganisms
Environmental Factors
Pathophysiologic Conditions
Other Factors
Etiology and Pathophysiology
Risk Factors.
Drug-Related Gastritis.
Diet.
Helicobacter pylori.
Other Risk Factors.
Autoimmune Gastritis.
Clinical Manifestations
Diagnostic Studies
TABLE 42-13 DRUG THERAPY: Helicobacter pylori Infection
Nursing and Collaborative Management Gastritis
Acute Gastritis
Chronic Gastritis
FIG. 42-9 Peptic ulcers, including an erosion, an acute ulcer, and a chronic ulcer. Both the acute ulcer and the chronic ulcer may penetrate the entire wall of the stomach.
FIG. 42-10 Peptic ulcer of the duodenum.
Peptic Ulcer Disease
Types
Etiology and Pathophysiology
TABLE 42-14 COMPARISON OF GASTRIC AND DUODENAL ULCERS
Helicobacter pylori.
FIG. 42-11 Disruption of gastric mucosa and pathophysiologic consequences of back diffusion of acids.
Medication-Induced Injury.
Lifestyle Factors.
FIG. 42-12 Relationship between mucosal blood flow and disruption of the gastric mucosal barrier.
Gastric Ulcers.
Duodenal Ulcers.
Stress-Related Mucosal Disease (SRMD).
Clinical Manifestations
FIG. 42-13 Duodenal ulcer of the posterior wall penetrating into the head of the pancreas, resulting in walled-off perforation.
Complications
Hemorrhage.
Perforation.
Gastric Outlet Obstruction.
Diagnostic Studies
FIG. 42-14 Esophagogastroduodenoscopy (EGD) directly visualizes the mucosal lining of the stomach with a flexible endoscope. Ulcers or tumors can be directly visualized and biopsies taken.
Collaborative Care Conservative Therapy
TABLE 42-15 COLLABORATIVE CARE: Peptic Ulcer Disease
Diagnostic
Collaborative Therapy
Drug Therapy.
Histamine (H2)-Receptor Blockers.
Proton Pump Inhibitors.
Antibiotic Therapy.
Antacids.
Cytoprotective Drug Therapy.
Other Drugs.
Nutritional Therapy.
Therapy Related to Complications of Peptic Ulcer Disease
Acute Exacerbation.
Perforation.
Gastric Outlet Obstruction.
Nursing Management Peptic Ulcer Disease
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
TABLE 42-16 NURSING ASSESSMENT: Peptic Ulcer Disease
Acute Intervention.
Hemorrhage.
Perforation.
Gastric Outlet Obstruction.
TABLE 42-17 PATIENT & CAREGIVER TEACHING GUIDE: Peptic Ulcer Disease (PUD)
Ambulatory and Home Care.
Evaluation
Collaborative Care Surgical Therapy for Peptic Ulcer Disease
Postoperative Complications.
Dumping Syndrome.
Postprandial Hypoglycemia.
Bile Reflux Gastritis.
Nutritional Therapy.
Nursing Management Surgical Therapy for Peptic Ulcer Disease
Preoperative Care
TABLE 42-18 NUTRITIONAL THERAPY: Postgastrectomy Dumping Syndrome
Postoperative Care
Gerontologic Considerations
Peptic Ulcer Disease
Stomach Cancer
FIG. 42-15 Stomach carcinoma. Gross photograph showing an ill-defined, excavated central ulcer surrounded by irregular, heaped-up borders.
Etiology and Pathophysiology
Clinical Manifestations
TABLE 42-19 COLLABORATIVE CARE: Stomach Cancer
Diagnostic
Collaborative Therapy
Diagnostic Studies
Collaborative Care
Surgical Therapy.
FIG. 42-16 Total gastrectomy for stomach cancer. A, Normal anatomic structure of the stomach. B, Removal of the stomach (total gastrectomy). C, Anastomosis of the esophagus with the jejunum (esophagojejunostomy).
Adjuvant Therapy.
Nursing Management Stomach Cancer
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention
Preoperative Care.
Postoperative Care.
Ambulatory and Home Care.
TABLE 42-20 TYPES OF UPPER GASTROINTESTINAL BLEEDING
Evaluation
Upper Gastrointestinal Bleeding
Etiology and Pathophysiology
TABLE 42-21 COMMON CAUSES OF UPPER GASTROINTESTINAL BLEEDING
Drug Induced
Esophagus
Stomach and Duodenum
Systemic Diseases
Esophageal Origin.
Stomach and Duodenal Origin.
Diagnostic Studies
Collaborative Care
Emergency Assessment and Management.
Endoscopic Therapy.
TABLE 42-22 DRUG THERAPY: Acute Gastrointestinal Bleeding*
Surgical Therapy.
Drug Therapy.
Nursing Management Upper Gastrointestinal Bleeding
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
TABLE 42-23 NURSING ASSESSMENT: Upper Gastrointestinal Bleeding
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Foodborne Illness
Escherichia coli O157:H7 Poisoning
TABLE 42-24 BACTERIAL FOOD POISONING
TABLE 42-25 PATIENT & CAREGIVER TEACHING GUIDE: Prevention of Food Poisoning
Case Study Peptic Ulcer Disease
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Chapter 43 Nursing Management: Lower Gastrointestinal Problems
Learning Outcomes
Key Terms
eFigures
eTables
Diarrhea
Etiology and Pathophysiology
TABLE 43-1 CAUSES OF ACUTE INFECTIOUS DIARRHEA*
Clinical Manifestations
Diagnostic Studies
Collaborative Care
TABLE 43-2 DRUG THERAPY: Antidiarrheal Drugs
Clostridium difficile Infection.
Nursing Management Acute Infectious Diarrhea
Nursing Assessment
TABLE 43-3 NURSING ASSESSMENT: Diarrhea
Nursing Diagnoses
Planning
Nursing Implementation
Fecal Incontinence
Etiology and Pathophysiology
TABLE 43-4 CAUSES OF FECAL INCONTINENCE
Traumatic
Neurologic
Inflammatory
Pelvic Floor Dysfunction
Functional
Other
Diagnostic Studies and Collaborative Care
Nursing Management Fecal Incontinence
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Constipation
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies and Collaborative Care
TABLE 43-5 DRUG THERAPY: Constipation
Nutritional Therapy.
TABLE 43-6 NUTRITIONAL THERAPY: High-Fiber Foods
Nursing Management Constipation
Nursing Assessment
Nursing Diagnosis
TABLE 43-7 NURSING ASSESSMENT: Constipation
Planning
Nursing Implementation
TABLE 43-8 PATIENT & CAREGIVER TEACHING GUIDE: Constipation
Acute Abdominal Pain
Etiology and Pathophysiology
TABLE 43-9 CAUSES OF ACUTE ABDOMINAL PAIN
Clinical Manifestations
Diagnostic Studies and Collaborative Care
Nursing Management Acute Abdominal Pain
Nursing Assessment
FIG. 43-1 Etiology of acute abdominal pain and pathophysiologic sequelae.
Nursing Diagnoses
Planning
Nursing Implementation
Acute Intervention
Preoperative Care.
Postoperative Care.
TABLE 43-10 EMERGENCY MANAGEMENT: Acute Abdominal Pain
Inflammation
Vascular Problems
Gynecologic Problems
Infectious Disease
Other
Abdominal and Gastrointestinal Findings
Hypovolemic Shock
Initial
Ongoing Monitoring
Ambulatory and Home Care.
Evaluation
Chronic Abdominal Pain
Gender Differences
Men
Women
Irritable Bowel Syndrome
Drug Alert
Abdominal Trauma
Etiology and Pathophysiology
Clinical Manifestations
TABLE 43-11 EMERGENCY MANAGEMENT: Abdominal Trauma
Blunt
Penetrating
Hypovolemic Shock
Surface Findings
Abdominal and Gastrointestinal Findings
Initial
Ongoing Monitoring
Diagnostic Studies
Nursing and Collaborative Management Abdominal Trauma
Inflammatory Disorders
Appendicitis
Etiology and Pathophysiology
FIG. 43-2 In appendicitis the blood supply of the appendix is impaired by inflammation and bacterial infection in the wall of the appendix, which may result in gangrene.
Clinical Manifestations
Diagnostic Studies and Collaborative Care
Nursing Management Appendicitis
TABLE 43-12 CAUSES OF PERITONITIS
Primary
Secondary
Peritonitis
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies and Collaborative Care
TABLE 43-13 COLLABORATIVE CARE: Peritonitis
Diagnostic
Collaborative Therapy
Nursing Management Peritonitis
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Gastroenteritis
Inflammatory Bowel Disease
TABLE 43-14 COMPARISON OF ULCERATIVE COLITIS AND CROHN’S DISEASE
Etiology and Pathophysiology
Cultural & Ethnic Health Disparities
Genetic Link
FIG. 43-3 Comparison of distribution patterns of Crohn’s disease and ulcerative colitis.
Pattern of Inflammation in Ulcerative Colitis Versus Crohn’s Disease.
TABLE 43-15 EXTRAINTESTINAL COMPLICATIONS OF IBD
Clinical Manifestations
Complications
Diagnostic Studies
Collaborative Care
Drug Therapy.
TABLE 43-16 COLLABORATIVE CARE: Inflammatory Bowel Disease
Diagnostic
Collaborative Therapy
Drug Alert
TABLE 43-17 DRUG THERAPY: Inflammatory Bowel Disease
TABLE 43-18 INDICATIONS FOR SURGICAL THERAPY FOR IBD
Surgical Therapy
Ulcerative Colitis.
Total Proctocolectomy With Ileal Pouch/Anal Anastomosis (IPAA).
Total Proctocolectomy With Permanent Ileostomy.
FIG. 43-4 Ileoanal pouch (reservoir). A, Formation of a pouch. B, Posterior suture lines completed. C, J-shaped configuration for ileoanal pouch (J-pouch). D, S-shaped configuration for ileoanal pouch (S-pouch).
Crohn’s Disease.
Postoperative Care.
Nutritional Therapy.
Nursing Management Inflammatory Bowel Disease
Nursing Assessment
Nursing Diagnoses
Planning
TABLE 43-19 NURSING ASSESSMENT: Inflammatory Bowel Disease
Nursing Implementation
Evaluation
Gerontologic Considerations
Inflammatory Bowel Disease
Intestinal Obstruction
Types of Intestinal Obstruction
Mechanical
Nonmechanical
Etiology and Pathophysiology
FIG. 43-5 Bowel obstructions. A, Adhesions. B, Strangulated inguinal hernia. C, Ileocecal intussusception. D, Intussusception from polyps. E, Mesenteric occlusion. F, Neoplasm. G, Volvulus of the sigmoid colon.
Clinical Manifestations
TABLE 43-20 MANIFESTATIONS OF SMALL AND LARGE INTESTINAL OBSTRUCTIONS
Diagnostic Studies
Collaborative Care
Nursing Management Intestinal Obstruction
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
FIG. 43-6 Endoscopic image of pedunculated polyp in descending colon.
Polyps of Large Intestine
Types of Polyps
Genetic Link
Diagnostic Studies and Collaborative Care
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
Colorectal Cancer
Etiology and Pathophysiology
Cultural & Ethnic Health Disparities
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
TABLE 43-21 RISK FACTORS FOR COLORECTAL CANCER
Clinical Manifestations
FIG. 43-7 The five stages of colorectal cancer. Stage 0 cancer has not grown beyond the mucosal layer. Stage I cancer has grown beyond the mucosa into the submucosa, but no lymph nodes are involved. Stage II cancer has grown beyond the submucosa into the muscle but there is no lymph node involvement or metastasis. Stage III cancer is any tumor with lymph node involvement but no metastasis. Stage IV cancer is any tumor with lymph node involvement and metastasis.
FIG. 43-8 Signs and symptoms of colorectal cancer by location of primary cancer.
Diagnostic Studies
TABLE 43-22 COLLABORATIVE CARE: Colorectal Cancer
Diagnostic
Collaborative Therapy
Collaborative Care
TABLE 43-23 TNM CLASSIFICATION OF COLORECTAL CANCER
TABLE 43-24 CLASSIFICATION SYSTEM USED TO STAGE COLORECTAL CANCER
Surgical Therapy.
Chemotherapy and Targeted Therapy.
Drug Alert
Radiation Therapy.
TABLE 43-25 NURSING ASSESSMENT: Colorectal Cancer
Nursing Management Colorectal Cancer
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Ostomy Surgery
Types
TABLE 43-26 COMPARISON OF ILEOSTOMY AND COLOSTOMY
FIG. 43-9 Types of ostomies.
End Stoma.
Loop Stoma.
FIG. 43-10 Sigmoid colostomy. Distal bowel is oversewn and left in place to create Hartmann’s pouch.
Double-Barreled Stoma.
Nursing Management Ostomy Surgery
Preoperative Care
FIG. 43-11 Loop colostomy.
Postoperative Care
TABLE 43-27 CHARACTERISTICS OF STOMA
Colostomy Care
Colostomy Irrigations.
TABLE 43-28 PATIENT & CAREGIVER TEACHING GUIDE: Ostomy Self-Care
Ileostomy Care
TABLE 43-29 PATIENT & CAREGIVER TEACHING GUIDE: Colostomy Irrigation
Delegation Decisions Ostomy Care
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Adaptation To An Ostomy
Sexual Function After Ostomy Surgery
Diverticulosis and Diverticulitis
Etiology and Pathophysiology
FIG. 43-12 Diverticula are outpouchings of the colon. When they become inflamed, the condition is diverticulitis. The inflammatory process can spread to the surrounding area in the intestine.
Clinical Manifestations and Complications
FIG. 43-13 Complications of diverticulitis.
TABLE 43-30 COLLABORATIVE CARE: Diverticulosis and Diverticulitis
Diagnostic
Collaborative Therapy
Diagnostic Studies
Nursing and Collaborative Management Diverticulosis and Diverticulitis
Hernias
Types
Gender Differences
Clinical Manifestations
Nursing and Collaborative Management Hernias
FIG. 43-14 A, Umbilical hernia. B, Femoral hernias (note swelling below the inguinal ligaments). C, Right inguinal hernia.
Malabsorption Syndrome
TABLE 43-31 CAUSES OF MALABSORPTION
Biochemical or Enzyme Deficiencies
Disturbed Lymphatic and Vascular Circulation
Bacterial Proliferation
Small Intestinal Mucosal Disruption
Surface Area Loss
Celiac Disease
TABLE 43-32 MANIFESTATIONS OF MALABSORPTION
Etiology and Pathophysiology
Genetic Link
Clinical Manifestations
Diagnostic Studies and Collaborative Care
TABLE 43-33 NUTRITIONAL THERAPY: Celiac Disease
Foods to Eat*
Foods to Avoid
Lactase Deficiency
Short Bowel Syndrome
Clinical Manifestations
Collaborative Care
Gastrointestinal Stromal Tumors
Anorectal Problems
Hemorrhoids
Etiology and Pathophysiology
Clinical Manifestations
FIG. 43-15 Anatomic structures of the rectum and anus with external and internal hemorrhoids.
Diagnostic Studies and Collaborative Care
FIG. 43-16 Thrombosed external hemorrhoids.
Nursing Management Hemorrhoids
Anal Fissure
FIG. 43-17 Common sites of anorectal abscesses and fistula formation.
Anorectal Abscess
Anal Fistula
Anal Cancer
Pilonidal Sinus
Case Study Colorectal Cancer
Patient Profile
Subjective Data
Objective Data
Physical Examination
Laboratory Tests
Collaborative Care
Surgical Procedure
Postoperative
Follow-Up Treatment
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 44 Nursing Management: Liver, Pancreas, and Biliary Tract Problems
Learning Outcomes
Key Terms
eFigures
eTable
Disorders of the Liver
Hepatitis
Viral Hepatitis
Hepatitis A Virus.
FIG. 44-1 Jaundiced patient.
TABLE 44-1 CHARACTERISTICS OF HEPATITIS VIRUSES
Hepatitis B Virus.
FIG. 44-2 Course of infection with hepatitis A virus (HAV). ALT, Alanine aminotransferase.
Hepatitis C Virus.
FIG. 44-3 Course of infection with hepatitis B virus (HBV). ALT, Alanine aminotransferase; anti-HBc, antibody to hepatitis B core antigen; anti-HBe, antibody to HBeAg; anti-HBs, antibody to HBsAg; HBeAg, hepatitis B e antigen; HBsAg, hepatitis B surface antigen.
Hepatitis D Virus.
Hepatitis E Virus.
Pathophysiology
Liver.
Systemic Effects.
TABLE 44-2 MANIFESTATIONS OF HEPATITIS
Acute Hepatitis
Chronic Hepatitis
Clinical Manifestations
TABLE 44-3 CLASSIFICATION OF JAUNDICE
Complications
Diagnostic Studies
TABLE 44-4 TESTS FOR VIRAL HEPATITIS
TABLE 44-5 DIAGNOSTIC FINDINGS IN ACUTE HEPATITIS
Collaborative Care
Drug Therapy.
Chronic Hepatitis B.
TABLE 44-6 COLLABORATIVE CARE: Viral Hepatitis
Diagnostic
Collaborative Therapy
Interferon.
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Nucleoside and Nucleotide Analogs.
Chronic Hepatitis C.
Drug Alert
Nutritional Therapy.
Nursing Management Viral Hepatitis
Nursing Assessment
Nursing Diagnoses
TABLE 44-7 NURSING ASSESSMENT: Hepatitis*
Planning
Nursing Implementation
Health Promotion.
TABLE 44-8 PREVENTIVE MEASURES FOR VIRAL HEPATITIS*
General Measures
Use of Immune Globulin
Special Considerations for Health Care Personnel
Sexual Transmission
General Measures
Special Considerations for Health Care Personnel
Hepatitis A.
Hepatitis B.
Hepatitis C.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Drug- and Chemical-Induced Liver Diseases
Drug Alert
Autoimmune, Genetic, and Metabolic Diseases
Autoimmune Hepatitis
Wilson’s Disease
Hemochromatosis
Primary Biliary Cirrhosis
Primary Sclerosing Cholangitis
Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis
Cirrhosis
Etiology and Pathophysiology
FIG. 44-4 Cirrhosis that developed secondary to alcoholism. The characteristic diffuse nodularity of the surface is due to the combination of regeneration and scarring of the liver.
Cultural & Ethnic Health Disparities
Hepatitis
Cirrhosis
Liver and Pancreatic Cancer
Gallbladder Disease
Clinical Manifestations
Early Manifestations.
Later Manifestations.
Jaundice.
FIG. 44-5 Continuum of liver dysfunction in cirrhosis and resulting manifestations. ADH, Antidiuretic hormone; ALT, alanine aminotransferase; AST, aspartate aminotransferase.
Skin Lesions.
Hematologic Problems.
Endocrine Problems.
FIG. 44-6 Systemic clinical manifestations of liver cirrhosis.
Peripheral Neuropathy.
Complications
Portal Hypertension and Esophageal and Gastric Varices.
Peripheral Edema and Ascites.
FIG. 44-7 Mechanisms for development of ascites.
TABLE 44-9 FACTORS INVOLVED IN ASCITES
FIG. 44-8 Gross ascites.
Hepatic Encephalopathy.
TABLE 44-10 FACTORS PRECIPITATING HEPATIC ENCEPHALOPATHY
Hepatorenal Syndrome.
Diagnostic Studies
TABLE 44-11 GRADING SCALE FOR HEPATIC ENCEPHALOPATHY
TABLE 44-12 COLLABORATIVE CARE: Cirrhosis of the Liver
Diagnostic
Collaborative Therapy
Collaborative Care
Ascites.
Esophageal and Gastric Varices.
Safety Alert
Shunting Procedures.
Hepatic Encephalopathy.
FIG. 44-9 Portosystemic shunts. A, Portacaval shunt. The portal vein is anastomosed to the inferior vena cava, diverting blood from the portal vein to the systemic circulation. B, Distal splenorenal shunt. The splenic vein is anastomosed to the renal vein. The portal venous flow remains intact while esophageal varices are selectively decompressed. (The short gastric veins are decompressed.) The spleen conducts blood from the high pressure of the esophageal and gastric varices to the low-pressure renal vein.
Drug Therapy.
Nutritional Therapy.
TABLE 44-13 DRUG THERAPY: Cirrhosis
Nursing Management Cirrhosis
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
TABLE 44-14 NURSING ASSESSMENT: Cirrhosis
Acute Intervention.
Bleeding Varices.
Ethical/Legal Dilemmas Rationing
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Hepatic Encephalopathy.
Ambulatory and Home Care.
Evaluation
TABLE 44-15 PATIENT & CAREGIVER TEACHING GUIDE: Cirrhosis
Acute Liver Failure
Clinical Manifestations and Diagnostic Studies
Nursing and Collaborative Management Acute Liver Failure
Liver Cancer (Hepatocellular Cancer)
FIG. 44-10 Multiple hepatic metastases from a primary colon cancer. A, Gross specimen showing outside of liver. B, Liver section showing metastatic lesions.
Clinical Manifestations and Diagnostic Studies
Nursing and Collaborative Management Liver Cancer
Liver Transplantation
Gerontologic Considerations
Liver Disease in the Older Adult
FIG. 44-11 Pathogenic process of acute pancreatitis.
Disorders of the Pancreas
Acute Pancreatitis
Etiology and Pathophysiology
FIG. 44-12 In acute pancreatitis, the pancreas appears edematous and is commonly hemorrhagic (H).
Clinical Manifestations
Complications
TABLE 44-16 DIAGNOSTIC STUDIES: Acute Pancreatitis
Diagnostic Studies
Collaborative Care
Conservative Therapy.
TABLE 44-17 COLLABORATIVE CARE: Acute Pancreatitis
Diagnostic
Collaborative Therapy
Surgical Therapy.
TABLE 44-18 DRUG THERAPY: Acute and Chronic Pancreatitis
Drug Therapy.
Nutritional Therapy.
Nursing Management Acute Pancreatitis
Nursing Assessment
Nursing Diagnoses
TABLE 44-19 NURSING ASSESSMENT: Acute Pancreatitis
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Safety Alert
Ambulatory and Home Care.
Evaluation
Chronic Pancreatitis
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Nursing Management Chronic Pancreatitis
Pancreatic Cancer
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Collaborative Care
FIG. 44-13 Whipple procedure or radical pancreaticoduodenectomy. This surgical procedure involves resection of the proximal pancreas, adjoining duodenum, distal portion of the stomach, and distal portion of the common bile duct. An anastomosis of the pancreatic duct, common bile duct, and stomach to the jejunum is done.
Nursing Management Pancreatic Cancer
FIG. 44-14 Cholesterol gallstones in a gallbladder that was removed.
Disorders of the Biliary Tract
Cholelithiasis and Cholecystitis
Etiology and Pathophysiology
Cholelithiasis.
Gender Differences
TABLE 44-20 MANIFESTATIONS OF OBSTRUCTED BILE FLOW
Cholecystitis.
Clinical Manifestations
Complications.
Diagnostic Studies
Collaborative Care
Conservative Therapy
Cholelithiasis.
FIG. 44-15 During endoscopic sphincterotomy, an endoscope is advanced through the mouth and stomach until its tip sits in the duodenum opposite the common bile duct. Inset, After widening the duct mouth by incising the sphincter muscle, the physician advances a basket attachment into the duct and snags the stone.
Cholecystitis.
Surgical Therapy.
TABLE 44-21 COLLABORATIVE CARE: Cholelithiasis and Acute Cholecystitis
Diagnostic
Collaborative Therapy
Transhepatic Biliary Catheter.
Drug Therapy.
FIG. 44-16 Placement of T tube. Dotted lines indicate parts removed.
Nutritional Therapy.
Nursing Management Gallbladder Disease
Nursing Assessment
TABLE 44-22 NURSING ASSESSMENT: Cholecystitis or Cholelithiasis
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Postoperative Care.
Ambulatory and Home Care.
Evaluation
Gallbladder Cancer
TABLE 44-23 PATIENT & CAREGIVER TEACHING GUIDE: Postoperative Laparoscopic Cholecystectomy
Case Study Cirrhosis of the Liver
Patient Profile
Subjective Data
Objective Data
Physical Examination
Laboratory Values
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Introduction
Patients
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Section 9 Problems of Urinary Function
Problems of Urinary Function
Pre-Test – Section 9
Interactive Review – Section 9
Chapter 45 Nursing Assessment: Urinary System
Learning Outcomes
Key Terms
Structures and Functions of Urinary System
Kidneys
Macrostructure.
FIG. 45-1 Organs of the urinary system. A, Upper urinary tract in relation to other anatomic structures. B, Male urethra in relation to other pelvic structures. C, Female urethra.
Microstructure.
FIG. 45-2 Longitudinal section of the kidney.
FIG. 45-3 The nephron is the basic functional unit of the kidney. This illustration of a single nephron unit also shows the surrounding blood vessels.
Blood Supply.
Physiology of Urine Formation.
Glomerular Function.
Tubular Function.
TABLE 45-1 FUNCTIONS OF NEPHRON SEGMENTS
FIG. 45-4 Renin-angiotensin-aldosterone system.
Other Functions of Kidneys.
Ureters
FIG. 45-5 Urinary bladder of a male.
Bladder
Urethra
Urethrovesical Unit
Gerontologic Considerations
Effects of Aging on Urinary System
TABLE 45-2 GERONTOLOGIC ASSESSMENT DIFFERENCES: Urinary System
Assessment of Urinary System
Subjective Data
Important Health Information
Past Health History.
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Inspect
Palpate
Percuss
Auscultate
Case Study Patient Introduction
Critical Thinking
TABLE 45-3 POTENTIALLY NEPHROTOXIC AGENTS
Medications.
Surgery or Other Treatments.
Functional Health Patterns.
TABLE 45-4 HEALTH HISTORY: Urinary System
Health Perception–Health Management Pattern.
Genetic Risk Alert
Nutritional-Metabolic Pattern.
Elimination Pattern.
Case Study—cont’d
TABLE 45-5 MANIFESTATIONS OF URINARY SYSTEM DISORDERS
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Objective Data
Physical Examination
Inspection.
Palpation.
Percussion.
FIG. 45-6 Palpating the right kidney.
Auscultation.
FIG. 45-7 Indirect fist percussion of the costovertebral angle (CVA). To assess the kidney, place one hand over the twelfth rib at the CVA on the back. Thump that hand with the ulnar edge of the other fist.
TABLE 45-6 NORMAL PHYSICAL ASSESSMENT OF URINARY SYSTEM
Case Study—cont’d
Diagnostic Studies of Urinary System
Case Study—cont’d
TABLE 45-7 ASSESSMENT ABNORMALITIES: Urinary System
TABLE 45-8 DIAGNOSTIC STUDIES: Urinary System
FIG. 45-8 Renal arteriogram showing stenosis of the right renal artery (arrow).
FIG. 45-9 Catheter insertion for a renal arteriogram.
FIG. 45-10 Cystoscopic examination of the bladder in a man. A, Flexible cystonephroscope. B, Scope inserted into bladder.
Urine Studies
Urinalysis.
Creatinine Clearance.
TABLE 45-9 DIAGNOSTIC STUDIES: Urinalysis
Urodynamic Studies
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
Glossary
Key Points
Videos
Chapter 46 Nursing Management: Renal and Urologic Problems
Learning Outcomes
Key Terms
eTables
Infectious and Inflammatory Disorders of Urinary System
Urinary Tract Infection
TABLE 46-1 CAUSES OF URINARY TRACT INFECTIONS
Cultural & Ethnic Health Disparities
Classification of Urinary Tract Infection
FIG. 46-1 Sites of infectious processes in the upper and lower urinary tracts.
Etiology and Pathophysiology
TABLE 46-2 RISK FACTORS FOR URINARY TRACT INFECTIONS
Clinical Manifestations
TABLE 46-3 LOWER URINARY TRACT SYMPTOMS (LUTS)
Diagnostic Studies
Collaborative Care
Drug Alert
TABLE 46-4 COLLABORATIVE CARE: Urinary Tract Infection
Nursing Management Urinary Tract Infection
Nursing Assessment
Nursing Diagnoses
TABLE 46-5 NURSING ASSESSMENT: Urinary Tract Infection
Planning
Nursing Implementation
Health Promotion.
Evidence-Based Practice Translating Research Into Practice
Do Cranberry Products Prevent Urinary Tract Infections?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Acute Intervention.
Ambulatory and Home Care.
TABLE 46-6 PATIENT & CAREGIVER TEACHING GUIDE: Urinary Tract Infection
Evaluation
Acute Pyelonephritis
Etiology and Pathophysiology
FIG. 46-2 Acute pyelonephritis. Cortical surface shows grayish white areas of inflammation and abscess formation (arrows).
Clinical Manifestations and Diagnostic Studies
Collaborative Care
Nursing Management Acute Pyelonephritis
Nursing Assessment
TABLE 46-7 COLLABORATIVE CARE: Acute Pyelonephritis
Nursing Diagnoses
Planning
Nursing Implementation
Evaluation
Chronic Pyelonephritis
Urethritis
Urethral Diverticula
Interstitial Cystitis/Painful Bladder Syndrome
Clinical Manifestations and Diagnostic Studies
Collaborative Care
Nursing Management Interstitial Cystitis/Painful Bladder Syndrome
Renal Tuberculosis
Immunologic Disorders of Kidney
Glomerulonephritis
TABLE 46-8 CAUSES OR RISK FACTORS FOR GLOMERULONEPHRITIS
Acute Poststreptococcal Glomerulonephritis
Nursing and Collaborative Management Acute Poststreptococcal Glomerulonephritis
Goodpasture Syndrome
Rapidly Progressive Glomerulonephritis
Chronic Glomerulonephritis
Nephrotic Syndrome
Etiology and Clinical Manifestations
TABLE 46-9 CAUSES OF NEPHROTIC SYNDROME
Primary Glomerular Disease
Extrarenal Causes
Nursing and Collaborative Management Nephrotic Syndrome
Obstructive Uropathies
FIG. 46-3 Sites and causes of upper and lower urinary tract obstruction.
Urinary Tract Calculi
Etiology and Pathophysiology
FIG. 46-4 Hydronephrosis of the kidney. Note the marked dilation of the pelvis and calyces and thinning of the renal parenchyma.
FIG. 46-5 A, Renal staghorn calculus. The renal pelvis is filled with a large calculus that is shaped to its contours, resembling the horns of a stag (S). B, Imbedded staghorn calculus (arrow) in hydronephrotic, infected, nonfunctioning kidney.
Gender Differences
TABLE 46-10 RISK FACTORS FOR URINARY TRACT CALCULI
Types of Urinary Calculi
Clinical Manifestations
TABLE 46-11 TYPES OF URINARY TRACT CALCULI
Diagnostic Studies
Collaborative Care
FIG. 46-6 A, Calcium oxalate stones. B, Plain abdominal x-ray showing large bladder calculus.
Endourologic Procedures.
Lithotripsy.
Surgical Therapy.
TABLE 46-12 NUTRITIONAL THERAPY: Urinary Tract Calculi
Nutritional Therapy.
Nursing Management Urinary Tract Calculi
Nursing Assessment
TABLE 46-13 NURSING ASSESSMENT: Urinary Tract Calculi
Nursing Diagnoses
Planning
Nursing Implementation
Evaluation
Strictures
Ureteral Strictures
Urethral Strictures
Renal Trauma
Renal Vascular Problems
Nephrosclerosis
Renal Artery Stenosis
Renal Vein Thrombosis
Hereditary Kidney Diseases
Polycystic Kidney Disease
Genetic Link
Genetics In Clinical Practice
FIG. 46-7 A, Comparison of polycystic kidney with normal kidney. B, Cysts in the liver.
Nursing and Collaborative Management Polycystic Kidney Disease
Medullary Cystic Disease
Alport Syndrome
Urinary Tract Tumors
Kidney Cancer
Clinical Manifestations and Diagnostic Studies
FIG. 46-8 Cross section of kidney with renal cell carcinoma. The carcinoma (black arrow) is on the pole of the kidney. Note that the renal vein is involved and thrombosed (white arrow).
Nursing and Collaborative Management Kidney Cancer
TABLE 46-14 COLLABORATIVE CARE: Renal Cell Carcinoma
Bladder Cancer
FIG. 46-9 A, Papillary transitional cell carcinoma (T) seen arising from the dome of the bladder as a cauliflower-like lesion (arrow). B, Opened bladder showing bladder cancer at an advanced stage. Yellow areas represent ulcerations and necrosis (arrows).
Clinical Manifestations and Diagnostic Studies
Nursing and Collaborative Management Bladder Cancer
Surgical Therapy
TABLE 46-15 COLLABORATIVE CARE: Bladder Cancer
Radiation Therapy and Chemotherapy
Intravesical Therapy
Gender Differences
Bladder Dysfunction
Urinary Incontinence
Etiology and Pathophysiology
TABLE 46-16 DRUG THERAPY: Drugs Affecting Lower Urinary Tract Function
Diagnostic Studies
Complementary & Alternative Therapies
Scientific Evidence
Nursing Implications
Collaborative Care
Drug Therapy.
TABLE 46-17 TYPES OF URINARY INCONTINENCE
Drug Alert
Surgical Therapy.
Nursing Management Urinary Incontinence
TABLE 46-18 INTERVENTIONS FOR URINARY INCONTINENCE
TABLE 46-19 PATIENT TEACHING GUIDE: Pelvic Floor Muscle (Kegel) Exercises
Urinary Retention
TABLE 46-20 DRUG THERAPY: Voiding Dysfunction*
Delegation Decisions Caring for the Incontinent Patient
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Etiology and Pathophysiology
Diagnostic Studies
Collaborative Care
Drug Therapy.
Surgical Therapy.
Nursing Management Urinary Retention
TABLE 46-21 INDICATIONS FOR URINARY CATHETERIZATION
Catheterization
Indications for and Complications of Catheterization
FIG. 46-10 Types of urinary catheters. A, Simple urethral catheter. B, Mushroom-tip de Pezzer catheter (can be for suprapubic catheterization). C, Wing-tip Malecot catheter. D, Indwelling urethral catheter with inflated balloon. E, Indwelling Tiemann catheter with coudé-tip–inflated balloon. F, Three-way indwelling catheter (third lumen can be used for irrigation).
Catheter Construction
Types of Catheters
Urethral Catheters
Delegation Decisions Urinary Catheters
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Ureteral Catheters
Suprapubic Catheters
Nephrostomy Tubes
Intermittent Catheterization
Surgery of the Urinary Tract
Renal and Ureteral Surgery
Surgical Procedure
Laparoscopic Nephrectomy.
Preoperative Management
Postoperative Management
Urine Output.
Respiratory Status.
Abdominal Distention.
Urinary Diversion
Incontinent Urinary Diversion
Continent Urinary Diversions
TABLE 46-22 URINARY DIVERSION SURGERY
FIG. 46-11 Methods of urinary diversion. A, Ureteroileosigmoidostomy. B, Ileal loop (ileal conduit). C, Ureterostomy (transcutaneous ureterostomy and bilateral cutaneous ureterostomies). D, Nephrostomy.
FIG. 46-12 Urinary stoma. Symmetric, no skin breakdown, protrudes about 1.5 cm. Mucosa is healthy red. This configuration is flat when the patient is upright or supine.
FIG. 46-13 Creation of a Kock pouch with implantation of ureters into one intussuscepted portion of the pouch and creation of a stoma with the other intussuscepted portion.
Orthotopic Bladder Reconstruction
Nursing Management Urinary Diversion
Preoperative Management
Postoperative Management
TABLE 46-23 PATIENT & CAREGIVER TEACHING GUIDE: Ileal Conduit Appliances
FIG. 46-14 Ammonia salt encrustation secondary to alkaline urine.
FIG. 46-15 Retracted urinary stoma with pressure sore from faceplate above stoma (arrow).
Case Study Urinary Tract Infection
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 47 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease
Learning Outcomes
Key Terms
eTables
Acute Kidney Injury
TABLE 47-1 COMPARISON OF ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE
TABLE 47-2 COMMON CAUSES OF ACUTE KIDNEY INJURY
Hypovolemia
Decreased Cardiac Output
Decreased Peripheral Vascular Resistance
Decreased Renovascular Blood Flow
Nephrotoxic Injury
Interstitial Nephritis
Other Causes
Etiology and Pathophysiology
Prerenal.
Intrarenal.
FIG. 47-1 Acute tubular necrosis. The kidneys are swollen and pale.
Postrenal.
Clinical Manifestations
TABLE 47-3 RIFLE CLASSIFICATION FOR STAGING ACUTE KIDNEY INJURY
Oliguric Phase.
Urinary Changes.
Fluid Volume.
Metabolic Acidosis.
Sodium Balance.
Potassium Excess.
Hematologic Disorders.
Waste Product Accumulation.
Neurologic Disorders.
Diuretic Phase.
Recovery Phase.
Diagnostic Studies
TABLE 47-4 COLLABORATIVE CARE: Acute Kidney Injury
Diagnostic
Collaborative Therapy
Collaborative Care
TABLE 47-5 THERAPIES FOR ELEVATED POTASSIUM LEVELS
Nutritional Therapy.
Nursing Management Acute Kidney Injury
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Informatics in Practice Computer Monitoring of Antibiotic Safety
Ambulatory And Home Care.
Evaluation
Gerontologic Considerations
Acute Kidney Injury
Chronic Kidney Disease
TABLE 47-6 STAGES OF CHRONIC KIDNEY DISEASE
Clinical Manifestations
Cultural & Ethnic Health Disparities
African Americans
Native Americans
Hispanics
Urinary System.
Metabolic Disturbances
Waste Product Accumulation.
Altered Carbohydrate Metabolism.
FIG. 47-2 Possible clinical manifestations of chronic kidney disease.
Elevated Triglycerides.
Electrolyte and Acid-Base Imbalances
Potassium.
Sodium.
Calcium and Phosphate.
Magnesium.
Metabolic Acidosis.
Hematologic System
Anemia.
Bleeding Tendencies.
Infection.
Cardiovascular System.
Respiratory System.
Gastrointestinal System.
Neurologic System.
Musculoskeletal System.
FIG. 47-3 Mechanisms of chronic kidney disease mineral and bone disorder (CKD-MBD). GFR, Glomerular filtration rate; PTH, parathyroid hormone.
Integumentary System.
Reproductive System.
Psychologic Changes.
Diagnostic Studies
TABLE 47-7 COLLABORATIVE CARE: Chronic Kidney Disease
Diagnostic
Collaborative Therapy
Collaborative Care
TABLE 47-8 INDICATORS OF KIDNEY FUNCTION
TABLE 47-9 RISK FACTORS FOR CHRONIC KIDNEY DISEASE
Drug Therapy
Hyperkalemia.
Hypertension.
Evidence-Based Practice Translating Research Into Practice
Can Exercise Improve Physical Fitness in Chronic Kidney Disease?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
CKD-MBD.
Anemia.
Dyslipidemia.
Complications of Drug Therapy.
Nutritional Therapy
Protein Restriction.
TABLE 47-10 NUTRITIONAL THERAPY: Chronic Kidney Disease*
Water Restriction.
Sodium and Potassium Restriction.
Phosphate Restriction.
Nursing Management Chronic Kidney Disease
Nursing Assessment
TABLE 47-11 NUTRITIONAL THERAPY: High-Potassium Foods*
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory And Home Care.
Healthy People
TABLE 47-12 PATIENT & CAREGIVER TEACHING GUIDE: Chronic Kidney Disease
Evaluation
Dialysis
TABLE 47-13 COMPARISON OF PERITONEAL DIALYSIS AND HEMODIALYSIS
General Principles of Dialysis
FIG. 47-4 Osmosis and diffusion across a semipermeable membrane.
Peritoneal Dialysis
Catheter Placement
FIG. 47-5 Peritoneal dialysis showing peritoneal catheter inserted into peritoneal cavity.
Dialysis Solutions and Cycles
FIG. 47-6 Peritoneal catheter exit site.
Peritoneal Dialysis Systems
Automated Peritoneal Dialysis.
Continuous Ambulatory Peritoneal Dialysis.
Complications of Peritoneal Dialysis
Exit Site Infection.
FIG. 47-7 Automated peritoneal dialysis that can be used while the patient is sleeping.
Peritonitis.
Hernias.
Lower Back Problems.
Bleeding.
Pulmonary Complications.
Protein Loss.
Effectiveness of Chronic Peritoneal Dialysis
Hemodialysis
Vascular Access
Arteriovenous Fistulas and Grafts.
FIG. 47-8 Vascular access for hemodialysis. A, Arteriovenous fistula. B, Arteriovenous graft.
Temporary Vascular Access.
FIG. 47-9 Arteriovenous fistula created by anastomosing an artery and a vein.
FIG. 47-10 Temporary double-lumen vascular access catheter for acute hemodialysis. A, Soft, flexible double-lumen tube is attached to a Y hub. B, The distance between the arterial intake lumen and the venous return lumen typically provides recirculation rates of 5% or less.
Dialyzers.
Procedure for Hemodialysis
FIG. 47-11 A, Right internal jugular placement for a tunneled, cuffed semipermanent catheter. B, Temporary hemodialysis catheter in place. C, Long-term cuffed hemodialysis catheter.
FIG. 47-12 Components of a hemodialysis system. Blood is removed via a needle inserted in a fistula or via catheter lumen. It is propelled to the dialyzer by a blood pump. Heparin is infused either as a bolus predialysis or through a heparin pump continuously to prevent clotting. Dialysate is pumped in and flows in the opposite direction of the blood. The dialyzed blood is returned to the patient through a second needle or catheter lumen. Old dialysate and ultrafiltrate are drained and discarded.
Settings and Schedules for Hemodialysis.
Complications of Hemodialysis
Hypotension.
FIG. 47-13 Home hemodialysis is growing in popularity, and machines are more compact.
Muscle Cramps.
Loss of Blood.
Hepatitis.
Effectiveness of Hemodialysis
Continuous Renal Replacement Therapy
TABLE 47-14 CONTINUOUS RENAL REPLACEMENT THERAPIES
FIG. 47-14 Basic schematic of continuous venovenous therapies. Blood pump is required to pump blood through the circuit. Replacement ports are used for instilling replacement fluids and can be given prefilter or postfilter. Dialysate port is used for infusing dialysis solution. Regardless of modality, ultrafiltrate is drained via the ultrafiltration drain port.
Kidney Transplantation
Recipient Selection
Histocompatibility Studies
Donor Sources
Ethical/Legal Dilemmas Allocation of Resources
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Live Donors.
Deceased Donors.
Surgical Procedure
Live Donor.
Kidney Transplant Recipient.
FIG. 47-15 A, Surgical incision for a renal transplant. B, Surgical placement of transplanted kidney.
Nursing Management Kidney Transplant Recipient
Preoperative Care
Postoperative Care
Live Donor.
Kidney Transplant Recipient.
Immunosuppressive Therapy
Complications of Transplantation
Rejection.
Infection.
TABLE 47-15 COMPLICATIONS OF DIALYSIS AND TRANSPLANTATION
Cardiovascular Disease.
Malignancies.
Recurrence of Original Kidney Disease.
Corticosteroid-Related Complications.
Gerontologic Considerations
Chronic Kidney Disease
Ethical/Legal Dilemmas Withdrawing Treatment
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Case Study Chronic Kidney Disease
Patient Profile
Subjective Data
Objective Data
Laboratory Data
Physical Examination
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Introduction
Patients
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Section 10 Problems Related to Regulatory and Reproductive Mechanisms
Problems Related to Regulatory and Reproductive Mechanisms
Pre-Test – Section 10
Interactive Review – Section 10
Chapter 48 Nursing Assessment: Endocrine System
Learning Outcomes
Key Terms
eFigure
Structures and Functions of Endocrine System
Glands
Hormones
FIG. 48-1 Location of the major endocrine glands. The parathyroid glands lie on the posterior surface of the thyroid gland.
Hormone Receptors.
Lipid-Soluble and Water-Soluble Hormones.
FIG. 48-2 The target cell concept. Hormones act only on cells that have receptors specific to that hormone, since the shape of the receptor determines which hormone can react with it. This is an example of the lock-and-key model of biochemical reactions.
FIG. 48-3 A, Lipid-soluble hormones (e.g., steroid hormones) penetrate the cell membrane and interact with intracellular receptors. B, Water-soluble hormones (e.g., protein hormones) bind to receptors located in the cell membrane. The hormone-receptor interaction stimulates various cell responses.
TABLE 48-1 ENDOCRINE GLANDS AND HORMONES
Regulation of Hormonal Secretion.
Simple Feedback.
Nervous System Control.
FIG. 48-4 Feedback mechanism between parathyroid hormone (PTH) and calcium.
Rhythms.
Hypothalamus
Pituitary
FIG. 48-5 Circadian rhythm of cortisol secretion.
Anterior Pituitary.
TABLE 48-2 HORMONES OF THE HYPOTHALAMUS
Posterior Pituitary.
FIG. 48-6 Relationship between the hypothalamus, pituitary, and target organs. The hypothalamus communicates with the anterior pituitary via a capillary system and with the posterior pituitary via nerve tracts. The anterior and posterior pituitary hormones are shown with their target tissues. FSH, Follicle-stimulating hormone; LH, luteinizing hormone.
FIG. 48-7 Relationship of plasma osmolality to antidiuretic hormone (ADH) release and action.
Pineal Gland
Thyroid Gland
Thyroxine and Triiodothyronine.
FIG. 48-8 Thyroid and parathyroid glands. Note the surrounding structures.
Calcitonin.
Parathyroid Glands
Parathyroid Hormone.
FIG. 48-9 The adrenal gland is composed of the adrenal cortex and the adrenal medulla.
Adrenal Glands
Adrenal Medulla.
Adrenal Cortex.
Cortisol.
Aldosterone.
Adrenal Androgens.
Pancreas
Glucagon.
Insulin.
Gerontologic Considerations
Effects of Aging on Endocrine System
TABLE 48-3 GERONTOLOGIC ASSESSMENT DIFFERENCES: Endocrine System
Assessment of Endocrine System
Subjective Data
Important Health Information
Past Health History.
Case Study Patient Introduction
Critical Thinking
TABLE 48-4 HEALTH HISTORY: Endocrine System
Medications.
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
Genetic Risk Alert
Pituitary
Thyroid
Multiple Endocrine Neoplasia
Diabetes Mellitus
Nutritional-Metabolic Pattern.
Elimination Pattern.
Case Study—cont’d
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Objective Data
Physical Examination.
Integument.
Head.
Neck.
FIG. 48-10 Posterior palpation of the thyroid gland.
Thorax.
Case Study—cont’d
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Inspect/Measure
Auscultate
Palpate
Abdomen.
Extremities.
Genitalia.
Diagnostic Studies of Endocrine System
TABLE 48-5 ASSESSMENT ABNORMALITIES: Endocrine System
TABLE 48-6 DIAGNOSTIC STUDIES: Endocrine System
Case Study—cont’d
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Videos
Chapter 49 Nursing Management: Diabetes Mellitus
Learning Outcomes
Key Terms
eFigure
eTable
Diabetes Mellitus
Etiology and Pathophysiology
Normal Insulin Metabolism.
FIG. 49-1 Normal endogenous insulin secretion. In the first hour or two after meals, insulin concentrations rise rapidly in blood and peak at about 1 hour. After meals, insulin concentrations promptly decline toward preprandial values as carbohydrate absorption from the gastrointestinal tract declines. After carbohydrate absorption from the gastrointestinal tract is complete and during the night, insulin concentrations are low and fairly constant, with a slight increase at dawn.
TABLE 49-1 COMPARISON OF TYPE 1 AND TYPE 2 DIABETES MELLITUS
Type 1 Diabetes Mellitus.
Etiology and Pathophysiology.
Genetic Link
FIG. 49-2 Altered mechanisms in type 1 and type 2 diabetes mellitus.
Genetics in Clinical Practice
Onset of Disease.
Type 2 Diabetes Mellitus.
Etiology and Pathophysiology.
Genetic Link
Onset of Disease.
Prediabetes.
Gestational Diabetes.
Other Specific Types of Diabetes.
Clinical Manifestations
Type 1 Diabetes Mellitus.
Type 2 Diabetes Mellitus.
Diagnostic Studies
Collaborative Care
TABLE 49-2 COLLABORATIVE CARE: Diabetes Mellitus
Drug Therapy: Insulin
Types of Insulin.
Insulin Regimens.
TABLE 49-3 DRUG THERAPY: Types of Insulin
FIG. 49-3 Commercially available insulin preparations showing onset, peak, and duration of action. Individual patient responses to each type of insulin are different and affected by many different factors.
TABLE 49-4 DRUG THERAPY: Insulin Regimens
Mealtime Insulin (Bolus).
Long- or Intermediate-Acting (Basal) Background Insulin.
Combination Insulin Therapy.
Storage of Insulin.
Administration of Insulin.
Insulin Injection.
TABLE 49-5 PATIENT & CAREGIVER TEACHING GUIDE: Insulin Therapy
FIG. 49-4 Mixing insulins. This step-order process avoids the problem of contaminating regular insulin with intermediate-acting insulin.
FIG. 49-5 Injection sites for insulin.
Insulin Pump.
FIG. 49-6 Parts of insulin pen.
FIG. 49-7 A, OmniPod Insulin Management System. The Pod holds and delivers insulin. B, The Personal Diabetes Manager (PDM) wirelessly programs insulin delivery via the Pod. The PDM has a built-in glucose meter.
Problems With Insulin Therapy.
TABLE 49-6 ASSESSING THE PATIENT TREATED WITH GLUCOSE-LOWERING AGENTS
Allergic Reactions.
Lipodystrophy.
Somogyi Effect and Dawn Phenomenon.
Drug Therapy: Oral and Noninsulin Injectable Agents
Biguanides.
Drug Alert
Sulfonylureas.
Meglitinides.
α-Glucosidase Inhibitors.
Thiazolidinediones.
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors.
TABLE 49-7 DRUG THERAPY: Oral Agents and Noninsulin Injectable Agents
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors.
Dopamine Receptor Agonist.
Combination Oral Therapy.
Glucagon-Like Peptide Receptor Agonists.
Drug Alert
Drug Alert
Amylin Analog.
Drug Alert
Other Drugs Affecting Blood Glucose Levels.
Nutritional Therapy
TABLE 49-8 NUTRITIONAL THERAPY: Diabetes Mellitus
Type 1 Diabetes Mellitus.
Type 2 Diabetes Mellitus.
Food Composition.
Carbohydrates.
Fats.
Protein.
Alcohol.
Patient Teaching Related to Nutritional Therapy.
Exercise
TABLE 49-9 ACTIVITIES THAT AFFECT CALORIC EXPENDITURE
Monitoring Blood Glucose
TABLE 49-10 PATIENT & CAREGIVER TEACHING GUIDE: Exercise for Patients With Diabetes Mellitus
FIG. 49-8 Blood glucose monitors are used to measure blood glucose levels. Medtronic OneTouch UltraLink glucose meter.
FIG. 49-9 The MiniMed Paradigm® REAL-Time Revel™ Insulin Pump (A) delivers insulin through a thin plastic tubing to an infusion set, which has a cannula (B) that sits under the skin. Continuous glucose monitoring occurs through a tiny sensor (C) inserted under the skin. Sensor data are sent continuously to the insulin pump through wireless technology giving a more complete picture of glucose levels, which can lead to better treatment decisions and better glucose control.
TABLE 49-11 PATIENT & CAREGIVER TEACHING GUIDE: Self-Monitoring of Blood Glucose (SMBG)
Bariatric Surgery
Pancreas Transplantation
Evidence-Based Practice Translating Research Into Practice
Bariatric Surgery for Obese Adults With Type 2 Diabetes
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Culturally Competent Care
Diabetes Mellitus
Cultural & Ethnic Health Disparities
Nursing Management Diabetes Mellitus
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
TABLE 49-12 NURSING ASSESSMENT: Diabetes Mellitus
TABLE 49-13 TESTING FOR DIABETES IN ASYMPTOMATIC, UNDIAGNOSED INDIVIDUALS
Healthy People
Acute Intervention.
Stress of Acute Illness and Surgery.
Ambulatory and Home Care.
Insulin Therapy.
Oral and Noninsulin Injectable Agents.
Personal Hygiene.
Medical Identification and Travel.
FIG. 49-10 Medical alerts. A patient with diabetes should carry a card and wear a bracelet or necklace that indicates diabetes. If the patient with diabetes is unconscious, these measures will ensure prompt and appropriate attention.
Patient and Caregiver Teaching.
Complementary & Alternative Therapies
Scientific Evidence*
Nursing Implications
Informatics in Practice Patient Teaching Using Gaming
Evaluation
TABLE 49-14 PATIENT & CAREGIVER TEACHING GUIDE: Management of Diabetes Mellitus
Acute Complications of Diabetes Mellitus
TABLE 49-15 PATIENT & CAREGIVER TEACHING GUIDE: Instructions for Patients With Diabetes Mellitus
TABLE 49-16 COMPARISON OF HYPERGLYCEMIA AND HYPOGLYCEMIA
Diabetic Ketoacidosis
Etiology and Pathophysiology
Clinical Manifestations
Collaborative Care
TABLE 49-17 COLLABORATIVE CARE: Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic Syndrome (HHS)
FIG. 49-11 Metabolic events leading to diabetic ketoacidosis.
TABLE 49-18 EMERGENCY MANAGEMENT Diabetic Ketoacidosis
Safety Alert
Hyperosmolar Hyperglycemic Syndrome
FIG. 49-12 Pathophysiology of hyperosmolar hyperglycemic syndrome.
Collaborative Care
Nursing Management Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome
Hypoglycemia
Nursing and Collaborative Management Hypoglycemia
TABLE 49-19 COLLABORATIVE CARE: Hypoglycemia
Chronic Complications of Diabetes Mellitus
Angiopathy
FIG. 49-13 Long-term complications of diabetes mellitus.
Macrovascular Complications
TABLE 49-20 MONITORING FOR LONG-TERM COMPLICATIONS OF DIABETES MELLITUS
Microvascular Complications
Diabetic Retinopathy
Etiology and Pathophysiology
Collaborative Care
Nephropathy
Neuropathy
Etiology and Pathophysiology
Classification
Sensory Neuropathy.
FIG. 49-14 Neuropathy: neurotrophic ulceration.
Autonomic Neuropathy.
FIG. 49-15 The necrotic toe developed as a complication of diabetes. A, Before amputation. B, After amputation.
Complications of Feet and Lower Extremities
TABLE 49-21 PATIENT & CAREGIVER TEACHING GUIDE*Foot Care
Integumentary Complications
Infection
FIG. 49-16 Necrobiosis lipoidica diabeticorum.
Psychologic Considerations
Delegation Decisions Caring for the Patient With Diabetes Mellitus
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Ethical/Legal Dilemmas Durable Power of Attorney for Health Care
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Gerontologic Considerations
Diabetes Mellitus
Case Study Diabetic Ketoacidosis
Patient Profile
Subjective Data (Provided by Wife)
Objective Data
Physical Examination
Diagnostic Studies
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 50 Nursing Management: Endocrine Problems
Learning Outcomes
Key Terms
eFigures
Disorders of Anterior Pituitary Gland
Acromegaly
Etiology and Pathophysiology
Clinical Manifestations
FIG. 50-1 Progressive development of facial changes associated with acromegaly.
Gender Differences
Diagnostic Studies
Collaborative Care
Surgical Therapy.
FIG. 50-2 Surgery on the pituitary gland is most commonly performed with the transsphenoidal approach. An incision is made in the inner aspect of the upper lip and gingiva. The sella turcica is entered through the floor of the nose and sphenoid sinuses.
Radiation Therapy.
Drug Therapy.
Nursing Management Acromegaly
Nursing Assessment
Nursing Implementation
Excesses of Other Tropic Hormones
Hypofunction of Pituitary Gland
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
TABLE 50-1 CLINICAL MANIFESTATIONS OF HYPOPITUITARISM
Nursing and Collaborative Management Hypopituitarism
FIG. 50-3 Pathophysiology of syndrome of inappropriate antidiuretic hormone (SIADH).
Disorders of Posterior Pituitary Gland
Syndrome of Inappropriate Antidiuretic Hormone
Etiology and Pathophysiology
Clinical Manifestations and Diagnostic Studies
TABLE 50-2 CAUSES OF SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE
Malignant Tumors
Central Nervous System Disorders
Drug Therapy
Miscellaneous Conditions
Nursing and Collaborative Management Syndrome of Inappropriate Antidiuretic Hormone
Diabetes Insipidus
Etiology and Pathophysiology
FIG. 50-4 Pathophysiology of diabetes insipidus (DI).
TABLE 50-3 TYPES OF DIABETES INSIPIDUS
Clinical Manifestations
Diagnostic Studies
Nursing and Collaborative Management Diabetes Insipidus
FIG. 50-5 Continuum of thyroid dysfunction.
Disorders of Thyroid Gland
Goiter
TABLE 50-4 GOITROGENS
Thyroid Inhibitors
Other Drugs
Foods*
FIG. 50-6 Exophthalmos and goiter of Graves’ disease.
Thyroiditis
Hyperthyroidism
Etiology and Pathophysiology
Graves’ Disease.
TABLE 50-5 CLINICAL MANIFESTATIONS OF THYROID DYSFUNCTION
Clinical Manifestations
Complications
TABLE 50-6 LABORATORY RESULTS FOR HYPERTHYROID AND HYPOTHYROID PATIENTS
Diagnostic Studies
TABLE 50-7 COMPARISON OF HYPERTHYROIDISM IN YOUNGER AND OLDER ADULTS
FIG. 50-7 Thyroid acropachy. Digital clubbing and swelling of fingers.
Collaborative Care
Drug Therapy.
Antithyroid Drugs.
TABLE 50-8 COLLABORATIVE CARE: Hyperthyroidism
Diagnostic
Collaborative Therapy
Iodine.
β-Adrenergic Blockers.
Radioactive Iodine Therapy.
FIG. 50-8 Subtotal thyroidectomy. Part of the thyroid gland is removed.
Surgical Therapy.
Nutritional Therapy.
Nursing Management Hyperthyroidism
Nursing Assessment
TABLE 50-9 NURSING ASSESSMENT: Hyperthyroidism
Nursing Diagnoses
Planning
Nursing Implementation
Acute Intervention.
Acute Thyrotoxicosis.
Thyroid Surgery.
Postoperative Care.
Safety Alert
Ambulatory and Home Care.
Evaluation
Hypothyroidism
Etiology and Pathophysiology
Clinical Manifestations
FIG. 50-9 Common features of myxedema. Dull, puffy skin; coarse, sparse hair; periorbital edema; and prominent tongue.
TABLE 50-10 COLLABORATIVE CARE: Hypothyroidism
Diagnostic
Collaborative Therapy
Complications
Diagnostic Studies
Collaborative Care
Drug Alert
Nursing Management Hypothyroidism
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute intervention.
Ambulatory and Home Care.
TABLE 50-11 PATIENT & CAREGIVER TEACHING GUIDE: Hypothyroidism
Evaluation
Thyroid Nodules and Cancer
Types of Thyroid Cancer
Clinical Manifestations and Diagnostic Studies
Nursing and Collaborative Management Thyroid Cancer
Multiple Endocrine Neoplasia
Disorders of Parathyroid Glands
Hyperparathyroidism
Etiology and Pathophysiology
TABLE 50-12 CLINICAL MANIFESTATIONS OF PARATHYROID DYSFUNCTION
Clinical Manifestations and Complications
Diagnostic Studies
Collaborative Care
Surgical Therapy.
Nonsurgical Therapy.
Nursing Management Hyperparathyroidism
Hypoparathyroidism
Nursing and Collaborative Management Hypoparathyroidism
Disorders of Adrenal Cortex
Cushing Syndrome
Etiology and Pathophysiology
Clinical Manifestations
TABLE 50-13 CLINICAL MANIFESTATIONS OF ADRENOCORTICAL DYSFUNCTION
FIG. 50-10 Cushing syndrome. Facies include a rounded face (“moon face”) with thin, reddened skin. Hirsutism may also be present.
FIG. 50-11 Common characteristics of Cushing syndrome.
FIG. 50-12 Cushing syndrome. Truncal obesity; broad, purple striae; and easy bruising (left antecubital fossa).
Diagnostic Studies
Collaborative Care
TABLE 50-14 COLLABORATIVE CARE: Cushing Syndrome
Diagnostic
Collaborative Therapy*
Nursing Management Cushing Syndrome
Nursing Assessment
Nursing Diagnoses
TABLE 50-15 NURSING ASSESSMENT: Cushing Syndrome
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Preoperative Care.
Postoperative Care.
Ambulatory and Home Care.
Evaluation
Adrenocortical Insufficiency
Etiology and Pathophysiology
Clinical Manifestations
Complications
FIG. 50-13 Hyperpigmentation typically seen in Addison’s disease.
Diagnostic Studies
Collaborative Care
Nursing Management Addison’s Disease
Nursing Implementation
Acute intervention.
TABLE 50-16 COLLABORATIVE CARE: Addison’s Disease
Diagnostic
Collaborative Therapy
Ambulatory and Home Care.
TABLE 50-17 PATIENT & CAREGIVER TEACHING GUIDE: Addison’s Disease
Corticosteroid Therapy
TABLE 50-18 DRUG THERAPY: Diseases and Disorders Treated With Corticosteroids
Drug Alert
TABLE 50-19 DRUG THERAPY: Effects and Side Effects of Corticosteroids
Hyperaldosteronism
TABLE 50-20 PATIENT & CAREGIVER TEACHING GUIDE: Corticosteroid Therapy
Nursing and Collaborative Management Primary Hyperaldosteronism
Disorders of Adrenal Medulla
Pheochromocytoma
Nursing and Collaborative Management Pheochromocytoma
Case Study Graves’ Disease
Patient Profile
Subjective Data
Objective Data
Physical Examination
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Chapter 51 Nursing Assessment: Reproductive System
Learning Outcomes
Key Terms
Structures and Functions of Male and Female Reproductive Systems
Male Reproductive System
FIG. 51-1 Male reproductive tract.
Testes.
Ducts.
FIG. 51-2 Seminiferous tubules, testis, epididymis, and ductus (vas) deferens in the male.
Glands.
External Genitalia.
Female Reproductive System
Pelvic Organs
Ovaries.
Fallopian Tubes.
Uterus.
FIG. 51-3 Female reproductive tract.
Vagina.
Pelvis.
External Genitalia.
Breasts.
FIG. 51-4 External female genitalia.
FIG. 51-5 The lactating female breast. A, Glandular structures are anchored to the overlying skin and the pectoralis muscle by suspensory ligaments of Cooper. Each lobule of glandular tissue is drained by a lactiferous duct that eventually opens through the nipple. B, Anterior view of a lactating breast. In nonlactating breasts, glandular tissue is less evident with adipose tissue comprising most of the breast.
Neuroendocrine Regulation of Reproductive System
FIG. 51-6 Hypothalamic-pituitary-gonadal axis. Only the major pituitary hormone actions are depicted. FSH, Follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; ICSH, interstitial cell–stimulating hormone; LH, luteinizing hormone.
TABLE 51-1 GONADAL FEEDBACK MECHANISMS
Menarche
FIG. 51-7 Events of the menstrual cycle. The lines depict the changes in blood hormone levels, the development of the follicles, and the changes in the endometrium during the cycle. FSH, Follicle-stimulating hormone; LH, luteinizing hormone.
Menstrual Cycle
TABLE 51-2 PATIENT TEACHING GUIDE: Characteristics of Menstruation
Menopause
Phases of Sexual Response
Male Sexual Response.
Female Sexual Response.
Gerontologic Considerations
Effects of Aging on Reproductive Systems
TABLE 51-3 GERONTOLOGIC ASSESSMENT DIFFERENCES: Reproductive Systems
Assessment of Male and Female Reproductive Systems
Subjective Data
Important Health Information.
Past Health History.
Gender Differences
Medications.
Case Study Patient Introduction
Critical Thinking
Surgery or Other Treatments.
TABLE 51-4 SURGERIES OF THE REPRODUCTIVE SYSTEMS
Functional Health Patterns.
Health Perception–Health Management Pattern.
Genetic Risk Alert
TABLE 51-5 HEALTH HISTORY: Reproductive System
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
TABLE 51-6 SEXUAL HISTORY FORMAT
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Objective Data
Physical Examination: Male.
Pubis.
Case Study—cont’d
Penis.
Scrotum and Testes.
Inguinal Region and Spermatic Cord.
Anus and Prostate.
Physical Examination: Female.
Breasts.
External Genitalia.
Internal Pelvic Examination.
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Inspect
Palpate
Case Study—cont’d
Diagnostic Studies of Reproductive Systems
Urine Studies
Pregnancy Testing.
TABLE 51-7 NORMAL PHYSICAL ASSESSMENT OF REPRODUCTIVE SYSTEM
Hormone Studies.
Blood Studies
Hormone Studies.
Tumor Markers.
TABLE 51-8 ASSESSMENT ABNORMALITIES: Breast
TABLE 51-9 ASSESSMENT ABNORMALITIES: Female Reproductive System
Serology Tests for Syphilis.
TABLE 51-10 ASSESSMENT ABNORMALITIES: Male Reproductive System
Cultures and Smears
TABLE 51-11 DIAGNOSTIC STUDIES: Male and Female Reproductive Systems
FIG. 51-8 Laparoscopic views of the female pelvis. A, Normal image. B, Pelvic inflammatory disease. Note reddish inflammatory membrane covering and fixing the ovary and uterus to the surrounding structures.
Case Study—cont’d
Radiologic Studies
Mammography.
Ultrasound.
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Animations
Answer Keys
Concept Map Creator
Content Updates
Glossary
Key Points
Videos
Chapter 52 Nursing Management: Breast Disorders
Learning Outcomes
Key Terms
Assessment of Breast Disorders
Breast Cancer Screening Guidelines
FIG. 52-1 Breast self-examination and patient instruction. 1, Lie down and place your left arm behind your head. Lying down spreads breast tissue evenly and thinly over the chest wall, making it easier to feel the tissue. 2, Use finger pads of three middle fingers on your right hand to feel for lumps in left breast. Use overlapping dime-sized circular motions to feel the breast tissue. Use three different levels of pressure to feel the breast tissue. Light pressure to feel tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. 3, The up-and-down (vertical) pattern is recommended for examining the entire breast. Move around the breast in an up-and-down pattern starting at an imaginary line straight down your side from the underarm (including the tail of Spence, which is the triangular breast tissue projecting into the axilla), and moving across the breast to the middle of the sternum. Examine the entire breast going down until you feel only ribs and up to the neck or clavicle. Repeat procedure while examining your right breast. 4, Stand in front of a mirror. Place your hands firmly on your hips, which will tighten the pectoralis muscles. Look at your breasts for size, shape, redness, scaliness, or dimpling of the breast skin or nipple. 5, Examine each underarm while standing or sitting with arm slightly raised. Check for any lump, hard knot, or thickening of tissue.
Diagnostic Studies
Radiologic Studies.
FIG. 52-2 Screening mammogram showing dense breast tissue and benign, scattered microcalcifications of a 57-year-old. A, Using conventional x-rays. B, Using digital x-rays.
Biopsies.
Benign Breast Disorders
Mastalgia
Breast Infections
Mastitis
Lactational Breast Abscess
TABLE 52-1 BENIGN BREAST DISORDERS*
FIG. 52-3 A, Normal breast tissue. B, Fibrocystic breast tissue.
Fibrocystic Changes
Nursing and Collaborative Management Fibrocystic Changes
Fibroadenoma
Nipple Discharge
Intraductal Papilloma
Ductal Ectasia
Gynecomastia in Men
Senescent Gynecomastia
Gerontologic Considerations
Age-Related Breast Changes
Breast Cancer
Etiology and Risk Factors
Risk Factors for Women.
TABLE 52-2 RISK FACTORS FOR BREAST CANCER
Genetic Link
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
Risk Factors for Men.
TABLE 52-3 TYPES OF BREAST CANCER
Prophylactic Oophorectomy and Mastectomy.
Pathophysiology
Types of Breast Cancer
Noninvasive Breast Cancer.
Invasive (Infiltrating) Ductal Carcinoma.
Inflammatory Breast Cancer.
Paget’s Disease.
Invasive (Infiltrating) Lobular Carcinoma.
Clinical Manifestations
FIG. 52-4 Distribution of where breast cancer occurs.
Complications
Diagnostic Studies
TABLE 52-4 SITES OF BREAST CANCER RECURRENCE AND METASTASIS
FIG. 52-5 Lymph nodes and drainage in the axilla. The sentinel lymph node is usually found in the external mammary nodes. A complete axillary dissection would remove all nodes.
Collaborative Care
TABLE 52-5 COLLABORATIVE CARE: Breast Cancer
Staging of Breast Cancer.
Surgical Therapy.
Breast-Conserving Surgery.
TABLE 52-6 STAGING OF BREAST CANCER
TABLE 52-7 SURGICAL PROCEDURES FOR BREAST CANCER
FIG. 52-6 Breast cancer surgery. A, Preoperative. B, Lumpectomy. C, Modified radical mastectomy.
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Axillary Lymph Node Dissection.
Modified Radical Mastectomy.
FIG. 52-7 Lymphedema. Accumulation of fluid in the tissue after excision of lymph nodes.
Postmastectomy Pain Syndrome.
Radiation Therapy.
Primary Radiation Therapy.
Brachytherapy.
Palliative Radiation Therapy.
Drug Therapy.
FIG. 52-8 High-dose brachytherapy for breast cancer. The MammoSite system involves the insertion of a single small balloon catheter (B) at the time of the lumpectomy or shortly thereafter into the tumor resection cavity (the space that is left after the surgeon removes the tumor). A tiny radioactive seed (A) is inserted into the balloon, connected to a machine called an afterloader (C), and delivers the radiation therapy.
Chemotherapy.
Drug Alert
Hormone Therapy.
Estrogen Receptor Blockers.
Drug Alert
TABLE 52-8 DRUG THERAPY: Breast Cancer
Aromatase Inhibitors.
Estrogen Receptor Modulator and Others.
Biologic and Targeted Therapy.
Drug Alert
Follow-up and Survivorship Care.
Evidence-Based Practice Translating Research Into Practice
What Is the Effect of Physical Activity in Cancer Survivors?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Culturally Competent Care
Breast Cancer
Cultural & Ethnic Health Disparities
Nursing Management Breast Cancer
Nursing Assessment
Nursing Diagnoses
Planning
TABLE 52-9 NURSING ASSESSMENT: Breast Cancer
Nursing Implementation
Health Promotion.
Acute Intervention.
FIG. 52-9 Postoperative exercises for the patient with a mastectomy or lumpectomy with axillary lymph node dissection.
Emotional and Psychologic Care.
Ambulatory and Home Care.
Complementary & Alternative Therapies
Scientific Evidence*
Nursing Implications
Evaluation
Gerontologic Considerations
Breast Cancer
Mammoplasty
Breast Reconstruction
Indications.
Types of Reconstruction
Breast Implants and Tissue Expansion.
FIG. 52-10 A, Appearance of chest after bilateral mastectomy. B, Postoperative breast reconstruction before nipple-areolar reconstruction. C, Postoperative breast reconstruction after nipple-areolar reconstruction.
FIG. 52-11 A, Tissue expander with gradual expansion. B, Tissue expander in place after mastectomy.
Tissue Flap Procedures.
Nipple-Areolar Reconstruction.
Breast Augmentation
Breast Reduction
FIG. 52-12 Transverse rectus abdominis musculocutaneous (TRAM) flap. A, TRAM flap is planned. B, The abdominal tissue, while attached to the rectus muscle, nerve, and blood supply, is tunneled through the abdomen to the chest. C, The flap is trimmed to shape the breast. The lower abdominal incision is closed. D, Nipple and areola are reconstructed after the breast is healed.
Case Study Breast Cancer
Patient Profile
Collaborative Care
Preoperative
Operative Procedure
Postoperative
Follow-up Findings and Treatment
Discussion Questions
Nursing Management Breast Augmentation and Reduction
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
Glossary
Key Points
Chapter 53 Nursing Management: Sexually Transmitted Infections
Learning Outcomes
Key Terms
Factors Affecting Incidence of Sexually Transmitted Infections
TABLE 53-1 CAUSES OF SEXUALLY TRANSMITTED INFECTIONS
Bacterial Infections
Gonorrhea
Cultural & Ethnic Health Disparities
Etiology and Pathophysiology
Clinical Manifestations
Men.
Women.
FIG. 53-1 Profuse, purulent drainage in a patient with gonorrhea.
FIG. 53-2 Endocervical gonorrhea. Cervical redness and edema with discharge.
General.
Complications
Diagnostic Studies
FIG. 53-3 Skin lesions with disseminated gonococcal infection. A, On the hand. B, On the fifth toe.
Gender Differences
Collaborative Care
Drug Therapy.
TABLE 53-2 COLLABORATIVE CARE: Gonorrhea
Drug Alert
Syphilis
Etiology and Pathophysiology
Clinical Manifestations
Complications
Diagnostic Studies
TABLE 53-3 STAGES OF SYPHILIS
FIG. 53-4 Primary syphilis chancre.
FIG. 53-5 Secondary syphilis. Mucous patch in the mouth.
FIG. 53-6 Destructive skin gummas associated with tertiary syphilis.
TABLE 53-4 COLLABORATIVE CARE: Syphilis
Collaborative Care
Drug Therapy.
Chlamydial Infections
Etiology and Pathophysiology
TABLE 53-5 RISK FACTORS FOR CHLAMYDIAL INFECTION
Evidence-Based Practice Translating Research Into Practice
What Strategies Improve Screening Rates for Repeat Chlamydial Infections?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Clinical Manifestations
FIG. 53-7 Chlamydial epididymitis. Red, swollen scrotum.
Complications
Diagnostic Studies
TABLE 53-6 COLLABORATIVE CARE: Chlamydial Infection
Collaborative Care
Drug Therapy.
Viral Infections
Genital Herpes
Etiology and Pathophysiology
Clinical Manifestations
Primary Episode.
FIG. 53-8 Unruptured vesicles of herpes simplex virus type 2 (HSV-2). A, Vulvar area. B, Perianal area. C, Penile herpes simplex, ulcerative stage.
Recurrent Episodes.
Complications
Diagnostic Studies and Collaborative Care
FIG. 53-9 Autoinoculation of herpes simplex virus (HSV) to the lips.
Drug Therapy.
TABLE 53-7 COLLABORATIVE CARE: Genital Herpes
Genital Warts
Clinical Manifestations and Complications
Diagnostic Studies and Collaborative Care
FIG. 53-10 Genital warts. A, Severe vulvar warts. B, Perineal wart. C, Multiple genital warts of the glans penis.
HPV Vaccines.
Nursing Management Sexually Transmitted Infections
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Healthy People
Measures to Prevent Infection.
TABLE 53-8 NURSING ASSESSMENT: Sexually Transmitted Infections
TABLE 53-9 PATIENT TEACHING GUIDE: Sexually Transmitted Infections
Screening Programs.
Case Finding.
Educational and Research Programs.
Acute Intervention
Psychologic Support.
Follow-up.
Hygiene Measures.
Sexual Activity.
Ethical/Legal Dilemmas Confidentiality and HIPAA
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Ambulatory and Home Care.
Evaluation
Case Study Gonorrhea and Chlamydial Infection
Patient Profile
Subjective Data
Objective Data
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Concept Map Creator
Content Updates
Glossary
Key Points
Chapter 54 Nursing Management: Female Reproductive Problems
Learning Outcomes
Key Terms
Infertility
Etiology and Pathophysiology
TABLE 54-1 COLLABORATIVE CARE: Infertility
Diagnostic Studies
Ovulatory Studies.
Tubal Patency Studies.
Postcoital Studies.
TABLE 54-2 DRUG THERAPY: Infertility
Nursing and Collaborative Management Infertility
Abortion
Spontaneous Abortion
Induced Abortion
TABLE 54-3 METHODS FOR INDUCING ABORTION
Problems Related to Menstruation
Premenstrual Syndrome
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies and Collaborative Care
TABLE 54-4 COLLABORATIVE CARE: Premenstrual Syndrome (PMS)
Drug Therapy.
Drug Alert
Dysmenorrhea
Etiology and Pathophysiology
Clinical Manifestations
Nursing and Collaborative Management Dysmenorrhea
Abnormal Vaginal Bleeding
Types of Irregular Bleeding
Oligomenorrhea and Amenorrhea.
Menorrhagia.
TABLE 54-5 CAUSES OF AMENORRHEA
Metrorrhagia.
Diagnostic Studies and Collaborative Care
Surgical Therapy.
FIG. 54-1 Balloon thermotherapy for treatment of menorrhagia. A, Balloon-tipped catheter is inserted into the uterus through the vagina and the cervix. B, The balloon is inflated with a sterile fluid that expands to fit the size and shape of the uterus. The fluid is heated to 188° F (87° C) and maintained for 8 minutes while the uterine lining is treated. C, Fluid is withdrawn from the balloon and the catheter is removed.
Nursing Management Abnormal Vaginal Bleeding
FIG. 54-2 Ectopic pregnancy occurring in the fallopian tube.
Ectopic Pregnancy
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Nursing and Collaborative Management Ectopic Pregnancy
FIG. 54-3 Laparoscopic treatment of ectopic pregnancy in the right fallopian tube.
Perimenopause and Postmenopause
Clinical Manifestations
TABLE 54-6 MANIFESTATIONS OF PERIMENOPAUSE AND POSTMENOPAUSE
TABLE 54-7 MANIFESTATIONS OF ESTROGEN DEFICIENCY
Collaborative Care
Drug Therapy.
Drug Alert
Nonhormonal Therapy.
Nutritional Therapy.
Complementary & Alternative Therapies
Nursing Management Perimenopause and Postmenopause
Culturally Competent Care
Menopause
Conditions of Vulva, Vagina, and Cervix
Etiology and Pathophysiology
Clinical Manifestations
TABLE 54-8 INFECTIONS OF THE LOWER GENITAL TRACT
Collaborative Care
Nursing Management Conditions of Vulva, Vagina, and Cervix
Pelvic Inflammatory Disease
Etiology and Pathophysiology
Clinical Manifestations
FIG. 54-4 Pelvic inflammatory disease. Acute infection of the fallopian tubes and the ovaries. The tubes and the ovaries have become an inflamed mass attached to the uterus. A tubo-ovarian abscess is also present.
Complications
Collaborative Care
Nursing Management Pelvic Inflammatory Disease
TABLE 54-9 NURSING ASSESSMENT: Pelvic Inflammatory Disease
Chronic Pelvic Pain
Endometriosis
FIG. 54-5 Common sites of endometriosis.
Etiology and Pathophysiology
Clinical Manifestations
Collaborative Care
TABLE 54-10 COLLABORATIVE CARE: Endometriosis
Drug Therapy.
Drug Alert
Surgical Therapy.
Nursing Management Endometriosis
Benign Tumors of the Female Reproductive System
Leiomyomas
Etiology and Pathophysiology
Clinical Manifestations
FIG. 54-6 Leiomyomas. Uterine section showing whorl-like appearance and locations of leiomyomas.
Collaborative Care
Cervical Polyps
FIG. 54-7 Large ovarian cyst.
Benign Ovarian Tumors
Polycystic Ovary Syndrome
FIG. 54-8 Polycystic ovary syndrome. Multiple fluid-filled cysts in the ovary.
Drug Alert
Cancers of the Female Reproductive System
Cervical Cancer
Cultural & Ethnic Health Disparities
Ovarian Cancer
Endometrial Cancer
Cervical Cancer
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
FIG. 54-9 Cervical cancer. View through a speculum inserted into the vagina.
TABLE 54-11 STAGING AND TREATMENT OF CERVICAL CANCER
Collaborative Care
Endometrial Cancer
Evidence-Based Practice Applying the Evidence
Your Action and Decision
Reference for Evidence
Etiology and Pathophysiology
Clinical Manifestations
Collaborative Care
Ovarian Cancer
Etiology and Pathophysiology
Genetic Link
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
TABLE 54-12 COLLABORATIVE CARE: Ovarian Cancer
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Vaginal Cancer
Vulvar Cancer
TABLE 54-13 SURGICAL PROCEDURES INVOLVING THE FEMALE REPRODUCTIVE SYSTEM
Surgical Procedures: Female Reproductive System
FIG. 54-10 A, Cross section of subtotal hysterectomy. Note that cervical stump, fallopian tubes, and ovaries remain. B, Cross section of total hysterectomy. Note that fallopian tubes and ovaries remain. C, Cross section of vaginal hysterectomy. Note that fallopian tubes and ovaries remain. D, Total hysterectomy, salpingectomy, and oophorectomy. Note that uterus, fallopian tubes, and ovaries are completely removed.
Radiation Therapy: Cancers of Female Reproductive System
External Radiation Therapy
Brachytherapy
Nursing Management Cancers of Female Reproductive System
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention Related to Surgery.
Hysterectomy.
Salpingectomy and Oophorectomy.
Vulvectomy.
FIG. 54-11 Total exenteration is removal of all pelvic organs with creation of an ileal conduit and a colostomy.
Pelvic Exenteration.
Acute Intervention with Radiation Therapy.
Evaluation
Problems with Pelvic Support
Uterine Prolapse
FIG. 54-12 Uterine prolapse. A, First-degree prolapse. B, Second-degree prolapse. C, Third-degree prolapse.
FIG. 54-13 A, Cystocele. B, Bladder has prolapsed into the vagina, causing a uterine prolapse.
Cystocele and Rectocele
FIG. 54-14 A, Rectocele. B, Rectum has prolapsed into the vagina.
Nursing Management Problems with Pelvic Support
Fistula
FIG. 54-15 Common fistulas involving the vagina.
Nursing Management Fistulas
Sexual Assault
Clinical Manifestations
Physical.
TABLE 54-14 EMERGENCY MANAGEMENT: Sexual Assault
Initial
Ongoing Monitoring
Psychologic.
Collaborative Care
Nursing Management Sexual Assault
TABLE 54-15 EVALUATION OF ALLEGED SEXUAL ASSAULT
TABLE 54-16 PATIENT TEACHING GUIDE: Sexual Assault Prevention
Case Study Uterine Prolapse and Vaginal Hysterectomy
Jupiterimages/Photos.com/Thinkstock
Patient Profile
Subjective Data
Objective Data
Physical Examination
Laboratory Studies
Postoperative Status
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
Glossary
Key Points
Chapter 55 Nursing Management: Male Reproductive Problems
Learning Outcomes
Key Terms
eFigures
Problems of the Prostate Gland
Benign Prostatic Hyperplasia
Etiology and Pathophysiology
FIG. 55-1 Areas of the male reproductive system in which problems are likely to develop.
FIG. 55-2 Benign prostatic hyperplasia. The enlarged prostate compresses the urethra.
FIG. 55-3 Views of the prostate by cystoscopy. A, Normal appearance. B, Moderate benign prostatic hyperplasia with urethral obstruction.
Clinical Manifestations
TABLE 55-1 AUA SYMPTOM INDEX TO DETERMINE SEVERITY OF PROSTATIC PROBLEMS
Complications
Diagnostic Studies
TABLE 55-2 COLLABORATIVE CARE: Benign Prostatic Hyperplasia
Collaborative Care
Drug Therapy.
5α-Reductase Inhibitors.
Drug Alert
α-Adrenergic Receptor Blockers.
Erectogenic Drugs.
Herbal Therapy.
Minimally Invasive Therapy.
Transurethral Microwave Thermotherapy.
TABLE 55-3 TREATMENT FOR BENIGN PROSTATIC HYPERPLASIA
Transurethral Needle Ablation.
Laser Prostatectomy.
Intraprostatic Urethral Stents.
Invasive Therapy (Surgery).
Transurethral Resection of the Prostate.
FIG. 55-4 Transurethral resection of the prostate.
Transurethral Incision of the Prostate.
Nursing Management Benign Prostatic Hyperplasia
Nursing Assessment
Nursing Diagnoses
TABLE 55-4 NURSING ASSESSMENT: Benign Prostatic Hyperplasia
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Preoperative Care.
Postoperative Care.
Ambulatory and Home Care.
Evaluation
Prostate Cancer
Etiology and Pathophysiology
Cultural & Ethnic Health Disparities
Prostate Cancer
Testicular Cancer
Genetic Link
Clinical Manifestations and Complications
FIG. 55-5 Metastasis of prostate cancer to the pelvis and lumbar spine indicated by arrows.
Diagnostic Studies
Collaborative Care
Active Surveillance.
TABLE 55-5 STAGE GROUPING OF PROSTATE CANCER
TABLE 55-6 COLLABORATIVE CARE: Prostate Cancer
Surgical Therapy
Radical Prostatectomy.
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
FIG. 55-6 Common approaches used to perform a prostatectomy. A, Retropubic approach involves a midline abdominal incision. B, Perineal approach involves an incision between the scrotum and the anus.
Nerve-Sparing Procedure.
Cryotherapy.
Radiation Therapy.
External Beam Radiation.
Brachytherapy.
Drug Therapy.
Androgen Deprivation Therapy.
FIG. 55-7 A, Prostate brachytherapy. Implantation of radioactive seeds with a needle guided by ultrasound and a template grid. B, Radioactive seeds.
Androgen Synthesis Inhibitors.
TABLE 55-7 DRUG THERAPY: Androgen Deprivation Therapy for Prostate Cancer
Androgen Receptor Blockers.
Chemotherapy.
Radiotherapy.
Orchiectomy.
Culturally Competent Care
Prostate Cancer
Delegation Decisions Caring for the Patient Receiving Bladder Irrigation
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Nursing Management Prostate Cancer
Nursing Assessment
Nursing Diagnoses
TABLE 55-8 NURSING ASSESSMENT: Prostate Cancer
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Prostatitis
Etiology and Pathophysiology
Clinical Manifestations and Complications
Diagnostic Studies
Nursing and Collaborative Management Prostatitis
Problems of the Penis
Congenital Problems
Problems of Prepuce
FIG. 55-8 A, Phimosis: inability to retract the foreskin due to secondary lesions on the prepuce. B, Paraphimosis: ulcer with edema from foreskin remaining contracted over the prepuce.
Problems of Erectile Mechanism
Cancer of Penis
Problems of Scrotum and Testes
Inflammatory and Infectious Problems
Skin Problems
Epididymitis
Orchitis
FIG. 55-9 Scrotal masses.
Congenital Problems
Acquired Problems
Hydrocele
Spermatocele
Varicocele
FIG. 55-10 Hydrocele.
Testicular Torsion
Testicular Cancer
Etiology and Pathophysiology
Clinical Manifestations and Complications
Diagnostic Studies
Nursing and Collaborative Management Testicular Cancer
Testicular Self-Examination
Collaborative Care
TABLE 55-9 PATIENT TEACHING GUIDE: Testicular Self-Examination
FIG. 55-11 Testicular self-examination.
FIG. 55-12 Vasectomy procedure. The ductus deferens is ligated or resected for the purpose of sterilization.
Sexual Function
Vasectomy
Erectile Dysfunction
Ethical/Legal Dilemmas Sterilization
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Etiology and Pathophysiology
Evidence-Based Practice Translating Research Into Practice
Do Lifestyle Changes and Cardiovascular Medication Improve Erectile Dysfunction?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Clinical Manifestations and Complications
Diagnostic Studies
TABLE 55-10 RISK FACTORS FOR ERECTILE DYSFUNCTION
Collaborative Care
TABLE 55-11 COLLABORATIVE CARE: Erectile Dysfunction
Erectogenic Drugs.
Drug Alert
Vacuum Constriction Devices.
Intraurethral Devices.
Penile Implants.
Sexual Counseling.
Nursing Management Erectile Dysfunction
Andropause
FIG. 55-13 Changes in testosterone plasma level in men as they age.
Infertility
Case Study Benign Prostatic Hyperplasia With Acute Urinary Retention
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Patient Profile
Subjective Data
Objective Data
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Introduction
Patients
iStockphoto/Thinkstock
iStockphoto/Thinkstock
iStockphoto/Thinkstock
iStockphoto/Thinkstock
Jupiterimages/Photos.com/Thinkstock
Jupiterimages/Photos.com/Thinkstock
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Section 11 Problems Related to Movement and Coordination
Problems Related to Movement and Coordination
Pre-Test – Section 11
Interactive Review – Section 11
Chapter 56 Nursing Assessment: Nervous System
Learning Outcomes
Key Terms
eFigure
eTable
Structures and Functions of Nervous System
Cells of Nervous System
Neurons.
FIG. 56-1 Structural features of neurons: dendrites, cell body, and axons.
Glial Cells.
Nerve Regeneration
Nerve Impulse
Synapse.
Neurotransmitters.
Central Nervous System
Spinal Cord.
TABLE 56-1 NEUROTRANSMITTERS*
Ascending Tracts.
FIG. 56-2 Basic diagram of the patellar “knee jerk” reflex arc, including the (1) sensory stretch receptor, (2) afferent sensory neuron, (3) interneuron, (4) efferent motor neuron, and (5) quadriceps muscle (effector organ).
Descending Tracts.
Lower and Upper Motor Neurons.
FIG. 56-3 Left hemisphere of cerebrum, lateral surface, showing major lobes and areas of the brain.
Reflex Arc.
Brain.
Cerebrum.
TABLE 56-2 FUNCTION OF CEREBRUM
FIG. 56-4 Major divisions of the central nervous system (CNS).
Brainstem.
Cerebellum.
Ventricles and Cerebrospinal Fluid.
Peripheral Nervous System
Spinal Nerves.
FIG. 56-5 Cross section of spinal cord showing attachments of spinal nerves and coverings of the spinal cord.
Cranial Nerves.
Autonomic Nervous System.
TABLE 56-3 CRANIAL NERVES
FIG. 56-6 Dermatomes of the body.
FIG. 56-7 The cranial nerves are numbered according to the order in which they leave the brain.
FIG. 56-8 Arteries of the head and neck. Brachiocephalic artery, right common carotid artery, right subclavian artery, and their branches. The major arteries to the head are the common carotid and vertebral arteries.
Cerebral Circulation
Blood-Brain Barrier.
FIG. 56-9 Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior cerebral arteries joined to each other by the anterior communicating cerebral artery and to the posterior cerebral arteries by the posterior communicating arteries.
Protective Structures
Meninges.
Skull.
Vertebral Column.
FIG. 56-10 The vertebral column (three views).
Gerontologic Considerations
Effects of Aging on Nervous System
Assessment of Nervous System
Subjective Data
Important Health Information
Past Health History.
Medications.
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
TABLE 56-4 GERONTOLOGIC ASSESSMENT DIFFERENCES: Nervous System
Case Study Patient Introduction
Critical Thinking
Genetic Risk Alert
Nutritional-Metabolic Pattern.
Elimination Pattern.
TABLE 56-5 HEALTH HISTORY: Nervous System
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Value-Belief Pattern.
Objective Data
Physical Examination.
Case Study—cont’d
Mental Status.
Cranial Nerves.
Olfactory Nerve.
Optic Nerve.
FIG. 56-11 A, Nurse checking visual fields. B, Nurse checking extraocular movement (EOM).
Oculomotor, Trochlear, and Abducens Nerves.
Trigeminal Nerve.
FIG. 56-12 A pupilometer can be used to measure the pupillary response using a light stimulus.
Facial Nerve.
Vestibulocochlear (Acoustic) Nerve.
Glossopharyngeal and Vagus Nerves.
Accessory Nerve.
Hypoglossal Nerve.
Motor System.
Sensory System.
Touch, Pain, and Temperature.
Vibration Sense.
Position Sense.
Cortical Sensory Functions.
Reflexes.
FIG. 56-13 The examiner strikes a swift blow over a stretched tendon to elicit a stretch reflex. A, Biceps reflex. B, Patellar reflex.
Diagnostic Studies of Nervous System
TABLE 56-6 NORMAL PHYSICAL ASSESSMENT OF NERVOUS SYSTEM*
Case Study—cont’d
Cerebrospinal Fluid Analysis
Lumbar Puncture.
TABLE 56-7 ASSESSMENT ABNORMALITIES: Nervous System
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Inspect/Observe
Palpate
Percuss
Radiologic Studies
Computed Tomography.
Magnetic Resonance Imaging.
Cerebral Angiography.
Case Study—cont’d
Electrographic Studies
Electroencephalography.
Electromyography and Nerve Conduction Studies.
TABLE 56-8 DIAGNOSTIC STUDIES: Nervous System
TABLE 56-9 NORMAL CEREBROSPINAL FLUID VALUES
FIG. 56-14 Cerebral angiogram illustrating an arteriovenous malformation (arrow).
FIG. 56-15 Normal images of the brain. A, Computed tomography scan. B, Magnetic resonance imaging.
Evoked Potentials.
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Animations
Answer Keys
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Videos
Chapter 57 Nursing Management: Acute Intracranial Problems
Learning Outcomes
Key Terms
eFigure
Intracranial Pressure
FIG. 57-1 Components of the brain.
Regulation and Maintenance of Intracranial Pressure
Normal Intracranial Pressure.
Normal Compensatory Adaptations.
TABLE 57-1 CALCULATION OF CEREBRAL PERFUSION PRESSURE
Cerebral Blood Flow
Autoregulation of Cerebral Blood Flow.
FIG. 57-2 Intracranial pressure-volume curve. (See text for descriptions of 1, 2, 3, and 4.)
Pressure Changes.
Factors Affecting Cerebral Blood Flow.
Increased Intracranial Pressure
Mechanisms of Increased Intracranial Pressure
FIG. 57-3 Progression of increased intracranial pressure (ICP).
Cerebral Edema
FIG. 57-4 Herniation. A, Normal relationship of intracranial structures. B, Shift of intracranial structures.
TABLE 57-2 CAUSES OF CEREBRAL EDEMA
Vasogenic Cerebral Edema.
Cytotoxic Cerebral Edema.
Interstitial Cerebral Edema.
Clinical Manifestations
Change in Level of Consciousness.
Changes in Vital Signs.
Ocular Signs.
Decrease in Motor Function.
Headache.
Vomiting.
FIG. 57-5 Decorticate and decerebrate posturing. A, Decorticate response. Flexion of arms, wrists, and fingers with adduction in upper extremities. Extension, internal rotation, and plantar flexion in lower extremities. B, Decerebrate response. All four extremities in rigid extension, with hyperpronation of forearms and plantar flexion of feet. C, Decorticate response on right side of body and decerebrate response on left side of body. D, Opisthotonic posturing.
Complications
Diagnostic Studies
TABLE 57-3 COLLABORATIVE CARE: Increased Intracranial Pressure
Monitoring Intracranial Pressure and Cerebral Oxygenation
Indications for Intracranial Pressure Monitoring.
Methods of Measuring Intracranial Pressure.
FIG. 57-6 Coronal section of brain showing potential sites for placement of intracranial pressure monitoring devices.
FIG. 57-7 Intracranial pressure (ICP) monitoring can be used to continuously measure ICP. The ICP tracing shows normal, elevated, and plateau waves. At high ICP the P2 peak is higher than the P1 peak, and the peaks become less distinct and plateau.
FIG. 57-8 Ventriculostomy in place. Cerebrospinal fluid (CSF) can be drained via a ventriculostomy when intracranial pressure (ICP) exceeds the upper pressure parameter set by the physician. Intermittent drainage involves opening the three-way stopcock to allow CSF to flow into the drainage bag for brief periods (30 to 120 seconds) until the pressure is below the upper pressure parameters.
TABLE 57-4 NORMAL INTRACRANIAL PRESSURE WAVEFORMS*
FIG. 57-9 A, Leveling a ventriculostomy. B, Cerebrospinal fluid is drained into a drainage system.
Cerebrospinal Fluid Drainage.
Cerebral Oxygenation Monitoring.
Collaborative Care
FIG. 57-10 A, The LICOX brain tissue oxygen system involves a catheter inserted through an intracranial bolt. B, The system measures oxygen in the brain (PbtO2), brain tissue temperature, and intracranial pressure.
Drug Therapy.
Nutritional Therapy.
Nursing Management Increased Intracranial Pressure
Nursing Assessment
Glasgow Coma Scale.
TABLE 57-5 GLASGOW COMA SCALE
Neurologic Assessment.
FIG. 57-11 Pupillary check for size and response.
FIG. 57-12 Common abnormal respiratory patterns associated with coma.
Nursing Diagnoses
Planning
Nursing Implementation
Acute Intervention
Respiratory Function.
Safety Alert
Fluid and Electrolyte Balance.
Monitoring Intracranial Pressure.
Body Position.
Protection From Injury.
Psychologic Considerations.
Evaluation
Head Injury
Types of Head Injuries
Scalp Lacerations.
Skull Fractures.
TABLE 57-6 TYPES OF SKULL FRACTURES
TABLE 57-7 MANIFESTATIONS OF SKULL FRACTURES
FIG. 57-13 A, Raccoon eyes and rhinorrhea. B, Battle’s sign (postauricular ecchymosis) with otorrhea. C, Battle’s sign. D, Halo or ring sign (see text).
Head Trauma.
Diffuse Injury.
Diffuse Axonal Injury.
Focal Injury.
FIG. 57-14 Coup-contrecoup injury. After the head strikes the wall, a coup injury occurs as the brain strikes the skull (primary impact). The contrecoup injury (the secondary impact) occurs when the brain strikes the skull surface opposite the site of the original impact.
Complications
Epidural Hematoma.
FIG. 57-15 Locations of epidural, subdural, and subarachnoid hematomas.
FIG. 57-16 Epidural hematoma covering a portion of the dura. Multiple small contusions are seen in the temporal lobe.
Subdural Hematoma.
TABLE 57-8 TYPES OF SUBDURAL HEMATOMAS
Intracerebral Hematoma.
Diagnostic Studies and Collaborative Care
TABLE 57-9 EMERGENCY MANAGEMENT: Head Injury
Blunt
Penetrating
Surface Findings
Respiratory
Central Nervous System
Initial
Ongoing Monitoring
Nursing Management Head Injury
Nursing Assessment
Nursing Diagnoses
TABLE 57-10 NURSING ASSESSMENT: Head Injury
Planning
Ethical/Legal Dilemmas Brain Death
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 57-11 PATIENT & CAREGIVER TEACHING GUIDE: Head Injury
Ambulatory and Home Care.
Evaluation
Brain Tumors
Types
Cultural & Ethnic Health Disparities
TABLE 57-12 TYPES OF BRAIN TUMORS
FIG. 57-17 A, A large glioblastoma (G) arises from one cerebral hemisphere and has grown to fill the ventricular system. B, Meningioma. These two different sections from different levels in the same brain show a meningioma (M) compressing the frontal lobe and distorting underlying brain.
FIG. 57-18 Each area of the brain controls a particular activity.
Clinical Manifestations and Complications
TABLE 57-13 MANIFESTATIONS OF BRAIN TUMORS
Diagnostic Studies
Collaborative Care
Surgical Therapy.
Ventricular Shunts.
Radiation Therapy and Stereotactic Radiosurgery.
Chemotherapy and Targeted Therapy.
Drug Alert
Other Therapies.
Nursing Management Brain Tumors
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Evaluation
TABLE 57-14 INDICATIONS FOR CRANIAL SURGERY
TABLE 57-15 TYPES OF CRANIAL SURGERY
Cranial Surgery
Types
Craniotomy.
Stereotactic Radiosurgery.
Nursing Management Cranial Surgery
Nursing Implementation
Acute Intervention.
FIG. 57-19 A, Patient in a stereotactic frame. B, Elekta’s Fraxion head frame helps ensure accuracy and precision in stereotactic radiation therapy (SRT) of cancer targets in the brain and cranium.
Ethical/Legal Dilemmas Withholding Treatment
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Ambulatory and Home Care.
TABLE 57-16 COMPARISON OF CEREBRAL INFLAMMATORY CONDITIONS
Inflammatory Conditions of the Brain
Brain Abscess
Bacterial Meningitis
Etiology and Pathophysiology
Clinical Manifestations
Complications
Diagnostic Studies
Collaborative Care
TABLE 57-17 COLLABORATIVE CARE: Bacterial Meningitis
Nursing Management Bacterial Meningitis
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Viral Meningitis
Encephalitis
Clinical Manifestations and Diagnostic Studies
Nursing and Collaborative Management Encephalitis
Rabies
Case Study Traumatic Brain Injury
Patient Profile
Subjective Data
Objective Data
Diagnostic Studies
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Animations
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Chapter 58 Nursing Management: Stroke
Learning Outcomes
Key Terms
TABLE 58-1 PATIENT & CAREGIVER TEACHING GUIDE: Warning Signs of Stroke
Pathophysiology of Stroke
Anatomy of Cerebral Circulation
Regulation of Cerebral Blood Flow
FIG. 58-1 Cerebral arteries and the circle of Willis. The top of the temporal lobe has been removed to show the course of the middle cerebral artery.
Risk Factors for Stroke
Nonmodifiable Risk Factors
Gender Differences
Cultural & Ethnic Health Disparities
African Americans
Other Ethnicities
Modifiable Risk Factors
Transient Ischemic Attack
Types of Stroke
Ischemic Stroke
Thrombotic Stroke.
TABLE 58-2 TYPES OF STROKE
FIG. 58-2 Major types of stroke.
Embolic Stroke.
Hemorrhagic Stroke
Intracerebral Hemorrhage.
FIG. 58-3 Massive hypertensive hemorrhage rupturing into a lateral ventricle of the brain.
Subarachnoid Hemorrhage.
Safety Alert
Clinical Manifestations of Stroke
Motor Function
TABLE 58-3 STROKE MANIFESTATIONS RELATED TO ARTERY INVOLVEMENT
FIG. 58-4 Manifestations of right-brain and left-brain stroke.
Communication
Affect
Intellectual Function
TABLE 58-4 TYPES OF APHASIA
Spatial-Perceptual Alterations
Elimination
Diagnostic Studies for Stroke
TABLE 58-5 DIAGNOSTIC STUDIES: Stroke
Collaborative Care for Stroke
Preventive Therapy
TABLE 58-6 COLLABORATIVE CARE: Stroke
Healthy People
Preventive Drug Therapy.
Evidence-Based Practice Translating Research Into Practice
Can Mirror Therapy Improve Functioning After Stroke?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Drug Alert
Surgical Therapy for TIA and Stroke Prevention.
FIG. 58-5 Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow.
FIG. 58-6 Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then inflated. The stent expands due to inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood.
Acute Care for Ischemic Stroke
TABLE 58-7 EMERGENCY MANAGEMENT: Stroke
Initial
Ongoing Monitoring
Drug Therapy for Ischemic Stroke.
Surgical Therapy for Ischemic Stroke.
FIG. 58-7 The MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. The retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny loops that latch onto the clot, and the clot can then be pulled out. To prevent the clot from breaking off, a balloon at the end of the catheter inflates to stop blood flow through the artery. MERCI, Mechanical embolus removal in cerebral ischemia.
Acute Care for Hemorrhagic Stroke
Drug Therapy for Hemorrhagic Stroke.
Surgical Therapy for Hemorrhagic Stroke.
FIG. 58-8 Clipping of aneurysms.
FIG. 58-9 Guglielmi detachable coil (GDC). A, A coil is used to occlude an aneurysm. Coils are made of soft, springlike platinum. The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of rupture of the aneurysm. B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is threaded up to the cerebral blood vessels. C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood from circulating through the aneurysm, reducing the risk of rupture.
Drug Alert
Rehabilitation Care
Nursing Management Stroke
Nursing Assessment
TABLE 58-8 NURSING ASSESSMENT: Stroke
Nursing Diagnoses
TABLE 58-9 NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS)
Planning
Nursing Implementation
Health Promotion.
Acute Intervention
Respiratory System.
Nursing Care Plan 58-1
Patient With Stroke
Nursing Diagnosis*
Patient Goal
Tissue Perfusion: Cerebral
Measurement Scale
Cerebral Perfusion Promotion
Nursing Diagnosis
Patient Goals
Respiratory Status: Airway Patency
Measurement Scale
Aspiration Precautions
Airway Management
Nursing Diagnosis
Patient Goals
Mobility
Exercise Therapy: Muscle Control
Nursing Diagnosis
Patient Goals
Communication
Communication Enhancement: Speech Deficit
Nursing Diagnosis
Patient Goals
Heedfulness of Affected Side
Unilateral Neglect Management
Nursing Diagnosis
Patient Goals
Urinary Continence
Measurement Scale
Urinary Habit Training
Nursing Diagnosis
Patient Goal
Swallowing Status
Measurement Scale
Swallowing Therapy
Nursing Diagnosis
Patient Goals
Self-Esteem
Self-Esteem Enhancement
Neurologic System.
Cardiovascular System.
Musculoskeletal System.
Integumentary System.
Delegation Decisions Caring for the Patient With an Acute Stroke
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Gastrointestinal System.
Urinary System.
Nutrition.
Safety Alert
Communication.
FIG. 58-10 Assistive devices for eating. A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips and swivel handles are helpful for some persons. B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C, Plate guards help keep food on the plate. D, Cup with special handle.
Sensory-Perceptual Alterations.
FIG. 58-11 Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemianopsia shows that food on the left side is not seen and thus is ignored.
TABLE 58-10 COMMUNICATION WITH A PATIENT WITH APHASIA
Coping.
Ambulatory and Home Care.
Rehabilitation.
Musculoskeletal Function.
Informatics in Practice Video Games for Stroke Recovery
FIG. 58-12 Loss of postural stability is common after stroke. When the nondominant hemisphere is involved, walking apraxia and loss of postural control are usually apparent. The patient is unable to sit upright and tends to fall sideways. Provide appropriate support with pillows or cushions.
Stroke Survivorship and Coping.
Sexual Function.
Community Integration.
Gerontologic Considerations
Stroke
Case Study Stroke
Patient Profile
Subjective Data
Objective Data
Past Medical History
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
Glossary
Key Points
Chapter 59 Nursing Management: Chronic Neurologic Problems
Learning Outcomes
Key Terms
eFigure
Headaches
TABLE 59-1 COMPARISON OF TYPES OF HEADACHES
Tension-Type Headache
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
FIG. 59-1 Location of pain for common headache syndromes. A, Tension headache is often described as feeling of a weight in or on the head or a band squeezing the head. B, Migraine headache is described as an intense throbbing or pounding pain that involves one temple. The pain usually is unilateral (on one side of the head), although it can be bilateral. C, Cluster headache pain is focused in and around one eye and is often described as sharp, penetrating, or burning.
TABLE 59-2 DIAGNOSTIC STUDIES: Headaches
Gender Differences
Migraine Headache
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Cluster Headache
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Other Types of Headaches
Collaborative Care for Headaches
Drug Therapy
Tension-Type Headache.
Migraine Headache.
Drug Alert
TABLE 59-3 COLLABORATIVE CARE: Headaches
Drug Alert
Cluster Headache.
Evidence-Based Practice Translating Research Into Practice
Can Botulinum Toxin A Prevent Headaches?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Other Headaches.
TABLE 59-4 NURSING ASSESSMENT: Headaches
Nursing Management Headaches
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
TABLE 59-5 PATIENT & CAREGIVER TEACHING GUIDE: Headaches
Evaluation
Chronic Neurologic Disorders
Seizure Disorders and Epilepsy
Etiology and Pathophysiology
Genetic Link
TABLE 59-6 CLASSIFICATION OF SEIZURE DISORDERS
Clinical Manifestations
Generalized Seizures.
Tonic-Clonic Seizures.
Typical Absence Seizures.
Atypical Absence Seizures.
FIG. 59-2 Algorithm for classification of seizures.
Other Types of Generalized Seizures.
Focal Seizures.
Psychogenic Seizures.
Complications
Physical.
Psychosocial.
Diagnostic Studies
TABLE 59-7 COLLABORATIVE CARE: Seizure Disorders and Epilepsy
Collaborative Care
Drug Therapy.
TABLE 59-8 EMERGENCY MANAGEMENT: Tonic-Clonic Seizures
Head Trauma
Drug-Related Processes
Infectious Processes
Intracranial Events
Metabolic Imbalances
Medical Disorders
Other
Initial
Ongoing Monitoring
TABLE 59-9 DRUG THERAPY: Seizure Disorders and Epilepsy
Drug Alert
Drug Alert
Gerontologic Considerations
Drug Therapy for Seizure Disorders
TABLE 59-10 SURGERY FOR SEIZURE DISORDERS
Surgical Therapy.
Other Therapies.
Nursing Management Seizure Disorders and Epilepsy
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 59-11 NURSING ASSESSMENT: Seizure Disorders and Epilepsy
Delegation Decisions Caring for the Patient With a Seizure Disorder
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Safety Alert
Ambulatory and Home Care.
TABLE 59-12 PATIENT & CAREGIVER TEACHING GUIDE: Seizure Disorders and Epilepsy
Evaluation
Restless Legs Syndrome
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
Nursing and Collaborative Management Restless Legs Syndrome
Degenerative Neurologic Disorders
Multiple Sclerosis
Etiology and Pathophysiology
FIG. 59-3 Pathogenesis of multiple sclerosis. A, Normal nerve cell with myelin sheath. B, Normal axon. C, Myelin breakdown. D, Myelin totally disrupted; axon not functioning.
Clinical Manifestations
FIG. 59-4 Chronic multiple sclerosis. Demyelination plaque (P) at gray-white junction and adjacent partially remyelinated shadow plaque (V).
TABLE 59-13 PATTERNS OF MULTIPLE SCLEROSIS
Diagnostic Studies
TABLE 59-14 COLLABORATIVE CARE: Multiple Sclerosis
Collaborative Care
Drug Therapy.
Drug Alert
TABLE 59-15 DRUG THERAPY: Multiple Sclerosis
FIG. 59-5 Water therapy provides exercise and recreation for the patient with a chronic neurologic disease.
Other Therapies.
Nursing Management Multiple Sclerosis
Nursing Assessment
TABLE 59-16 NURSING ASSESSMENT: Multiple Sclerosis
Nursing Diagnoses
Planning
Informatics in Practice Phone Applications in Multiple Sclerosis
Nursing Implementation
Evaluation
Parkinson’s Disease
Etiology and Pathophysiology
Genetic Link
FIG. 59-6 Nigrostriatal disorders produce parkinsonism. Left-sided view of the human brain showing the substantia nigra and the corpus striatum (shaded area) lying deep within the cerebral hemisphere. Nerve fibers extend upward from the substantia nigra, divide into many branches, and carry dopamine to all regions of the corpus striatum.
FIG. 59-7 In Parkinson’s disease there is a deficit in dopamine. These deficits create an imbalance between dopamine and the excitatory neurotransmitter acetylcholine. A, In a healthy person, dopamine (DA) released from neurons originating in the substantia nigra inhibits the firing of neurons in the striatum that release γ-aminobutyric acid (GABA). Conversely, neurons located within the striatum, which release acetylcholine (ACh), excite the GABAergic neurons. Under normal conditions, the inhibitory actions of DA are balanced by the excitatory actions of ACh, and controlled movement results. B, In Parkinson’s disease, the neurons in the substantia nigra that supply DA to the striatum degenerate. When there is a deficit of DA, the excitatory effects of ACh go unopposed, resulting in disturbed movements (tremor, rigidity).
Clinical Manifestations
Tremor.
FIG. 59-8 In Parkinson’s disease, positron emission tomography (PET) scan showing reduced fluorodopa uptake in the basal ganglia (right) compared with a normal control (left).
Rigidity.
Bradykinesia.
FIG. 59-9 Characteristic appearance of a patient with Parkinson’s disease.
Complications
Diagnostic Studies
Collaborative Care
Drug Therapy.
TABLE 59-17 COLLABORATIVE CARE: Parkinson’s Disease
Drug Alert
Drug Alert
TABLE 59-18 DRUG THERAPY: Parkinson’s Disease
Surgical Therapy.
FIG. 59-10 A deep brain stimulator can be used to treat the tremors and uncontrolled movements in Parkinson’s disease. Electrodes are surgically placed in the brain and connected to a neurostimulator (pacemaker device) in the chest.
Nutritional Therapy.
Nursing Management Parkinson’s Disease
Nursing Assessment
TABLE 59-19 NURSING ASSESSMENT: Parkinson’s Disease
Nursing Diagnoses
Planning
Nursing Implementation
Safety Alert
Evaluation
Myasthenia Gravis
Etiology and Pathophysiology
Clinical Manifestations and Complications
FIG. 59-11 “Peek” sign in myasthenia gravis. During sustained forced eyelid closure he is unable to bury his eyelashes (left) and, after 30 sec, he is unable to keep the lids fully closed (right).
Diagnostic Studies
Collaborative Care
Drug Therapy.
TABLE 59-20 COLLABORATIVE CARE: Myasthenia Gravis
Surgical Therapy.
Other Therapies.
Nursing Management Myasthenia Gravis
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
TABLE 59-21 COMPARISON OF MYASTHENIC AND CHOLINERGIC CRISES
Evaluation
Amyotrophic Lateral Sclerosis
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
Huntington’s Disease
Informatics in Practice Social Networking in Huntington’s Disease
Case Study Epilepsy With Headache
Patient Profile
Subjective Data
Objective Data
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Chapter 60 Nursing Management: Alzheimer’s Disease, Dementia, and Delirium
Learning Outcomes
Key Terms
eTable
Dementia
TABLE 60-1 COMPARISON OF DEMENTIA, DELIRIUM, AND DEPRESSION
FIG. 60-1 Causes of dementia.
Etiology and Pathophysiology
Risk Factors.
TABLE 60-2 CAUSES OF DEMENTIA
Clinical Manifestations
Diagnostic Studies
Nursing and Collaborative Management Dementia
Alzheimer’s Disease
Etiology and Pathophysiology
Gender Differences
Genetics in Clinical Practice
Genetic Basis
Early Onset (Familial) (<60 Yr Old at Onset)
Late Onset (Sporadic) (>60 Yr Old at Onset)
Incidence
Early Onset
Late Onset
Genetic Testing
Early Onset
Late Onset
Clinical Implications
FIG. 60-2 Pathologic changes in Alzheimer’s disease A, Plaque with central amyloid core (white arrow) next to a neurofibrillary tangle (red arrow) on the histologic specimen from a brain autopsy. B, Schematic representation of amyloid plaque and neurofibrillary tangle.
Genetic Link
FIG. 60-3 Current etiologic theories for the development of Alzheimer’s disease. A, Abnormal amounts of β-amyloid are cleaved from the amyloid precursor protein (APP) and released into the circulation. The β-amyloid fragments come together in clumps to form plaques that attach to the neuron. Microglia react to the plaque, and an inflammatory response results. B, Tau proteins provide structural support for the neuron microtubules. Chemical changes in the neuron produce structural changes in tau proteins. This results in twisting and tangling (neurofibrillary tangles).
Environmental Factors.
Clinical Manifestations
FIG. 60-4 Effects of Alzheimer’s disease on the brain. This figure compares a normal brain (left) with a brain that has been affected by Alzheimer’s disease (right).
Retrogenesis.
TABLE 60-3 PATIENT & CAREGIVER TEACHING GUIDE: Early Warning Signs of Alzheimer’s Disease
Diagnostic Criteria for Alzheimer’s Disease
TABLE 60-4 STAGES OF ALZHEIMER’S DISEASE
TABLE 60-5 COMPARISON OF NORMAL FORGETFULNESS AND MEMORY LOSS
TABLE 60-6 RETROGENESIS IN ALZHEIMER’S DISEASE
TABLE 60-7 DIAGNOSTIC CRITERIA FOR ALZHEIMER’S DISEASE*
Preclinical Stage.
Mild Cognitive Impairment.
Diagnostic Studies
TABLE 60-8 COLLABORATIVE CARE: Alzheimer’s Disease
Diagnostic
Collaborative Therapy
FIG. 60-5 Positron emission tomography (PET) scan can be used to assist in the diagnosis of Alzheimer’s disease (AD). Radioactive fluorine is applied to glucose (fluorodeoxyglucose), and the yellow areas indicate metabolically active cells. A, A normal brain. B, Advanced AD is recognized by hypometabolism in many areas of the brain.
TABLE 60-9 THE MINI-COG
FIG. 60-6 Clock drawing is a simple test that can be used as an assessment technique in dementia. The person undergoing testing is asked to draw a clock, put in all of the numbers, and set the hands at 10 past 11. A, Shows a clock drawn by a person with no dementia. B and C show clocks drawn by people with dementia.
Collaborative Care
Drug Therapy.
TABLE 60-10 DRUG THERAPY: Alzheimer’s Disease
FIG. 60-7 Mechanism of action of cholinesterase inhibitors. A, Acetylcholine is released from the nerve synapses and carries a message across the synapse. B, Cholinesterase breaks down acetylcholine. C, Cholinesterase inhibitors block cholinesterase, thus giving acetylcholine more time to transmit the message.
Nursing Management Alzheimer’s Disease
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
TABLE 60-11 NURSING ASSESSMENT: Alzheimer’s Disease
Acute Intervention.
Ambulatory and Home Care.
Behavioral Problems.
Safety.
Safety Alert
Delegation Decisions Caring for the Patient With Alzheimer’s Disease
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Pain Management.
Eating and Swallowing Difficulties.
Oral Care.
Infection Prevention.
Skin Care.
Elimination Problems.
Caregiver Support.
FIG. 60-8 Caregivers of patients with dementia face an incredible challenge that often causes deterioration in their own physical and emotional health.
TABLE 60-12 FAMILY & CAREGIVER TEACHING GUIDE: Alzheimer’s Disease
Evaluation
TABLE 60-13 GUIDELINES FOR DEALING WITH DEMENTIA PATIENTS
FIG. 60-9 Support groups are an effective way to help caregivers cope.
Other Neurodegenerative Diseases
Evidence-Based Practice Translating Research Into Practice
Does Cognitive Reframing Help Caregivers of Patients With Dementia?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Delirium
TABLE 60-14 FACTORS THAT PRECIPITATE DELIRIUM
Demographic Characteristics
Cognitive Status
Environmental
Functional Status
Sensory
Decreased Oral Intake
Drugs
Coexisting Medical Conditions
Surgery
Etiology and Pathophysiology
TABLE 60-15 MNEMONIC FOR CAUSES OF DELIRIUM
Clinical Manifestations
Diagnostic Studies
TABLE 60-16 CONFUSION ASSESSMENT METHOD (CAM)
Nursing And Collaborative Management Delirium
Ethical/Legal Dilemmas Board of Nursing Disciplinary Action
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Drug Therapy
Case Study Alzheimer’s Disease
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 61 Nursing Management: Peripheral Nerve and Spinal Cord Problems
Learning Outcomes
Key Terms
eFigures
eTable
Cranial Nerve Disorders
Trigeminal Neuralgia
Etiology and Pathophysiology
FIG. 61-1 A, Trigeminal (fifth cranial) nerve and its three main divisions: ophthalmic, maxillary, and mandibular nerves. B, Cutaneous innervation of the head.
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Drug Therapy.
TABLE 61-1 COLLABORATIVE CARE: Trigeminal Neuralgia
TABLE 61-2 SURGICAL THERAPY FOR TRIGEMINAL NEURALGIA
Conservative Therapy.
Surgical Therapy.
FIG. 61-2 A, Patient with trigeminal neuralgia having needle placed. B, Physician injecting glycerol.
Nursing Management Trigeminal Neuralgia
Bell’s Palsy
Etiology and Pathophysiology
FIG. 61-3 Facial characteristics of Bell’s palsy. A, At rest the face may look almost normal, but the patient is not able to wrinkle her forehead on the affected side and the right corner of the mouth droops. B, When she is asked to close her eyes and show her teeth, the differences between the affected and unaffected sides become more obvious.
Clinical Manifestations and Diagnostic Studies
Collaborative Care
Nursing Management Bell’s Palsy
Polyneuropathies
Guillain-Barré Syndrome
Etiology and Pathophysiology
Clinical Manifestations and Complications
Diagnostic Studies
Nursing and Collaborative Management Guillain-Barré Syndrome
Botulism
Tetanus
Neurosyphilis
Spinal Cord Problems
Spinal Cord Injury
Etiology and Pathophysiology
Types of Injury.
Primary Injury.
Secondary Injury.
Ethical/Legal Dilemmas Right to Refuse Treatment
Situation
Ethical/Legal Points for Consideration
Discussion Questions
FIG. 61-4 Cascade of metabolic and cellular events that leads to spinal cord ischemia and hypoxia of secondary injury. RBCs, Red blood cells; SCBF, spinal cord blood flow.
Spinal and Neurogenic Shock.
Classification of Spinal Cord Injury.
Mechanisms of Injury.
Level of Injury.
Degree of Injury.
Clinical Manifestations
American Spinal Injury Association (ASIA) Impairment Scale.
Respiratory System.
FIG. 61-5 Mechanisms of spinal cord injury. Many situations may produce these injuries. This only shows some examples. A, Flexion injury of the cervical spine ruptures the posterior ligaments. B, Hyperextension injury of the cervical spine ruptures the anterior ligaments. C, Compression fractures crush the vertebrae and force bony fragments into the spinal canal. D, Flexion-rotation injury of the cervical spine often results in tearing of ligamentous structures that normally stabilize the spine.
Cardiovascular System.
FIG. 61-6 Symptoms, degree of paralysis, and potential for rehabilitation depend on the level of the injury.
FIG. 61-7 The American Spinal Injury Association Impairment Scale. See eFig. 61-2 on the website for this chapter for standard neurologic classification of spinal cord injury.
Urinary System.
Gastrointestinal System.
TABLE 61-3 INCOMPLETE SPINAL CORD INJURY SYNDROMES
Integumentary System.
TABLE 61-4 LEVEL OF SPINAL CORD INJURY AND REHABILITATION POTENTIAL
Thermoregulation.
Metabolic Needs.
Peripheral Vascular Problems.
Diagnostic Studies
Collaborative Care
TABLE 61-5 EMERGENCY MANAGEMENT: Spinal Cord Injury
Blunt Trauma
Penetrating Trauma
Initial
Ongoing Monitoring
TABLE 61-6 COLLABORATIVE CARE: Cervical Cord Injury
Acute Care
Rehabilitation and Home Care
Nonoperative Stabilization.
Surgical Therapy.
Drug Therapy.
Nursing Management Spinal Cord Injury
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 61-7 NURSING ASSESSMENT: Spinal Cord Injury
Immobilization.
Safety Alert
FIG. 61-8 Cervical traction is attached to tongs inserted in the skull.
FIG. 61-9 The RotoRest Therapy System helps prevent and treat pulmonary complications for immobile patients, including those with unstable cervical, thoracic, and lumbar fractures. Kinetic therapy, the continual side-to-side bilateral rotation of the patient, redistributes pulmonary blood flow and mobilizes secretions to improve ventilation and perfusion matching. The therapy system also helps to prevent pressure ulcers.
Respiratory Dysfunction.
FIG. 61-10 Sternal-occipital-mandibular immobilizer brace.
FIG. 61-11 Halo vest. The halo traction brace immobilizes the cervical spine, which allows the patient to ambulate and participate in self-care.
Cardiovascular Instability.
Fluid and Nutritional Maintenance.
Bladder and Bowel Management.
Evidence-Based Practice Applying the Evidence
Your Decision and Action
References for Evidence
Temperature Control.
Stress Ulcers.
Sensory Deprivation.
Reflexes.
Autonomic Dysreflexia.
Rehabilitation and Home Care.
Respiratory Rehabilitation.
TABLE 61-8 PATIENT & CAREGIVER TEACHING GUIDE: Autonomic Dysreflexia
Neurogenic Bladder.
FIG. 61-12 Patient participating in occupational therapy.
TABLE 61-9 TYPES OF NEUROGENIC BLADDER
TABLE 61-10 COLLABORATIVE CARE: Neurogenic Bladder
TABLE 61-11 PATIENT & CAREGIVER TEACHING GUIDE: Bowel Management After Spinal Cord Injury
Neurogenic Bowel.
Neurogenic Skin.
TABLE 61-12 PATIENT & CAREGIVER TEACHING GUIDE: Skin Care After Spinal Cord Injury
Sexuality.
TABLE 61-13 PATIENT & CAREGIVER TEACHING GUIDE: Halo Vest Care
Grief and Depression.
TABLE 61-14 GRIEF RESPONSE IN SPINAL CORD INJURY
Evaluation
Gerontologic Considerations
Spinal Cord Injury
Spinal Cord Tumors
Etiology and Pathophysiology
FIG. 61-13 Types of spinal cord tumors.
TABLE 61-15 CLASSIFICATION OF SPINAL CORD TUMORS
Clinical Manifestations
Nursing and Collaborative Management Spinal Cord Tumors
Case Study Spinal Cord Injury
Patient Profile
Acute Phase
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions (Acute Phase)
Patient Profile
Rehabilitation Phase
Subjective Data
Objective Data
Physical Examination
Discussion Questions (Rehabilitation Phase)
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 62 Nursing Assessment: Musculoskeletal System
Learning Outcomes
Key Terms
Structures and Functions of Musculoskeletal System
Bone
Function.
Microscopic Structure.
Gross Structure.
FIG. 62-1 Bone structure. A, Cortical (compact) bone showing numerous structural units called osteons. B, Anatomy of a long bone (tibia) showing cancellous and compact bone.
Types.
Joints
FIG. 62-2 Classification of joints. A to C, Synarthrotic (immovable) and amphiarthrotic (slightly movable) joints. D and E, Diarthrodial (freely movable) joints.
Cartilage
Muscle
Types.
FIG. 62-3 Structure of diarthrodial (synovial) joint.
FIG. 62-4 Types of diarthrodial (synovial) joints.
Structure.
Contractions.
FIG. 62-5 Structure of a muscle.
Neuromuscular Junction.
Energy Source.
FIG. 62-6 Neuromuscular junction.
Ligaments and Tendons
Fascia
Bursae
Gerontologic Considerations
Effects of Aging on Musculoskeletal System
TABLE 62-1 GERONTOLOGIC ASSESSMENT DIFFERENCES: Musculoskeletal System
Assessment of Musculoskeletal System
Subjective Data
Important Health Information.
Past Health History.
Case Study Patient Introduction
Critical Thinking
Medications.
Surgery or Other Treatments.
Functional Health Patterns.
Health Perception–Health Management Pattern.
TABLE 62-2 HEALTH HISTORY: Musculoskeletal System
Genetic Risk Alert
Autoimmune Diseases
Osteoporosis
Osteoarthritis, Gout, and Scoliosis
Muscular Dystrophy
Nutritional-Metabolic Pattern.
Elimination Pattern.
Activity-Exercise Pattern.
Sleep-Rest Pattern.
Cognitive-Perceptual Pattern.
Self-Perception–Self-Concept Pattern.
Role-Relationship Pattern.
Sexuality-Reproductive Pattern.
Coping–Stress Tolerance Pattern.
Case Study—cont’d
Value-Belief Pattern.
Objective Data
Physical Examination.
Inspection.
Palpation.
FIG. 62-7 A, Goniometer. B, Measurement of joint range of motion using a goniometer.
Motion.
TABLE 62-3 SYNOVIAL JOINT MOVEMENTS
Muscle-Strength Testing.
Measurement.
TABLE 62-4 MUSCLE STRENGTH SCALE
Other.
FIG. 62-8 Scoliosis in a standing erect posture.
TABLE 62-5 NORMAL PHYSICAL ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM
Focused Assessment
Subjective
Objective: Diagnostic
Objective: Physical Examination
Inspect and Palpate
Diagnostic Studies of Musculoskeletal System
Case Study—cont’d
FIG. 62-9 Knee arthroscopy in progress. Notice the monitor in the background.
TABLE 62-6 ASSESSMENT ABNORMALITIES: Musculoskeletal System
TABLE 62-7 DIAGNOSTIC STUDIES: Musculoskeletal System
Case Study—cont’d
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Animations
Answer Keys
Concept Map Creator
Content Updates
Glossary
Key Points
Videos
Chapter 63 Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery
Learning Outcomes
Key Terms
eFigures
Safety Alert
TABLE 63-1 PATIENT & CAREGIVER TEACHING GUIDE: Prevention of Musculoskeletal Problems in Older Adults
Soft Tissue Injuries
Sprains and Strains
TABLE 63-2 SPORTS-RELATED INJURIES
Nursing Management Sprains and Strains
Nursing Implementation
Health Promotion.
Acute Intervention.
Healthy People
TABLE 63-3 EMERGENCY MANAGEMENT: Acute Soft Tissue Injury
Initial
Ongoing Monitoring
Ambulatory and Home Care.
Dislocation and Subluxation
FIG. 63-1 Soft tissue injury of the hip. A, Normal. B, Subluxation (partial dislocation). C, Dislocation.
Nursing and Collaborative Management Dislocation
Repetitive Strain Injury
Carpal Tunnel Syndrome
FIG. 63-2 Wrist structures involved in carpal tunnel syndrome. Median nerve distribution. Shaded areas depict the locations of pain in carpal tunnel syndrome.
Nursing and Collaborative Management Carpal Tunnel Syndrome
Rotator Cuff Injury
FIG. 63-3 A torn rotator cuff is repaired using arthroscopic surgery.
Meniscus Injury
FIG. 63-4 Arthroscopic views of the meniscus. A, Normal meniscus. B, Torn meniscus. C, Surgically repaired meniscus.
Nursing and Collaborative Management Meniscus Injury
Anterior Cruciate Ligament Injury
Nursing and Collaborative Management Anterior Cruciate Ligament Injury
FIG. 63-5 Anterior cruciate ligament (ACL) injury. A, Partial tear. B, Complete tear. C, Avulsion.
Bursitis
Fractures
Classification
FIG. 63-6 Fracture classification according to communication with the external environment.
FIG. 63-7 Types of fractures. A, Transverse fracture: the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis. B, Spiral fracture: the line of the fracture extends in a spiral direction along the bone shaft. C, Greenstick fracture: an incomplete fracture with one side splintered and the other side bent. D, Comminuted fracture: a fracture with more than two fragments. The smaller fragments appear to be floating. E, Oblique fracture: the line of the fracture extends in an oblique direction. F, Pathologic fracture: a spontaneous fracture at the site of a bone disease. G, Stress fracture: occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running.
Clinical Manifestations
TABLE 63-4 MANIFESTATIONS OF FRACTURE
Fracture Healing
FIG. 63-8 Bone healing (schematic representation). A, Bleeding at fractured ends of the bone with subsequent hematoma formation. B, Organization of hematoma into fibrous network. C, Invasion of osteoblasts, lengthening of collagen strands, and deposition of calcium. D, Callus formation: new bone is built up as osteoclasts destroy dead bone. E, Remodeling is accomplished as excess callus is resorbed and trabecular bone is laid down.
TABLE 63-5 COMPLICATIONS OF FRACTURE HEALING
TABLE 63-6 COLLABORATIVE CARE: Fractures
Diagnostic
Collaborative Therapy
Fracture Immobilization
Open Fractures
Collaborative Care
Fracture Reduction
Closed Reduction.
Open Reduction.
Traction.
FIG. 63-9 Buck’s traction is most commonly used for fractures of the hip and femur.
Delegation Decisions Caring for the Patient With a Cast or Traction
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
FIG. 63-10 Balanced suspension skeletal traction. Most commonly used for fractures of the femur, hip, and lower leg.
Fracture Immobilization.
Casts.
FIG. 63-11 Common types of casts.
Upper Extremity Injuries.
Vertebral Injuries.
Lower Extremity Injuries.
FIG. 63-12 Knee immobilizer.
External Fixation.
Internal Fixation.
Electrical Bone Growth Stimulation.
FIG. 63-13 External fixators. A, Stabilization of hand injury. B, Stabilization of a tibial fracture.
FIG. 63-14 Views of internal fixation devices to stabilize a fractured tibia and fibula.
Drug Therapy.
Nutritional Therapy.
Nursing Management Fractures
Nursing Assessment
Neurovascular Assessment.
TABLE 63-7 EMERGENCY MANAGEMENT: Fractured Extremity
Blunt Trauma
Penetrating Trauma
Other
Initial
Ongoing Monitoring
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 63-8 NURSING ASSESSMENT: Fracture
Preoperative Management.
Postoperative Management.
Evidence-Based Practice Translating Research Into Practice
Do Vitamin D Supplements Improve Strength in Older Adults?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Other Measures.
Traction.
Informatics in Practice Staying Connected While Immobilized
Ambulatory and Home Care
Cast Care.
Psychosocial Problems.
TABLE 63-9 PATIENT & CAREGIVER TEACHING GUIDE: Cast Care
TABLE 63-10 PROBLEMS ASSOCIATED WITH MUSCULOSKELETAL INJURIES
Ambulation.
Assistive Devices.
Counseling and Referrals.
Evaluation
Complications of Fractures
Infection
Compartment Syndrome
Clinical Manifestations.
Collaborative Care.
FIG. 63-15 Fasciotomy associated with compartment syndrome. Stabilization of fracture with external fixator.
Venous Thromboembolism
Fat Embolism Syndrome
Clinical Manifestations.
Collaborative Care.
Types of Fractures
Colles’ Fracture
FIG. 63-16 Colles’ fracture. Fracture of the distal radius (R) and ulnar (U) styloid from patient falling on the outstretched hand.
Fracture of Humerus
Fracture of Pelvis
Ethical/Legal Dilemmas Entitlement to Treatment
Situation
Ethical/Legal Points for Consideration
Discussion Questions
FIG. 63-17 Femur with location of various types of fracture.
Fracture of Hip
Clinical Manifestations
Collaborative Care
FIG. 63-18 Types of surgical repair for a hip fracture.
FIG. 63-19 Total hip replacement (arthroplasty) with a cementless femoral prosthesis of metal alloy with a plastic acetabular socket.
Nursing Management Hip Fracture
Nursing Implementation
Preoperative Management.
Postoperative Management.
TABLE 63-11 PATIENT & CAREGIVER TEACHING GUIDE: Hip Replacement*
FIG. 63-20 Maintaining postoperative abduction following total hip replacement.
Ambulatory and Home Care.
Evaluation
Gerontologic Considerations
Hip Fracture
Femoral Shaft Fracture
Fracture of Tibia
Stable Vertebral Fracture
Facial Fracture
Mandibular Fracture
TABLE 63-12 MANIFESTATIONS OF FACIAL FRACTURES
Nursing Management Mandibular Fracture
FIG. 63-21 Intermaxillary fixation.
Amputation
Clinical Indications
TABLE 63-13 COLLABORATIVE CARE: Amputation
Diagnostic
Collaborative Therapy
Surgical
Rehabilitation
Diagnostic Studies
Collaborative Care
FIG. 63-22 Location and description of amputation sites of the upper and lower extremities. AKA, Above-the-knee amputation.
Nursing Management Amputation
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Preoperative Management.
Postoperative Management.
FIG. 63-23 A double amputee fitted with prostheses.
FIG. 63-24 Mirror therapy, a type of treatment that may reduce phantom limb sensation and pain.
FIG. 63-25 Bandaging for the above-the-knee amputation residual limb. Figure-eight style covers progressive areas of the residual limb. Two elastic wraps are required.
Ambulatory and Home Care.
Special Considerations in Upper Limb Amputation.
TABLE 63-14 PATIENT & CAREGIVER TEACHING GUIDE: Following an Amputation
Evaluation
Gerontologic Considerations
Amputation
Common Joint Surgical Procedures
Types of Joint Surgeries
Synovectomy
Osteotomy
Debridement
Arthroplasty
Hip Arthroplasty.
Hip Resurfacing.
Knee Arthroplasty.
Finger Joint Arthroplasty.
Elbow and Shoulder Arthroplasty.
Ankle Arthroplasty.
Arthrodesis
Complications of Joint Surgery
Collaborative Care
Preoperative Management.
Postoperative Management.
Nursing Management Joint Surgery
Case Study Hip Fracture Surgery
Patient Profile
Subjective Data
Collaborative Care
Preoperative
Operative Procedure
Postoperative
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Chapter 64 Nursing Management: Musculoskeletal Problems
Learning Outcomes
Key Terms
Osteomyelitis
Etiology and Pathophysiology
TABLE 64-1 ORGANISMS CAUSING OSTEOMYELITIS
Clinical Manifestations and Complications
FIG. 64-1 Development of osteomyelitis infection with involucrum and sequestrum.
Diagnostic Studies
FIG. 64-2 Resection of femur due to osteomyelitis.
Collaborative Care
Drug Alert
Nursing Management Osteomyelitis
Nursing Assessment
Nursing Diagnoses
TABLE 64-2 NURSING ASSESSMENT: Osteomyelitis
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Bone Tumors
Benign Bone Tumors
Osteochondroma
Malignant Bone Tumors
Osteosarcoma
TABLE 64-3 TYPES OF PRIMARY BONE TUMORS
FIG. 64-3 A, Osteosarcoma. B, Chondrosarcoma.
Metastatic Bone Cancer
Nursing Management Bone Cancer
Muscular Dystrophy
Genetic Link
TABLE 64-4 TYPES OF MUSCULAR DYSTROPHY
Low Back Pain
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
Acute Low Back Pain
Nursing and Collaborative Management Acute Low Back Pain
Nursing Assessment
Nursing Implementation
Health Promotion.
TABLE 64-5 NURSING ASSESSMENT: Low Back Pain
Healthy People
Acute Intervention.
TABLE 64-6 PATIENT & CAREGIVER TEACHING GUIDE: Low Back Problems
Ambulatory and Home Care.
Chronic Low Back Pain
Spinal Stenosis
Nursing and Collaborative Management Chronic Low Back Pain
Evidence-Based Practice Translating Research Into Practice
Can Yoga Improve Chronic Low Back Pain?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Intervertebral Disc Disease
Etiology and Pathophysiology
Clinical Manifestations
FIG. 64-4 Common causes of degenerative disc damage.
Diagnostic Studies
Collaborative Care
Surgical Therapy.
TABLE 64-7 MANIFESTATIONS OF LUMBAR DISC HERNIATION*
TABLE 64-8 COLLABORATIVE CARE: Intervertebral Disc Disease
FIG. 64-5 The Charité artificial disc, used in degenerative disc disease to replace a damaged intervertebral disc. The Charité artificial disc consists of two cobalt-chromium alloy endplates sandwiched around a movable high-density plastic core. The disc’s design helps align the spine and preserve its natural ability to move.
Nursing Management Vertebral Disc Surgery
Neck Pain
TABLE 64-9 CAUSES OF NECK PAIN
TABLE 64-10 PATIENT & CAREGIVER TEACHING GUIDE: Neck Exercises
Foot Disorders
Nursing Management Foot Disorders
Nursing Implementation
Health Promotion.
Acute Intervention.
FIG. 64-6 A, Severe hallux valgus with bursa formation. B, Postoperative correction.
FIG. 64-7 Postoperative supportive dressing for a moderate forefoot deformity. Dressing must be conforming and binding enough to hold toe in exact position.
TABLE 64-11 COMMON FOOT DISORDERS
Ambulatory and Home Care.
Gerontologic Considerations
Foot Problems
Metabolic Bone Diseases
Osteomalacia
Osteoporosis
FIG. 64-8 A, Normal bone. B, Osteoporotic bone.
Etiology and Pathophysiology
Cultural & Ethnic Health Disparities
TABLE 64-12 RISK FACTORS FOR OSTEOPOROSIS
Clinical Manifestations
Gender Differences
FIG. 64-9 The effects of osteoporosis. A, Comparison of young woman with an older woman. B, Severe fixed kyphosis producing a question-mark appearance.
Diagnostic Studies
Nursing and Collaborative Management Osteoporosis
TABLE 64-13 COLLABORATIVE CARE: Osteoporosis
TABLE 64-14 NUTRITIONAL THERAPY: Sources of Calcium
TABLE 64-15 ELEMENTAL CALCIUM CONTENT OF CALCIUM PREPARATIONS
Drug Therapy
Evidence-Based Practice Applying the Evidence
Your Action and Decision
Reference for Evidence
Drug Alert
Paget’s Disease
Safety Alert
Gerontologic Considerations
Metabolic Bone Diseases
Case Study Osteoporosis
Patient Profile
Subjective Data
Objective Data
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
Glossary
Key Points
Chapter 65 Nursing Management: Arthritis and Connective Tissue Diseases
Learning Outcomes
Key Terms
eFigure
Arthritis
Osteoarthritis
Etiology and Pathophysiology
TABLE 65-1 CAUSES OF OSTEOARTHRITIS
Clinical Manifestations
Systemic.
Joints.
Gender Differences
FIG. 65-1 Pathologic changes in osteoarthritis. A, Normal synovial joint. B, Early change in osteoarthritis is destruction of articular cartilage and narrowing of the joint space. There is inflammation and thickening of the joint capsule and synovium. C, With time, thickening of subarticular bone occurs, caused by constant friction of the two bone surfaces. Osteophytes form around the periphery of the joint by irregular overgrowths of bone. D, In osteoarthritis of the hands, osteophytes on the distal interphalangeal joints of the fingers, termed Heberden’s nodes, appear as small nodules.
Deformity.
Diagnostic Studies
FIG. 65-2 Joints most frequently involved in osteoarthritis.
Collaborative Care
Rest and Joint Protection.
Heat and Cold Applications.
TABLE 65-2 COLLABORATIVE CARE: Osteoarthritis
Nutritional Therapy and Exercise.
Complementary and Alternative Therapies.
Drug Therapy.
Complementary & Alternative Therapies
Scientific Evidence*
Nursing Implications
Complementary & Alternative Therapies
Scientific Evidence*
Nursing Implications
TABLE 65-3 DRUG THERAPY: Arthritis and Connective Tissue Disorders*
Surgical Therapy.
Nursing Management Osteoarthritis
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
TABLE 65-4 PATIENT & CAREGIVER TEACHING GUIDE: Joint Protection and Energy Conservation
Healthy People
Acute Intervention.
Ambulatory and Home Care.
Evaluation
Rheumatoid Arthritis
Etiology and Pathophysiology
Cultural & Ethnic Health Disparities
TABLE 65-5 ANATOMIC STAGES OF RHEUMATOID ARTHRITIS
FIG. 65-3 Rheumatoid arthritis. A, Early pathologic change in rheumatoid arthritis is rheumatoid synovitis. The synovium is inflamed. Lymphocytes and plasma cells increase greatly. B, With time, articular cartilage destruction occurs, vascular granulation tissue grows across the surface of the cartilage (pannus) from the edges of the joint, and the articular surface shows loss of cartilage beneath the extending pannus, most marked at joint margins. C, Inflammatory pannus causes focal destruction of bone. At edges of the joint there is osteolytic destruction of bone, responsible for erosions seen on x-rays. This phase is associated with joint deformity. D, Multiple deformities of the foot associated with rheumatoid arthritis.
Genetic Link
Clinical Manifestations
Joints.
TABLE 65-6 COMPARISON OF RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS
Extraarticular Manifestations.
Diagnostic Studies
FIG. 65-4 Typical deformities of rheumatoid arthritis. A, Ulnar drift. B, Boutonnière deformity. C, Hallux valgus. D, Swan neck deformity.
FIG. 65-5 Extraarticular manifestations of rheumatoid arthritis.
Collaborative Care
TABLE 65-7 DIAGNOSTIC CRITERIA FOR RHEUMATOID ARTHRITIS*
TABLE 65-8 COLLABORATIVE CARE: Rheumatoid Arthritis
Drug Therapy
Disease-Modifying Antirheumatic Drugs.
Biologic and Targeted Therapies.
Drug Alert
Drug Alert
Other Drug Therapy.
Nutritional Therapy.
Surgical Therapy.
Nursing Management Rheumatoid Arthritis
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 65-9 NURSING ASSESSMENT: Rheumatoid Arthritis
Ambulatory and Home Care
Rest.
Joint Protection.
TABLE 65-10 PATIENT & CAREGIVER TEACHING GUIDE: Protection of Small Joints
Heat and Cold Therapy and Exercise.
Psychologic Support.
Gerontologic Considerations
Arthritis
Gout
TABLE 65-11 CAUSES OF HYPERURICEMIA
Etiology and Pathophysiology
Clinical Manifestations and Complications
Gender Differences
FIG. 65-6 Tophi associated with chronic gout. Nodules are painless and filled with uric acid crystals.
Diagnostic Studies
Collaborative Care
TABLE 65-12 COLLABORATIVE CARE: Gout
Drug Therapy.
Nutritional Therapy.
Nursing Management Gout
Lyme Disease
FIG. 65-7 Erythema migrans. Characteristic skin lesion of Lyme disease that occurs at the site of tick bite.
TABLE 65-13 PATIENT & CAREGIVER TEACHING GUIDE: Prevention and Early Treatment of Lyme Disease
Septic Arthritis
Spondyloarthropathies
Ankylosing Spondylitis
Etiology and Pathophysiology
Clinical Manifestations and Complications
FIG. 65-8 Advanced ankylosing spondylitis. Kyphotic posture causes many patients to have a protuberant abdomen secondary to pulmonary restriction.
Genetics in Clinical Practice
Genetic Basis
Incidence
Genetic Testing
Clinical Implications
Diagnostic Studies
Collaborative Care
Nursing Management Ankylosing Spondylitis
Psoriatic Arthritis
Reactive Arthritis
Systemic Lupus Erythematosus
Etiology and Pathophysiology
Clinical Manifestations and Complications
Dermatologic Problems.
Musculoskeletal Problems.
Cardiopulmonary Problems.
Renal Problems.
FIG. 65-9 Multisystem involvement in systemic lupus erythematosus.
FIG. 65-10 Butterfly rash of systemic lupus erythematosus.
Nervous System Problems.
Hematologic Problems.
Infection.
TABLE 65-14 DIAGNOSTIC CRITERIA FOR SYSTEMIC LUPUS ERYTHEMATOSUS*
Diagnostic Studies
Collaborative Care
Drug Therapy.
Nursing Management Systemic Lupus Erythematosus
Nursing Assessment
TABLE 65-15 COLLABORATIVE CARE: Systemic Lupus Erythematosus
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Acute Intervention.
TABLE 65-16 NURSING ASSESSMENT: Systemic Lupus Erythematosus
Ambulatory and Home Care.
Lupus and Pregnancy.
TABLE 65-17 PATIENT & CAREGIVER TEACHING GUIDE: Systemic Lupus Erythematosus
Psychosocial Issues.
Evaluation
Scleroderma
Etiology and Pathophysiology
FIG. 65-11 Skin changes in scleroderma.
Clinical Manifestations
Raynaud’s Phenomenon.
FIG. 65-12 Hand of a patient with scleroderma showing sclerodactyly.
Skin and Joint Changes.
Internal Organ Involvement.
Diagnostic Studies
Collaborative Care
Drug Therapy.
TABLE 65-18 COLLABORATIVE CARE: Scleroderma
Nursing Management Scleroderma
Polymyositis and Dermatomyositis
Etiology and Pathophysiology
Clinical Manifestations and Complications
Muscular.
Dermal.
Other Manifestations.
FIG. 65-13 Dermatomyositis skin changes. Gottron’s papules.
Diagnostic Studies
Nursing and Collaborative Management Polymyositis and Dermatomyositis
Mixed (Overlapping) Connective Tissue Disease
Sjögren’s Syndrome
Myofascial Pain Syndrome
Fibromyalgia
Etiology and Pathophysiology
TABLE 65-19 COMMONALITIES BETWEEN FIBROMYALGIA AND CHRONIC FATIGUE SYNDROME
Clinical Manifestations and Complications
FIG. 65-14 Tender points in fibromyalgia.
Diagnostic Studies
Collaborative Care
Nursing Management Fibromyalgia
Chronic Fatigue Syndrome
Etiology and Pathophysiology
Clinical Manifestations
Diagnostic Studies
TABLE 65-20 DIAGNOSTIC CRITERIA FOR CHRONIC FATIGUE SYNDROME*
Nursing and Collaborative Management Chronic Fatigue Syndrome
Case Study Rheumatoid Arthritis
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Patients
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Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Section 12 Nursing Care in Critical Care Settings
Nursing Care in Critical Care Settings
Pre-Test – Section 12
Interactive Review – Section 12
Chapter 66 Nursing Management: Critical Care
Learning Outcomes
Key Terms
eFigures
eTable
eSupplement
Critical Care Nursing
FIG. 66-1 Tele-intensive care unit control room.
Critical Care Units
FIG. 66-2 Typical intensive care unit.
Critical Care Nurse
Critical Care Patient
Common Problems of Critical Care Patients.
Nutrition.
Anxiety.
Pain.
Informatics in Practice Smart Infusion Pumps
Impaired Communication.
Sensory-Perceptual Problems.
Sleep Problems.
Issues Related to Caregivers
Ethical/Legal Dilemmas Family Presence and Visitation in the Adult ICU
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Culturally Competent Care
Critical Care Patients
Hemodynamic Monitoring
Hemodynamic Terminology
Cardiac Output and Cardiac Index.
TABLE 66-1 RESTING HEMODYNAMIC PARAMETERS
Preload.
Afterload.
Vascular Resistance.
Contractility.
FIG. 66-3 Components of a pressure monitoring system. The cannula, shown entering the radial artery, is connected via pressure (nondistensible) tubing to the transducer. The transducer converts the pressure wave into an electronic signal. The transducer is wired to the electronic monitoring system, which amplifies, conditions, displays, and records the signal. Stopcocks are inserted into the line for specimen withdrawal and for referencing and zero-balancing procedures. A flush system, consisting of a pressurized bag of IV fluid, tubing, and a flush device, is connected to the system. The flush system provides continuous slow (approximately 3 mL/hr) flushing and provides a mechanism for fast flushing of lines.
Principles of Invasive Pressure Monitoring
FIG. 66-4 Identification of the phlebostatic axis. A, Phlebostatic axis is an external landmark used to identify the level of the atria in the supine patient. It is defined as the intersection of two imaginary lines: one drawn horizontally from the axilla, midway between the anterior and posterior chest walls, and the other drawn vertically through the fourth intercostal space along the lateral chest wall. B, Air-fluid interface (zeroing the stopcock) is level with the phlebostatic axis using a carpenter’s or laser level.
FIG. 66-5 Optimally damped system. Dynamic response test (square wave test) using the fast flush system: normal response. No adjustment in the monitoring system is required.
TABLE 66-2 INVASIVE ARTERIAL BLOOD PRESSURE MEASUREMENT
Safety Alert
Types of Invasive Pressure Monitoring
Arterial Blood Pressure.
Measurements.
Complications.
FIG. 66-6 A, Simultaneously recorded electrocardiogram (ECG) tracing and B, systemic arterial pressure tracing. Systolic pressure is the peak pressure. The dicrotic notch indicates aortic valve closure. Diastolic pressure is the lowest value before contraction. Mean pressure is the average pressure over time calculated by the monitoring equipment.
Arterial Pressure–Based Cardiac Output.
FIG. 66-7 FloTrac sensor and Vigileo monitor.
Measurements.
Pulmonary Artery Flow-Directed Catheter.
TABLE 66-3 INDICATIONS AND CONTRAINDICATIONS FOR PULMONARY ARTERY CATHETERIZATION*
FIG. 66-8 Pulmonary artery (PA) catheter. A, Illustrated catheter has five lumens. When properly positioned, the distal lumen exit port is in the PA and the proximal lumen ports are in the right atrium and right ventricle. The distal and one of the proximal ports are used to measure PA and central venous pressures, respectively. A balloon surrounds the catheter near the distal end. The balloon inflation valve is used to inflate the balloon with air to allow reading of the pulmonary artery wedge pressure. A thermistor located near the distal tip senses PA temperature and is used to measure thermodilution cardiac output when solution cooler than body temperature is injected into a proximal port. B, Photo of an actual catheter.
Pulmonary Artery Catheter Insertion.
Central Venous or Right Atrial Pressure Measurement.
FIG. 66-9 Position of the pulmonary artery flow-directed catheter during progressive stages of insertion with corresponding pressure waveforms.
Venous Oxygen Saturation Monitoring.
FIG. 66-10 Cardiac events that produce the central venous pressure (CVP) waveform with a, c, and v waves. The a wave represents atrial contraction. The x descent represents atrial relaxation. The c wave represents the bulging of the closed tricuspid valve into the right atrium during ventricular systole. The v wave represents atrial filling. The y descent represents opening of the tricuspid valve and filling of the ventricle.
Noninvasive Arterial Oxygenation Monitoring
TABLE 66-4 INTERPRETATION OF ScvO2/SvO2 * MEASUREMENTS
Noninvasive Hemodynamic Monitoring: Impedance Cardiography
Nursing Management Hemodynamic Monitoring
Circulatory Assist Devices
Intraaortic Balloon Pump
TABLE 66-5 INDICATIONS AND CONTRAINDICATIONS FOR IABP THERAPY*
FIG. 66-11 Intraaortic balloon pump machine.
Effects of Counterpulsation.
Complications With IABP Therapy.
FIG. 66-12 Intraaortic balloon pump. A, During systole the balloon is deflated, which facilitates ejection of blood into the periphery. B, In early diastole, the balloon begins to inflate. C, In late diastole, the balloon is totally inflated, which augments aortic pressure and increases the coronary perfusion pressure with the end result of increased coronary and cerebral blood flow.
TABLE 66-6 HEMODYNAMIC EFFECTS OF COUNTERPULSATION
TABLE 66-7 MANAGING COMPLICATIONS OF IABP THERAPY
Ventricular Assist Devices
FIG. 66-13 Schematic diagram of a biventricular assist device (BVAD).
Implantable Artificial Heart
Nursing Management Circulatory Assist Devices
Artificial Airways
Endotracheal Tubes
FIG. 66-14 Endotracheal tube. A, Parts of an endotracheal tube. B, Tube in place with cuff deflated. C, Tube in place with the cuff inflated. D, Photo of tube before placement.
Evidence-Based Practice Translating Research Into Practice
Does Timing of Tracheotomy Affect Critically Ill Patient Outcomes?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Endotracheal Intubation Procedure
FIG. 66-15 Closed tracheal suction system.
Nursing Management Artificial Airway
Maintaining Correct Tube Placement
Safety Alert
Maintaining Proper Cuff Inflation
Monitoring Oxygenation and Ventilation
TABLE 66-8 SUCTIONING PROCEDURES FOR PATIENT ON MECHANICAL VENTILATOR
Maintaining Tube Patency
Providing Oral Care and Maintaining Skin Integrity
TABLE 66-9 ORAL CARE PROCEDURES FOR PATIENT ON MECHANICAL VENTILATOR
Fostering Comfort and Communication
Complications of Endotracheal Intubation
Safety Alert
FIG. 66-16 Continuous subglottal suctioning can be provided by the Hi Lo Evac Tube. A dorsal lumen above the cuff allows for suctioning of secretions from the subglottic area.
Mechanical Ventilation
FIG. 66-17 Negative pressure ventilator.
Types of Mechanical Ventilation
Negative Pressure Ventilation.
Positive Pressure Ventilation.
Volume Ventilation.
FIG. 66-18 Patient receiving mechanical ventilation.
Pressure Ventilation.
Settings of Mechanical Ventilators
Modes of Volume Ventilation
TABLE 66-10 SETTINGS OF MECHANICAL VENTILATION
Assist-Control Mechanical Ventilation.
TABLE 66-11 INTERPRETING MECHANICAL VENTILATION ALARMS
Synchronized Intermittent Mandatory Ventilation.
TABLE 66-12 MODES OF MECHANICAL VENTILATION
Modes of Pressure Ventilation
Pressure Support Ventilation.
Pressure-Control Inverse Ratio Ventilation.
Airway Pressure Release Ventilation.
Other Modes.
Other Ventilatory Maneuvers
Positive End-Expiratory Pressure.
Continuous Positive Airway Pressure.
Automatic Tube Compensation.
Bilevel Positive Airway Pressure.
High-Frequency Oscillatory Ventilation.
Nitric Oxide.
Prone Positioning.
Extracorporeal Membrane Oxygenation.
Complications of Positive Pressure Ventilation
Cardiovascular System.
Pulmonary System
Barotrauma.
Volutrauma.
Alveolar Hypoventilation.
Alveolar Hyperventilation.
Ventilator-Associated Pneumonia.
Sodium and Water Imbalance.
Neurologic System.
Gastrointestinal System.
Musculoskeletal System.
Psychosocial Needs.
FIG. 66-19 Placement of electrodes along ulnar nerve.
Machine Disconnection or Malfunction.
Nutritional Therapy: Patient Receiving Positive Pressure Ventilation
Delegation Decisions Caring for the Patient Requiring Mechanical Ventilation
Role of Registered Nurse (RN)
Role of Licensed Practical/Vocational Nurse (LPN/LVN)
Role of Unlicensed Assistive Personnel (UAP)
Weaning From Positive Pressure Ventilation and Extubation
TABLE 66-13 INDICATORS FOR WEANING
Chronic Mechanical Ventilation
Nursing Management Mechanical Ventilation
Other Critical Care Content
TABLE 66-14 CROSS-REFERENCES TO CRITICAL CARE CONTENT
Case Study Critical Care and Mechanical Ventilation
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
eTables
Glossary
Key Points
Chapter 67 Nursing Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome
Learning Outcomes
Key Terms
eFigures
Shock
Classification of Shock
FIG. 67-1 Relationship of shock, systemic inflammatory response syndrome, and multiple organ dysfunction syndrome. CNS, Central nervous system. (See Table 67-1 for causes of shock states.)
TABLE 67-1 CLASSIFICATION OF SHOCK STATES
Cardiogenic Shock.
FIG. 67-2 The pathophysiology of cardiogenic shock.
Hypovolemic Shock.
TABLE 67-2 DIAGNOSTIC STUDIES: Laboratory Changes in Shock
Distributive Shock
Neurogenic Shock.
TABLE 67-3 CLINICAL PRESENTATION OF TYPES OF SHOCK
FIG. 67-3 The pathophysiology of hypovolemic shock.
Anaphylactic Shock.
FIG. 67-4 The pathophysiology of neurogenic shock.
Septic Shock.
TABLE 67-4 DIAGNOSTIC CRITERIA FOR SEPSIS
Obstructive Shock.
Stages of Shock
Compensatory Stage.
FIG. 67-5 The pathophysiology of septic shock. CNS, Central nervous system.
FIG. 67-6 The pathophysiology of obstructive shock.
TABLE 67-5 MANIFESTATIONS OF STAGES OF SHOCK*
Progressive Stage.
Irreversible Stage.
Diagnostic Studies
Collaborative Care: General Measures
Oxygen and Ventilation.
Fluid Resuscitation.
TABLE 67-6 EMERGENCY MANAGEMENT: Shock
Surgical
Medical
Trauma
Initial
Ongoing Monitoring
TABLE 67-7 FLUID THERAPY IN SHOCK
Safety Alert
Drug Therapy.
Sympathomimetic Drugs.
TABLE 67-8 DRUG THERAPY: Shock
Vasodilator Drugs.
Nutritional Therapy.
Collaborative Care: Specific Measures
Cardiogenic Shock.
Hypovolemic Shock.
Septic Shock.
Drug Alert
TABLE 67-9 COLLABORATIVE CARE: Shock
Neurogenic Shock.
Anaphylactic Shock.
Obstructive Shock.
Nursing Management Shock
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health Promotion.
Safety Alert
Acute Intervention.
Neurologic Status.
Cardiovascular Status.
Respiratory Status.
Renal Status.
Body Temperature and Skin Changes.
Gastrointestinal Status.
Personal Hygiene.
Emotional Support and Comfort.
Ambulatory and Home Care.
Evaluation
Systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome
Etiology and Pathophysiology
Organ and Metabolic Dysfunction.
Clinical Manifestations of SIRS and MODS
Nursing and Collaborative Management Sirs and Mods
Prevention and Treatment of Infection
Maintenance of Tissue Oxygenation
Nutritional and Metabolic Needs
Support of Failing Organs
TABLE 67-10 MANIFESTATIONS AND MANAGEMENT OF SIRS AND MODS
Case Study Shock
Patient Profile
Subjective Data
Objective Data
Physical Examination
Diagnostic Studies
Collaborative Care (in the ED)
Surgical Procedure
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eFigures
Glossary
Key Points
Chapter 68 Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome
Learning Outcomes
Key Terms
eTable
Acute Respiratory Failure
FIG. 68-1 Normal gas exchange unit in the lung.
Etiology and Pathophysiology
Hypoxemic Respiratory Failure.
Ventilation-Perfusion Mismatch.
FIG. 68-2 Classification of respiratory failure.
TABLE 68-1 CAUSES OF HYPOXEMIC AND HYPERCAPNIC RESPIRATORY FAILURE*
Respiratory System
Cardiac System
Respiratory System
Central Nervous System
Chest Wall
Neuromuscular System
FIG. 68-3 Regional V/Q differences in the normal lung. At the lung apex, the V/Q ratio is 3.3, at the midpoint 1.0, and at the base 0.63. This difference causes the PaO2 to be higher at the apex of the lung and lower at the base. Values for PaCO2 are the opposite (i.e., lower at the apex and higher at the base). Blood that exits the lung is a mixture of these values.
FIG. 68-4 Range of ventilation-to-perfusion (V/Q) relationships. A, Absolute shunt, no ventilation because of fluid filling the alveoli. B, V/Q mismatch, ventilation partially compromised by secretions in the airway. C, Normal lung unit. D, V/Q mismatch, perfusion partially compromised by emboli obstructing blood flow. E, Dead space, no perfusion because of obstruction of the pulmonary capillary.
Shunt.
Diffusion Limitation.
FIG. 68-5 Diffusion limitation. Exchange of CO2 and O2 cannot occur because of the thickened alveolar-capillary membrane.
Alveolar Hypoventilation.
Interrelationship of Mechanisms.
Hypercapnic Respiratory Failure.
Airway and Alveoli Abnormalities.
Central Nervous System Abnormalities.
Chest Wall Abnormalities.
Neuromuscular Conditions.
Tissue Oxygen Needs.
Clinical Manifestations
TABLE 68-2 MANIFESTATIONS OF HYPOXEMIA AND HYPERCAPNIA*
Consequences of Hypoxemia and Hypoxia.
Specific Clinical Manifestations.
FIG. 68-6 Tripod positioning is used to increase chest and lung expansion and decrease work of breathing for patients with COPD or asthma.
Diagnostic Studies
Nursing and Collaborative Management Acute Respiratory Failure
Nursing Assessment
Nursing Diagnoses
TABLE 68-3 NURSING ASSESSMENT: Acute Respiratory Failure
Planning
Prevention
Respiratory Therapy
Oxygen Therapy.
TABLE 68-4 COLLABORATIVE CARE: Acute Respiratory Failure
Mobilization of Secretions.
Effective Coughing and Positioning.
FIG. 68-7 Augmented coughing is performed by placing one or both hands on the anterolateral base of the lungs. After the patient takes a deep inspiration and at the beginning of expiration, move the hand(s) forcefully upward. This increases abdominal pressure and aids in producing a forceful cough.
Hydration and Humidification.
Chest Physiotherapy.
Airway Suctioning.
Positive Pressure Ventilation.
FIG. 68-8 Noninvasive bilevel positive pressure ventilation. A mask is placed over the nose or nose and mouth. Positive pressure from a mechanical ventilator assists the patient’s breathing efforts, decreasing the work of breathing.
Drug Therapy
Relief of Bronchospasm.
Reduction of Airway Inflammation.
Drug Alert
Reduction of Pulmonary Congestion.
Treatment of Pulmonary Infections.
Reduction of Severe Anxiety, Pain, and Agitation.
Safety Alert
Safety Alert
Medical Supportive Therapy
Treating the Underlying Cause.
Maintaining Adequate Cardiac Output.
Maintaining Adequate Hemoglobin Concentration.
Nutritional Therapy
Evaluation
Gerontologic Considerations
Respiratory Failure
Acute Respiratory Distress Syndrome
FIG. 68-9 Stages of edema formation in acute respiratory distress syndrome. A, Normal alveolus and pulmonary capillary. B, Interstitial edema occurs with increased flow of fluid into the interstitial space. C, Alveolar edema occurs when the fluid crosses the blood-gas barrier.
TABLE 68-5 PREDISPOSING CONDITIONS TO ARDS
Etiology and Pathophysiology
FIG. 68-10 Pathophysiology of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).
Injury or Exudative Phase.
Reparative or Proliferative Phase.
Fibrotic Phase.
Clinical Progression
Clinical Manifestations and Diagnostic Studies
TABLE 68-6 DIAGNOSTIC FINDINGS IN ALI AND ARDS
FIG. 68-11 Chest x-ray of a patient with acute respiratory distress syndrome (ARDS). The x-ray shows new, bilateral, diffuse, homogeneous pulmonary infiltrates without cardiac failure, fluid overload, chest infection, or chronic lung disease.
Complications
Ventilator-Associated Pneumonia.
TABLE 68-7 COMPLICATIONS ASSOCIATED WITH ARDS
TABLE 68-8 COMPONENTS OF A VENTILATOR BUNDLE
Barotrauma.
Evidence-Based Practice Translating Research Into Practice
How Effective Is Subglottic Secretion Drainage on Ventilator-Associated Pneumonia?
Clinical Question
Best Available Evidence
Critical Appraisal and Synthesis of Evidence
Conclusion
Implications for Nursing Practice
Reference for Evidence
Volutrauma.
Stress Ulcers.
Renal Failure.
Nursing and Collaborative Management Acute Respiratory Distress Syndrome
TABLE 68-9 COLLABORATIVE CARE: Acute Respiratory Distress Syndrome
Nursing Assessment
Nursing Diagnoses
Planning
Oxygen Administration.
Positive Pressure Ventilation.
Positioning Strategies.
FIG. 68-12 A, Turning patient prone on Vollman Prone Positioner. B, Patient lying prone on Vollman Prone Positioner.
Medical Supportive Therapy
Maintenance of Cardiac Output and Tissue Perfusion.
Maintenance of Nutrition and Fluid Balance.
FIG. 68-13 TotalCare SpO2RT Bed System offers continuous lateral rotation therapy and percussion and vibration therapies. Patients can easily and quickly be repositioned.
Evaluation
Case Study Acute Respiratory Distress Syndrome
Patient Profile
Past Medical History
Postoperative Orders
Postoperative Day 1
Subjective Data
Objective Data
Physical Assessment
Diagnostic Findings
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Pageburst Integrated Resources
Answer Keys
Care Plans
Case Studies
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Chapter 69 Nursing Management: Emergency, Terrorism, and Disaster Nursing
Learning Outcomes
Key Terms
eTables
TABLE 69-1 EMERGENCY MANAGEMENT Emergency Management Tables
Care of Emergency Patient
Triage
TABLE 69-2 FIVE-LEVEL EMERGENCY SEVERITY INDEX (ESI)
TABLE 69-3 EMERGENCY ASSESSMENT: PRIMARY SURVEY
Primary Survey
TABLE 69-4 POTENTIAL LIFE-THREATENING CONDITIONS FOUND DURING PRIMARY SURVEY*
A = Airway With Cervical Spine Stabilization and/or Immobilization.
FIG. 69-1 Jaw-thrust maneuver is the recommended procedure for opening the airway of an unconscious patient with a possible neck or spinal injury. With the patient lying supine, kneel at the top of the head. Place one hand on each side of the patient’s head, resting your elbows on the surface. Grasp the angles of the patient’s lower jaw and lift the jaw forward with both hands without tilting the head.
B = Breathing.
C = Circulation.
D = Disability.
E = Exposure or Environmental Control.
Secondary Survey
F = Full Set of Vital Signs, Focused Adjuncts, Facilitate Family Presence.
G = Give Comfort Measures.
H = History and Head-to-Toe Assessment.
TABLE 69-5 EMERGENCY ASSESSMENT: SECONDARY SURVEY
Head, Neck, and Face.
Chest.
Abdomen and Flanks.
Pelvis and Perineum.
Extremities.
I = Inspect Posterior Surfaces.
Intervention and Evaluation
TABLE 69-6 TETANUS VACCINES AND TIG FOR WOUND MANAGEMENT
Post–Cardiac Arrest Hypothermia
Evidence-Based Practice Applying the Evidence
Your Decision and Action
Reference for Evidence
Death in the Emergency Department
Gerontologic Considerations
Emergency Care
Environmental Emergencies
TABLE 69-7 RISK FACTORS FOR HEAT-RELATED EMERGENCIES
Heat-Related Emergencies
Heat Cramps
Heat Exhaustion
TABLE 69-8 EMERGENCY MANAGEMENT: Hyperthermia
Environmental
Trauma
Metabolic
Drugs
Other
Heat Cramps
Heat Exhaustion
Heatstroke
Initial
Ongoing Monitoring
Heatstroke
Collaborative Care.
Cold-Related Emergencies
Frostbite
FIG. 69-2 Edema and blister formation 24 hours after frostbite injury occurring in an area covered by a tightly fitted boot.
FIG. 69-3 Gangrenous necrosis 6 weeks after the frostbite injury shown in Fig. 69-2.
Hypothermia
TABLE 69-9 EMERGENCY MANAGEMENT: Hypothermia
Environmental
Metabolic
Health Care Associated
Other
Initial
Ongoing Monitoring
Collaborative Care.
Submersion Injuries
Collaborative Care
FIG. 69-4 Pathophysiology of submersion injury.
Stings and Bites
TABLE 69-10 EMERGENCY MANAGEMENT: Submersion Injuries
Pulmonary
Cardiac
Other
Initial
Ongoing Monitoring
Hymenopteran Stings
Safety Alert
FIG. 69-5 Tick removal. A, Use tweezers to grasp the tick close to the skin. B, With a steady motion, pull the tick’s body up and away from the skin. Do not be alarmed if the tick’s mouthparts remain in the skin. Once the mouthparts are removed from the rest of the tick, it can no longer transmit disease.
Tick Bites
Animal and Human Bites
FIG. 69-6 Probable human bite injury, though denied by patient. Human bites cause extensor tendon injuries, fractures, and joint capsule injuries and can harbor foreign bodies.
Collaborative Care.
Drug Alert
Poisonings
TABLE 69-11 COMMON POISONS
Violence
Agents of Terrorism
Emergency and Mass Casualty Incident Preparedness
FIG. 69-7 American Red Cross.
Ethical/Legal Dilemmas Good Samaritan
Situation
Ethical/Legal Points for Consideration
Discussion Questions
Case Study Trauma
Patient Profile
Subjective Data
Objective Data
Physical Examination
Discussion Questions
Bridge to NCLEX Examination
References
Resources
Case Study Managing Multiple Patients
Patients
Management Discussion Questions
Case Study Progression
Pageburst Integrated Resources
Answer Keys
Case Studies
Concept Map Creator
Content Updates
eTables
Glossary
Key Points
Appendixes
Appendix A Basic Life Support for Health Care Providers
Cardiopulmonary Resuscitation
Chest Compressions
FIG. A-1 The head tilt–chin lift maneuver is used to open the victim’s airway to give rescue breaths. A, Rescuer places one hand on the victim’s forehead and applies firm, backward pressure with the palm to tilt the head back. The chin is lifted and brought forward with the fingers of the other hand. B, Mouth-to-barrier device: Rescuer places the device tightly over the victim’s mouth and nose and delivers a regular breath. C, Mouth-to-mouth technique: Rescuer pinches the victim’s nostrils, tightly seals mouth over victim’s mouth, and delivers a regular breath. NOTE: Rescuer should observe for a rise in the victim’s chest (blue arrows).
TABLE A-1 ADULT ONE- AND TWO-RESCUER BASIC LIFE SUPPORT WITH AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
Defibrillation
FIG. A-2 Cardiopulmonary resuscitation. A, Position of the hands during chest compressions. B, When pressure is applied, the sternum is displaced posteriorly with the heel of the hand. C, Arms are kept straight and the rescuer pushes deep (at least 2 in) and fast (a rate of at least 100 compressions per minute).
FIG. A-3 Automatic external defibrillator (AED) located in a shopping center.
Airway and Breathing
TABLE A-2 MANAGEMENT OF THE ADULT CHOKING VICTIM
FIG. A-4 Abdominal thrusts (Heimlich maneuver) administered to a conscious (standing) choking victim.
Hands-Only CPR
References
Resources
Appendix B Nursing Diagnoses
Appendix C Laboratory Reference Intervals
TABLE C-1 SERUM, PLASMA, AND WHOLE BLOOD CHEMISTRIES
TABLE C-2 HEMATOLOGY
TABLE C-3 SEROLOGY-IMMUNOLOGY
TABLE C-4 URINE CHEMISTRY
TABLE C-5 FECAL ANALYSIS
TABLE C-6 CEREBROSPINAL FLUID ANALYSIS
Glossary
Glossary
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
R
S
T
U
V
W
Illustration Credits
Illustration Credits
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 8
Chapter 9
Chapter 10
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37
Chapter 38
Chapter 39
Chapter 40
Chapter 41
Chapter 42
Chapter 43
Chapter 44
Chapter 45
Chapter 46
Chapter 47
Chapter 48
Chapter 49
Chapter 50
Chapter 51
Chapter 52
Chapter 53
Chapter 54
Chapter 55
Chapter 56
Chapter 57
Chapter 58
Chapter 59
Chapter 60
Chapter 61
Chapter 62
Chapter 63
Chapter 64
Chapter 65
Chapter 66
Chapter 67
Chapter 68
Chapter 69
Index
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Abbreviations
Abbreviations

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