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MedSurg Notes Nurse S Clinical Pocket Guide FA Davis 2007 PDF
MedSurg Notes Nurse S Clinical Pocket Guide FA Davis 2007 PDF
2nd Edition
MedSurg
Notes
Nurses Clinical Pocket Guide
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
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visit www.fadavis.com.
1
Legal Issues in MedSurg Care
Legal issues affect all aspects of nursing care. Urgent care situations, in
which the patients life may be lost or potential quality of life compromised,
require even more vigilant attention to nursing standards of care and best
practices.
The nurse practice law of each state defines the scope of nursing
practice for that state.
Advanced practice nurses, such as nurse midwives, nurse anesthetists, and
clinical nurse specialists, function under a broader scope of practice.
Know your states nurse practice law; contact your state board of nursing
for a copy.
Know your states requirements for licensure, and maintain your nursing
license as required.
Keep informed of local, state, and national nursing issues; get involved as
a lobbyist in your state; contact your state representatives regarding
issues that affect nursing practice.
Know if and how a nursing union could affect your practice.
Nurses have a duty of care of careful and continuous monitoring
of the patients status.
Nurses assess and directly intervene on patients more than any other healthcare professionals.
Monitor each patients vital signs, neurological status, intake and output,
status per physician order, nursing care plan, hospital policy and
procedure; increase frequency of vital signs if indicated, and notify the
physician.
Evaluate family members concerns as soon as possible; the family often
detects subtle changes in a patients status.
Nurses have a duty to communicate the patients status to the
medical staff, particularly on an immediate/STAT basis when the
patients status warrants.
The nurse is usually the first team member to detect an urgent care situation
and has an obligation to report any changes in patient condition to the
medical staff for timely intervention.
Notify the physician as soon as you detect any change in the patients
condition that indicates deterioration in status. Document assessment,
time of call to physician, and nursing interventions and patients response.
Use the hospitals chain of command if the physician fails to respond
within minutes. Notify the nursing supervisor if the physician does not
respond immediately.
(Continued on the following page)
BASICS
BASICS
The nurse must maintain accurate nursing notes, flow sheets, medical
Kardexes, and nursing care plans that record the patients symptoms, time
symptoms were present, time physician was notified, and time physician
arrived. The medical chart should be a factual record of the patients
medical treatment, responses thereto, vital signs, and all nursing
interventions.
Nurses have a duty to administer medications safely at all times,
including urgent care situations.
Medication errors are the most common source of nursing negligence.
Procedural safeguards should be followed to prevent medication errors. The
five rights of medication administration are minimum practice standards.
Give the right drug in the right dose to the right patient by the right route
at the right time.
Document the five rightswhich medication, to whom, in what dose,
through which route, and at what time.
Document fully any suspected adverse drug reaction, time and nature
of the reaction, time physician notified, interventions taken, and patients
response.
Nurses have a duty to know about all the drugs they administer: drug
names, drug categories, dosage, timing, technique of administration,
expected therapeutic response, duration of drug use, and procedures to
minimize the incidence or severity of adverse drug effects.
Nurses have a duty to maintain safe patient care conditions.
This is akin to the nurses duty to advocate for the patient at all times.
Report an unsafe staffing condition to the nursing supervisor as soon as
it is apparent. The nurse-patient ratio in intensive care settings should not
exceed 1:2; on general floors, 1:6.
Working beyond a 12-hour shift can create a substantial decline in
performance.
Know the nurse practice limitations on nurses under your supervision;
licensed practical nurses and student nurses cannot perform all the
actions of the registered nurse.
Nurses have a duty to keep the patient safe from self-harm.
The nurse must be vigilant regarding any changes in the patients sensorium/
mental status. Any patient can experience a psychiatric crisis from a myriad
of causes, including hypoxia, drug reaction, drug withdrawal, ICU psychosis,
or underlying organic disease.
Assess the patients mental status with each nursing intervention; note
subtle changes, and notify the physician.
Signs of impending psychiatric crisis include changes in orientation to
person, place, and time; verbal abusiveness; restlessness; increased
anxiety; and agitation.
3
If a patient is at risk of self-harm and/or of harming others, restraints can
be applied.
Most states require a written physician order before restraining the
patient, except in an emergency. The physician must be notified
immediately of the use of restraints.
If restraints are applied, the patient must be monitored closely for changes
in medical condition and mental status, for maintenance of adequate circulation, and for prevention of positional asphyxiation. Document all assessments and frequency of checks (no less frequent than every 15 minutes).
Know the hospitals policy and procedure regarding use of restraints, and
follow them at all times.
Nurses have a duty to carry out physician orders as required by
state law, hospital policy and procedure, and nursing practice
standards.
Concurrently, as patient advocate, the nurse must question an order he or
she deems problematic, particularly when an urgent care situation is present
or when one could arise from fulfillment of the order.
Contact the physician immediately for any order that is unclear, contrary
to standard drug dosage/route/frequency of administration, or that does
not address the acuity of the patients medical condition; e.g., an order for
vital signs every shift for a postoperative patient recently transferred to a
general surgical floor.
Question an order for a patients discharge from the hospital when the
patients medical condition is not stable, when delay in treatment resulting
from discharge could injure the patient, or when the patient is going to a
potentially unsafe environment. Document interaction with the physician
and health-care team.
Follow written physician orders; be particularly vigilant in carrying out an
order that changes over time; e.g., tapering of medication or oxygen at
specified time intervals.
Informed consent is the process of informing the patient, not
simply completing the form with the patients signature.
Informed consent involves providing the patient with adequate medical
information so that he or she can make a reasonable decision as to
treatment based upon that information. In urgent care situations it can
be impossible to obtain a patients informed consent for an immediate
intervention.
State laws differ regarding the informed consent standards; know your
states informed consent law and the hospitals policy and procedure for
obtaining informed consent.
(Continued on the following page)
BASICS
BASICS
5
Document as you go. It establishes a timeline for the incident as well as
conveying the interventions and outcomes accurately. Time, date, and sign
every individual entry.
Always note at what time, by what route, and how much medication you
or another member of the team has administered. Always record
response to the medication and the time the response(s) occurred or the
time you observed for a response, whether there was a response or not.
The same applies to any non-drug intervention.
Always note the time you called the physician or nurse practitioner and
his or her response.
If you do not get the response from the physician or nurse practitioner
you think is required for the patients best interests, call your
administrative superior (nurse manager), and report the problems.
Document your call and the supervisors response. Do not blame or
complain about someone; just note that you called the supervisor to
report the patients condition.
If you fail to document something, write another entry called Addendum
to the note above, and give the time and date of the first note.
Delegation Guidelines
The National Council of State Boards of Nursing defines delegation as
transferring to a competent individual the authority to perform a selected
nursing task in a selected situation. The nurse retains accountability for the
delegation. Check your states nurse practice act for details about which
nursing activities cannot be delegated.
Sample of nursing tasks that cannot be delegated:
BASICS
BASICS
7
Analyzing
Analysis involves breaking the whole into parts and discovering the
relationships of the part to the whole. Is the problem hypotension? Think
about the factors that influence blood pressure: What is the hemoglobin
level, urinary output, recent blood loss? Can you assess cardiac output?
Is the patient on medications that affect blood pressure?
Think about what you have discovered through assessment. Ask if the
laboratory values or tests suggest a cause.
Consider if the data fit any of the known complications of the patients
condition. Do the data suggest something is worsening? Link the data
to the patients physical status. Do the data fit?
Ask yourself if you are making the data fit and if you have overlooked
another cause.
Ask yourself what other information is needed. Do you need to assess
another body system? Have you asked the patient about all recent related
events? Should you check the medication record?
Other types of problems may require a different set of information (What
other supplies are needed? Does the patient require referral to a religious
leader? Does the family need to see a social worker?).
While you analyze, double-check that you are not making erroneous
assumptions. Ask yourself if the data can be interpreted another way.
Ask yourself what other issues or conditions could cause similar signs
and symptoms.
Diagnosing
The end result of analysis is a conclusion. For nurses who are thinking
critically about a problem, this conclusion is a nursing diagnosis or a
definition of the problem.
State the problem clearly, what the problem is related to, and what data
support this conclusion. State the desired outcomes as well and in what
time frame you expect them to be achieved.
Determine the significance of this problem. Ask yourself again: Is it urgent?
Does it have the potential to cause a sudden and rapid deterioration in the
patients health status? Is it imperative that you act immediately? Do you
need help?
Planning
Consider which intervention(s) will be most effective; predict the consequences of the intervention and if it will produce the desired outcome.
Urgent problems require that you immediately summon a
physician or nurse practitioner.
Implement the plan; document all problems and interventions.
(Continued on the following page)
BASICS
BASICS
Evaluating
Evaluation is the step that lets you know if the plan is working.
Assess the status of the problem at appropriate intervals; evaluate if the
interventions are effective.
Determine if further intervention is required.
9
Be careful switching from oral to IV, IM, IT, or other route. Dosages
change, and different drugs may not provide as much pain relief. Use an
equianalgesic dosing table for guidance.
Teach or arrange for instruction in biofeedback, relaxation exercises, and
hypnosis.
All can reduce pain and stress and give a greater sense of control.
Do not avoid opioids because of fear the patient will become addicted.
Encourage patients to request pain medication before pain becomes
severe.
Suggest administering medication on an around-the-clock schedule to
maintain therapeutic blood levels.
Suggest time-released pain medications to avoid peaks and valleys in
pain control.
Consult with a pain management clinical specialist, if available.
Include family in pain control plan.
Pain Management
Numeric Scale
0
No
pain
1
2
Mild
pain
4
5
Moderate
pain
6
7
Severe
pain
8
9
Very severe
pain
10
Worst
possible
pain
2
HURTS
LITTLE BIT
HURTS
LITTLE MORE
HURTS
EVEN MORE
8
HURTS
WHOLE LOT
10
HURTS
WORST
Wong-Baker FACES Pain Rating Scale. Use for children over 3 years. (From Hockenberry
MJ, Wilson D, Winkelstein ML: Wongs Essentials of Pediatric Nursing, ed. 7, St. Louis,
2005, p. 1259. Used with permission. Copyright, Mosby.)
BASICS
BASICS
PQRST
P (provokes/point) ............What provokes the pain (exertion, spontaneous
onset, stress, postprandial, etc.)
Point to where the pain is.
Q (quality) .........................Is it dull, achy, sharp, stabbing, pressing, deep,
surface, etc.? Is it similar to pain you have had
before?
R (radiation/relief) ............Does it travel anywhere (to the jaw, back, arms,
etc.)? What makes it better (position, being still)?
What makes it worse (deep inspiration,
movement)?
S (severity/s/s) ..................Explain the 10/10 pain scale and have patient rate
pain. Are there any signs or symptoms associated
with this pain (n/v, dizziness, diaphoresis, pallor,
SOB, dyspnea, abnormal vital signs, etc.)?
T (time/onset) ...................When did it start? Is it constant or intermittent?
How long does it last? Sudden or gradual onset?
Does it start after you have eaten? Frequency?
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COLDERRA
Characteristics..........................................Dull, achy, sharp, stabbing, pressure?
Onset ..........................................................................................When did it start?
Location ..................................................................................Where does it hurt?
Duration .........................................................How long does it last? Frequency?
Exacerbation ......................................................................What makes it worse?
Radiation...........................................Does it travel to another part of the body?
Relief.....................................................................................What provides relief?
Associated s/s ......................................Nausea, anxiety, autonomic responses?
Advantages
Disadvantages
Oral
IM
Subcutaneous
BASICS
BASICS
Advantages
Disadvantages
IV PCA
IT Epidural
Transdermal
Sublingual
Cultural Sensitivity
It is not possible for nurses to know intimately all other cultures different
from his or her own. It is possible, however, to acknowledge that significant
cultural variations exist and to adopt an attitude of sensitivity that includes
a desire to learn about and respect the culture of the patients for whom you
care.
Potential for Stereotyping
Books that list cultural characteristics of various groups have some value but
can lead to stereotyping. Too often people make assumptions based on the
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color of someones skin or other overt characteristics. The challenge for
nurses is to learn whether a person considers himself or herself to be a
member of a group and to recognize that significant variation exists within
groups.
Cultural Assessment
Cultural assessment covers many factors, too numerous for this book. Keep
in mind that cultural variation is frequently expressed within domains
applicable to any culture. Maintain a respectful and open attitude as you
learn about each patient. Common domains of importance related to health
care include:
Communication styleseye contact, personal space, tone of voice, and
more. Observe each patient, and follow his or her lead. If you are not sure,
ask politely and respectfully.
Religionyou may ask how important religion is to the patient in daily life
and if he or she consults with another member of that religion in healthcare matters.
Languageit is very important to use competent interpreters when
obtaining and receiving health information. Do not automatically use
a family member. Sensitive information may be embarrassing for the
two people to discuss. Try to get someone of about the same age and
gender as the patient. Always ask if the patient is willing to use the
interpreter. In an emergency, communicate through the oldest family
member present.
Family relationshipsfamilies may have a hierarchy that includes a
spokesperson, so to speak. Show respect for that persons role. As always,
do not reveal confidential information about a persons health without the
express consent of the patient.
Food preferencesproviding the patients preferred food can be
instrumental in rate of recovery. Ask about any natural remedies the
patient has or is using.
Health beliefsWhat causes illness, how care is provided, how the patient
handles being ill or in pain are powerful cultural beliefs. Ask the patient or
family members about these issues and integrate the information into
your plan of care.
Birth and death ritualsEnd-of-life beliefs can vary significantly within
any culture. Suggest meeting with the family if the patient approves of
you sharing or receiving information about personal preferences. Discuss
issues such as organ donation, autopsy if applicable to the case, special
care of the body, and what the family will want to do in the immediate
time after death.
BASICS
BASICS
Spiritual Care
Providing spiritual care means different things to different people. Some
nurses may be too intimidated to address this issue. Many do not feel
competent to do so or that it is none of their business. You can always ask
the patient how he or she feels spiritually. The answer will be very revealing
in terms of willingness to discuss the topic. Follow the patients lead, and
never impose your own beliefs. Often, the best spiritual intervention is to
ask open-ended questions and then listen.
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15
Focused Assessment of the CV System
A focused assessment of CV status includes:
The core cardiovascular systemthe heart, its rate and rhythm, the
carotid arteries, blood pressure, and other hemodynamic measures.
The peripheral vascular systemthe extremities, particularly the
lower extremities.
The lungsadventitious sounds, cough, and oxygenation status.
Mental statuslevel of alertness, restlessness, confusion, irritability,
or stupor.
Vital signs:
Blood pressure, heart rate, respiratory rate, O2 saturation.
Mental status, head and neck:
Look for restlessness, LOC, circumoral cyanosis, color of conjunctiva,
jugular venous distention.
Inspect the anterior chest:
Look for visible pulsations of the chest wall.
Palpate the anterior chest:
Locate apical beat, which is the point of maximum impulse (PMI).
Assess for heavesa very forceful PMI.
Assess for thrillsa palpable murmur; feels like a cat purring.
Auscultate the heart and lungs:
Obtain rate and rhythm; assess for rhythm abnormalities.
Listen for normal heart sounds and possible murmurs.
Use the diaphragm of stethoscope first, then the bell.
Listen for carotid abdominal and femoral bruits.
Assess extremities: Check for:
Cyanosis, temperature, color, and amount of moisture.
Capillary refill time in hands and feet.
Changes in foot color, ulcers, varicose veins.
Edema of lower extremities (check sacrum if client is bedridden).
Presence and equality of pedal pulses. If pulses are not palpable,
use a Doppler sonogram.
Assess current symptoms:
RED FLAG symptoms require immediate attention and intervention.
Shortness of breath.
Chest pain, possibly with neck, jaw, or left arm pain.
Syncope possibly with palpitations and shortness of breath.
Palpitations possibly with chest pain and dizziness.
Cyanosis of lips, fingers, or nailbeds.
Pain, coolness, pallor, or pulse changes in extremities.
Sweating, nausea, vomiting, fatigue (especially in women).
CARDIAC
CARDIAC
Assessment Guides
Circulation Scale
Pulse Scale
Capillary Refill
Pulse Strength
Normal
3 sec
Absent
Delayed
3 sec
Weak
Normal
Full
Bounding
Edema Scale
Press thumb carefully into edematous area, usually on the shin
(pretibial edema) or dorsum of foot (pedal edema):
01/4 inch; disappears in 5 sec
Potential Causes
Cardiac
Pulmonary
Combined cardiopulmonary
Other
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Arterial Hematoma
CLINICAL PICTURE
The patient may have:
Pressure dressing to radial/brachial/femoral artery insertion site that is
saturated with blood.
Cannulated artery that has been inadvertently decannulated and is
hemorrhaging.
Hematoma, possibly pulsatile, around arterial puncture site.
IMMEDIATE INTERVENTIONS
Notify physician or NP.
Place patient in a supine position with affected limb extended.
Don sterile gloves and, using folded sterile gauze dressings, apply
firm pressure 2 cm above puncture site, using the first three fingers
of one hand.
Continue to apply pressure for 10 minutes or more, until bleeding has
been controlled.
CARDIAC
CARDIAC
FOCUSED ASSESSMENT
Monitor distal pulses, skin color, temperature, and sensation of affected
limb.
Assess VS, noting decrease in BP or increase in HR.
Assess LOC and patients ability to maintain extremity in immobile,
neutral position.
Assess for pain.
BE PREPARED TO
Assist physician or NP with cannulation of an alternate arterial site.
Obtain IV access for the administration of blood, clotting factors, or
anticoagulant reversal agents such as protamine sulfate.
POSSIBLE ETIOLOGIES
Hemophilia, von Willebrands disease, thrombocytopenia, DIC, vascular
trauma or iatrogenic arterial injury, anticoagulant therapy, antiplatelet
therapy, thrombolytic therapy.
Arterial Occlusion
CLINICAL PICTURE
The patient may have:
Numbness, tingling, severe burning pain, or coolness in affected extremity.
Loss of sensation in the extremity.
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Pale, mottled, cyanotic, or ashen extremity.
Edematous, tight, shiny skin over affected extremity.
Capillary refill 3 sec or absent.
IMMEDIATE INTERVENTIONS
Check all arterial pulses in the affected extremity. Compare with those in
contralateral extremity.
Assess any sites of arterial puncture (e.g., arteriogram puncture site or
A-line insertion site) for swelling or hematoma.
Assess mobility of affected extremity; compare with that of contralateral
extremity.
Assess VS.
Notify physician or NP.
Document patients status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
Assess for pallor, pain, paresthesias, paralysis, and pulselessness (5 Ps)
by assessing circulation (skin color, capillary refill, pulses), movement
(flexion, extension, rotation), and sensation (response to pinprick or light
touch; pain level) of affected extremity.
Assess pulses with Doppler amplification.
Assess bandages or cast proximal to diminished pulses.
BE PREPARED TO
Remove any external fixtures (casts) on the extremity, or assist the
physician or NP with fasciotomy for immediate relief of pressure.
Prepare the patient for surgery.
Initiate large-bore IV access.
POSSIBLE ETIOLOGIES
Compartment syndrome, major vascular injury, thrombus, ruptured aortic
aneurysm, local or regional block anesthesia, cord injury, lymphedema,
fracture, hypotension, hypothermia, dehydration, shock.
CARDIAC
CARDIAC
Bradycardia
CLINICAL PICTURE
The patient may have:
HR 60 bpm.
Nausea and vomiting, dizziness or lightheadedness.
Signs of unstable bradycardia:
Altered LOC.
Chest pain, shortness of breath (SOB).
Hypotension, pulmonary congestion, and/or cyanosis.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Monitor VS.
Set up cardiac monitoring, and monitor rate and rhythm.
Assess recent laboratory results.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
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POSSIBLE ETIOLOGIES
Medication toxicity, vasovagal response, hyperkalemia, hypothermia,
hypothyroidism, sepsis, severe infection, hypoglycemia, hypothermia,
excellent physical condition (athletes), myocardial infarction, shock.
Chest Pain
CLINICAL PICTURE
The patient may have (see table below on Possible Causes of Chest Pain):
Substernal or epigastric sensations of fullness, pressure, or tightness; pain
may radiate to left neck, jaw, back, and/or arm.
Cool, pale, and/or diaphoretic skin.
Nausea, vomiting.
SOB, tachypnea.
Dizziness, fatigue, fainting.
Marked anxiety, expression of impending doom.
IMMEDIATE INTERVENTIONS
Elevate head of bed (HOB) to facilitate breathing.
Administer high-flow O2 by nonrebreather mask (1015 L/min) or by nasal
cannula (46 L/min).
Assess VS, character and quality of pain (PQRST), skin color.
Check for standing orders of nitrogylcerine (NTG) sublingual 0.4 mg q
5 min 3 doses maximum (hold for BP 90 mm Hg) and one 325 mg
nonenteric-coated aspirin. Administer STAT.
Check for IV access. Prepare to initiate saline lock IV access.
Notify physician or NP.
Document patients status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
CARDIAC
CARDIAC
BE PREPARED TO
POSSIBLE ETIOLOGIES
22
Quality
and Relief
Location and
Radiation
Severity and
Time (Duration)
No provocation;
large, heavy meal;
extreme exertion,
stress, or fright.
Sudden onset.
Pressure,
squeezing.
No relief.
Substernal
anterior chest or
epigastrium,
to left neck, jaw,
arm, back
Severe, lasting
longer than
20 min.
Angina
Provoked by exertion.
Sudden onset.
Pressure,
tightness.
Rest or sl NTG
provides relief
Same as MI
Mild to moderate,
lasting 2 min.
Pneumonia
No provocation or
coughing.
Gradual or sudden
onset.
Anterior chest,
shoulder, neck.
Moderate, lasting
hours.
PE
No provocation.
Sudden.
Variable.
None, mild, or
moderate of
variable
duration.
23
MI
CARDIAC
Etiology
Etiology
Provocation
and Onset
Quality
and Relief
Location and
Radiation
Severity and
Time (Duration)
Pericarditis
No provocation;
deep breathing,
coughing.
Gradual or sudden
onset.
Sharp.
Substernal
anterior chest.
Moderate to
severe, endures
for hours to
days.
Epigastric
disorders
Gradual or sudden.
Sharp, burning
when patient
in upright
position,
antacids
provide relief.
Chest, throat,
RUQ, LUQ, back.
Musculoskeletal
disorders
Gradual or sudden.
Dull ache;
possible sharp
pain.
Rest and mild
analgesics or
NSAIDs
provide relief.
Arm, shoulder,
neck, back,
sternum, ribs,
abdomen.
Mild to moderate,
lasting minutes
to hours.
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CARDIAC
25
Heart Failure
CLINICAL PICTURE
The patient may have:
Fatigue, weakness, anxiety.
SOB, orthopnea, dyspnea, adventitious breath sounds (rales or crackles),
cyanosis.
Change in mental status anxiety, restlessness, confusion.
Edema, jugular vein distention, increased CVP, positive fluid balance.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
CARDIAC
CARDIAC
Hemorrhage/Wound Hemorrhage
CLINICAL PICTURE
The patient may have:
Saturated postoperative dressings.
Excessive amounts of blood in wound drainage system.
Peri-incisional swelling and hematoma.
Subtle changes in LOC, anxiety, irritability, restlessness, decreased
alertness (early CNS signs of blood loss).
Confusion, combativeness, lethargy, coma (later CNS signs).
Increased HR to severe tachycardia.
Delayed capillary refill (3 sec), diminished peripheral pulses (l2),
cool extremities and pale, mottled, or cyanotic skin.
Slightly elevated RR to severe tachypnea.
Hypotension.
Narrowing of pulse pressure.
Thirst.
Bruising around umbilicus or retroperitoneally in flank areas (internal
bleeding).
IMMEDIATE INTERVENTIONS
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FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
Hypertensive Urgency/Emergency
Hypertensive urgency: systolic BP 200 mm Hg or a diastolic BP 120 mm
Hg. Hypertensive emergency: diastolic BP 140 mm Hg with evidence of
acute end-organ damage.
CLINICAL PICTURE
The patient may have:
Fatigue, headache, restlessness, confusion, visual disturbances, seizure.
Dyspnea, tachycardia, bradycardia, pedal edema, chest pain.
Lightheadedness, dizziness.
Nausea, vomiting.
CARDIAC
CARDIAC
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
Hypotension
CLINICAL PICTURE
The patient may have:
A systolic BP of 90 mm Hg or systolic BP 40 mm Hg less than baseline.
Altered LOC or orientation.
Cool, pale, ashen, cyanotic, diaphoretic skin.
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SOB, dyspnea.
Nausea and vomiting.
Tachycardia or bradycardia.
Decreased urine output (30 mL/hr).
IMMEDIATE INTERVENTIONS
Place patient in a supine position with legs elevated above heart level to
increase circulation to vital organs. Note: This position is contraindicated
if the airway is compromised; to maintain airway patency, place patient
in supine or low Fowlers position (HOB slightly elevated).
If respiratory effort inadequate (RR 8, cyanosis, SaO2 90%), administer
high-flow O2 via mask (1015 L/min), or manually assist ventilations with
an Ambu bag (mask-valve device).
Control bleeding, if any, with direct pressure.
Check for patent IV access. Note: IVF is not routinely administered until
reason for hypotension is determined. Hypotension could be due to
cardiac compromise, in which case fluids might be contraindicated.
Notify physician or NP.
Document patients status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
Assess LOC, orientation, baseline VS (temperature, HR, RR, BP), and pulse
quality and rhythm.
Assess respiratory effort and airway patency.
Assess skin for color, temperature, moistness, turgor, and capillary refill.
Assess for associated symptoms (chest pain, dyspnea, nausea).
Assess I&O; ask patient about recent history of vomiting, diarrhea, or
urinary symptoms (burning, frequency, flank pain, hematuria).
Assess MAR for medications that can affect blood pressure.
BE PREPARED TO
CARDIAC
CARDIAC
POSSIBLE ETIOLOGIES
Palpitations
CLINICAL PICTURE
The patient may have or be:
Sensation of fluttering in chest, heart racing, or dizziness.
Tachycardia, bradycardia, irregular rate.
Cold and clammy skin, hypotensive (drop in BP 20 mm Hg from
baseline).
SOB, dyspnea, nausea.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
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Keep IV line patent, and infuse IVF.
Review laboratory data such as Hgb/Hct; BUN and creatinine; electrolytes,
other chemistries, blood glucose, liver and cardiac enzymes.
Check MAR for possible drug side effect or interactions.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
POSSIBLE ETIOLOGIES
Conditions
Cardiac
Drugs
Vascular
Other
CARDIAC
CARDIAC
Syncope
CLINICAL PICTURE
The patient may have or be:
Lightheadedness, feeling faint.
Palpitations.
Tachypnea, hyperventilation.
Nausea, vomiting.
Cool, pale, diaphoretic skin.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
32
33
Test stool for occult blood.
Chart patient status and convey to physician or NP.
BE PREPARED TO
Obtain IV access.
Administer IVF or a fluid challenge.
Obtain a chemstick blood sugar level.
Administer 50% dextrose IV.
Order specific laboratory tests to be drawn STAT.
POSSIBLE ETIOLOGIES
Conditions
Cardiac
Neurological
Vascular
Other
Hyperventilation, hypoxia.
Tachycardia
CLINICAL PICTURE
The patient may have:
HR 100150 bpm (sinus tachycardiamay be asymptomatic);
HR 150 bpm (supraventricular tachycardia).
Palpitations, dizziness or lightheadedness.
Chest discomfort, SOB.
Anxiety, restlessness.
CARDIAC
CARDIAC
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
34
35
POSSIBLE ETIOLOGIES
A & P Snapshot
Brachiocephalic artery
Aortic arch
Left pulmonary
artery
Right pulmonary
artery
Left atrium
Left pulmonary
veins
Mitral valve
Right pulmonary
veins
Pulmonary
semilunar valve
Left ventricle
Aortic
semilunar
valve
Right atrium
Tricuspid
valve
Interventricular
septum
Inferior vena
cava
Chordae
tendinea
Apex
Right
ventricle
Papillary
muscles
CARDIAC
CARDIAC
Maxillary
Facial
External carotid
Common carotid
Subclavian
Axillary
Pulmonary
Occipital
Internal carotid
Vertebral
Brachiocephalic
Aortic arch
Intercostal
Brachial
Renal
Gonadal
Inferior
mesenteric
Radial
Ulnar
Celiac
Left gastric
Hepatic
Splenic
Superior
mesenteric
Abdominal aorta
Right
common iliac
Internal iliac
Deep
palmar
arch
External iliac
Deep femoral
Superficial
palmar arch
Femoral
Popliteal
Anterior tibial
Posterior tibial
Arterial circulation.
36
37
Focused Respiratory System Assessment
A focused assessment of respiratory status includes:
Ease of breathing and respiratory rate
Lung sounds
Use of O2 and oxygenation
ABGs
Ventilator assessment, if applicable
Mental status level of alertness, restlessness, confusion, irritability,
or stupor
Ease of breathing and respiratory rate:
Ask the patient how his breathing is; use his subjective terminology
when documenting. Ask if SOB is triggered by activity and if rest
relieves the feeling. Ask about energy levels and if the patient can eat
and talk comfortably.
Assess ratenormal rate is 1220; however, most adults have a
respiratory rate in the lower end of the range. Rates 20
respirations/min should be investigated. A rate 26 is cause for alarm,
unless its the patients baseline.
Assess use of accessory muscles or nasal flaring, both of which indicate
respiratory distress.
Lung sounds:
Listen to lung sounds in all fields. Ask the patient to breathe deeply with
his mouth open.
Note adventitious sounds, areas where air movement is not heard,
or areas where breath sounds are diminished.
Use of O2 and oxygenation:
Note the amount of O2 ordered and the method of delivery (e.g., 3
L/min via nasal cannula).
Note if the patient is wearing the O2 all the time and if the device is
correctly applied.
Check pulse oximetry to assess percentage of oxygen saturation (SaO2):
97% to 99% is normal, although 93% to 97% may be normal for some
patients. Always look at the whole picture, not just a single reading.
Also, pulse oximetry can be inaccurate in the presence of peripheral
vascular disease. Reading of 90% or less indicates possible need for
ventilation support. Compare trends in O2 saturation to determine if
oxygen therapy is effective.
Analyze ABG results:
ABG allows for assessment of acid-base balance, ventilation, and
oxygenation. It also tells how well the lungs and kidneys are
compensating or responding to treatments.
RESP
RESP
Aspiration
CLINICAL PICTURE
The patient may have:
Sudden onset of coughing and shortness of breath (SOB) associated with
eating, drinking, or regurgitation.
Tachypnea, dyspnea, cyanosis, decreased breath sounds.
Tachycardia, bradycardia.
Crackles and rhonchi (usually on the right, but may be on the left or
bilaterally).
Altered mental status.
Fever.
Chest pain (pleuritic).
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
38
39
Assess effectiveness of measures taken to clear airway.
Assess oxygenation status: level of consciousness (LOC), SaO2, presence
of circumoral and nailbed cyanosis.
Assess HR, BP, respirations (rate, rhythm, and effort), and work of
breathing.
Auscultate lung fields.
BE PREPARED TO
POSSIBLE ETIOLOGIES
Emesis; disorders that affect normal swallowing and gag reflex (depression of the laryngeal reflexes, stroke); disorders of the esophagus
(esophageal stricture, gastroesophageal reflux); use of sedative drugs;
anesthesia; coma; excessive alcohol consumption; tracheitis; epiglottitis;
foreign body aspiration.
IMMEDIATE INTERVENTIONS
Immediately cover chest tube insertion site with sterile petroleum gauze
(occlusive dressing) covered with several 4 4 pads.
Maintain constant pressure, but do not tape dressing in order to allow air
to escape from chest cavity.
RESP
RESP
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
Dyspnea/SOB
CLINICAL PICTURE
The patient may have or be:
Mild sensation of discomfort to feeling of suffocation.
Difficulty breathing; inability to take a deep breath.
Cyanotic, ashen or pale, and diaphoretic.
40
41
Tachypneic, wheezing, poor air movement, use of accessory muscles.
Restless, confused, anxious, fearful, agitated.
Maintaining an upright position to facilitate breathing.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
RESP
RESP
BE PREPARED TO
Obtain IV access.
Change or set up an O2 delivery system.
Assist with diagnostic testing.
Obtain ABGs.
Place a nasal or oral airway.
Suction the oropharynx/trachea.
Administer medication.
Assist with intubation or chest tube placement.
Transfer to ICU.
POSSIBLE ETIOLOGIES
Potential Causes
Cardiac
Pulmonary
Combined
cardiopulmonary
Other
42
43
Hypoventilation/Ineffective Breathing Pattern
CLINICAL PICTURE
The patient may have or be:
Dyspnea at rest or on exertion.
Hypoxic and appear cyanotic, ashen, or pale.
Lethargic, stuporous, obtunded, or unconscious.
Rapid and shallow breathing pattern, periods of apnea as in CheyneStokes (neurological), or notably slow (narcotic) breathing.
Signs of right-sided heart failure (JVD, peripheral edema, and
hepatomegaly).
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
RESP
RESP
POSSIBLE ETIOLOGIES
Pulmonary Embolism
CLINICAL PICTURE
The patient may have or be:
Dyspnea, pleuritic chest pain, tachycardia.
Anxiety, diaphoresis.
Syncope, hypotension.
Wheezing.
Lower extremity edema.
Signs and symptoms of thrombophlebitis.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
44
45
BE PREPARED TO
Obtain IV access.
Change or set up an O2 delivery system.
Administer medications or fluids to maintain blood pressure.
Assist with obtaining diagnostic studies (CXR, V/Q scan, spiral CT scan,
pulmonary angiogram).
Obtain ABGs.
Obtain serial PTTs, and titrate heparin infusion.
Transfer to ICU for high acuity care or thrombolytic therapy.
POSSIBLE ETIOLOGIES
Embolization of thrombi from deep veins of the femur, pelvis, and lower
extremities from multiple causes including venous stasis, hypercoagulable
states, surgery and trauma, oral contraceptive and estrogen replacement
therapy, pregnancy, malignancy.
Respiratory Distress/Failure
CLINICAL PICTURE
The patient may have:
Dyspnea, excessive work of breathing.
Cyanosis of skin and mucous membranes.
Anxiety, confusion, restlessness, or somnolence.
Tachycardia and dysrhythmias (due to hypoxemia and acidosis).
Decreased O2 saturation (SaO2 90% is considered abnormal, and
levels below this can represent unstable respiratory status that requires immediate intervention; however, evaluate in context of patient
baselinesome patients with COPD may never have SaO2 greater than
88% but are stable.
Abnormal ABG results: Hypoxemic respiratory failure, characterized by
a PaO2 60 mm Hg and a normal or low PaCO2, is most common and
is caused by any acute disease of the lung (pulmonary edema, pneumonia). Hypercapnic respiratory failure, characterized by a PaCO2 50 mm Hg,
is associated with drug overdose, neuromuscular disease, chest wall
abnormalities, and severe airway disorders such as asthma or
emphysema.
Seizures (may occur with severe hypoxemia).
IMMEDIATE INTERVENTIONS
RESP
RESP
FOCUSED ASSESSMENT
BE PREPARED TO
Call a code.
Assist with intubation.
Transfer to ICU.
POSSIBLE ETIOLOGIES
46
47
Ventilators/Mechanical Ventilation
Indications
Airway obstruction.
Inadequate oxygenationO2 saturation (90% on hi-flow oxygen via
nonrebreather mask).
Inadequate ventilationhypoventilation (high pCO2, pH acidosis).
Increased work of breathing, ineffective breathing pattern.
Airway protection.
Common Settings
AC (assist control)patient triggers ventilator to deliver a breath. If apnea
occurs, a minimum rate and volume will be delivered to the patient.
CPAP (continuous positive airway pressure)continuous, nonstop
positive pressure is applied throughout entire respiratory cycle.
BiPAP (bilevel positive airway pressure)same as CPAP but with two
preset pressure settings: one for inspiration and one for expiration.
CMV (continuous mandatory ventilation)ventilator delivers a set tidal
volume at a set rate regardless of patients own attempts to breathe.
Expect patient to require sedation.
IMV (intermittent mandatory ventilation)ventilator delivers a set tidal
volume at a set rate, yet also allows the patient to initiate breaths.
PSV (pressure support ventilation)for patients with spontaneous
breathing. Ventilator delivers a preset positive pressure for the duration
of inspiration when the patient initiates a breath.
SIMV (synchronized intermittent mandatory ventilation)ventilator
is triggered only by a patient-activated demand valve and, therefore,
synchronizes with the patients own respiratory efforts.
PEEP (positive end-expiratory pressure)maintains a preset positive
airway pressure at the end of each expiration. PEEP is used to treat a
PaO2 of 60 mm Hg on FiO2 of 50%.
RESP
RESP
Alarm
Low-Pressure
Alarm
Usually caused by
system disconnections or leaks.
Interventions
Reconnect patient to ventilator.
Evaluate cuff, and reinflate if needed (if
ruptured, ET tube will need to be
replaced).
Evaluate connections, and tighten or
replace as needed.
Check ET tube placement (auscultate lung
fields, and assess for equal, bilateral
breath sounds).
48
49
Alarm
Interventions
High-Pressure
Alarm
Usually caused by
resistance within
the system. Can
be kink or water
in ET tubing,
patient biting the
tube, copious
secretions, or
plugged tube.
High Respiratory
Rate
Can be caused by
anxiety or pain,
secretions in ET
tube/airway,
hypoxia
Suction patient.
Look for source of anxiety (e.g., pain).
Evaluate oxygenation.
Low Exhaled
Volume
Usually caused
by ET tubing
disconnection,
inadequate seal
Tracheostomy Dislodgement
CLINICAL PICTURE
The patient:
Coughs out tracheostomy tube.
If on a ventilator, low pressure alarms may sound.
IMMEDIATE INTERVENTIONS
RESP
RESP
FOCUSED ASSESSMENT
Assess patients ability to breathe through stoma. Look, listen, and feel for
signs of air movement through stoma.
Assess tracheostomy site for secretions (blood, mucus, etc.), swelling, or
trauma.
Auscultate lungs, and assess patients ability to cough effectively and clear
airway.
BE PREPARED TO
Call a code.
Assist with the insertion of a new tracheostomy tube.
Perform tracheostomy care.
50
51
POSSIBLE ETIOLOGIES
RESP
RESP
52
53
Oxygen Delivery Systems
Cannula (nasal prongs)
Indicated when low-flow, smallpercentage oxygen therapy is desired.
Flow rate of 16 L/min delivers
24%44% oxygen.
Allows patient to eat, drink, and talk.
Extended use can dry the nose and
nasopharynx; use with humidifier.
Simple Mask
Indicated when desired FiO2 to be
delivered is 40%60%.
Flow rate of 610 L/min delivers
35%60% oxygen.
Lateral perforations permit exhalation
of CO2.
Permits humidification.
Exhalation
ports
Elastic
strap
To oxygen
source
Simple mask.
Bag-Mask (nonrebreather)
Indicated when high concentrations of O2
are desired.
Flow rate of up to 15 L/min delivers up to
100% oxygen.
One-way flaps open and close with respiration, resulting in a high concentration of
delivered oxygen and minimal to no CO2
rebreathed by the patient.
(one-way valves)
Exhalation
port
Inhalation
port
Bag-mask (nonrebreather).
RESP
RESP
One-way
valve
Reservoir
Mask
Bag
O2 supply
Humidified Systems
Indicated for patients requiring longterm oxygen therapy to prevent
drying of mucous membranes.
Setup may vary among brands.
Fill canister with sterile water to
recommended level, attach to
oxygen source, and attach mask
or cannula to humidifier.
Adjust flow rate.
To oxygen
source
To patient
Maximum
fill line
Sterile water
in reservoir
Humidified systems.
54
Minimum
water level
line
55
Transtracheal Oxygenation
Indicated for patients with a
tracheostomy who require longterm oxygen therapy and/or
intermittent, transtracheal
aerosol treatment.
Ensure proper placement (over
stoma, tracheal tube).
Assess for and clear secretions
as needed.
Assess skin for signs of irritation.
Chain necklace
Tract
Transtracheal catheter
(connect to oxygen)
Trachea
Transtracheal oxygenation.
Artificial Airways
Oropharyngeal Airway
Indicated for unconscious
patients who do not have a
gag reflex.
Measure either from the corner of the mouth to the earlobe
or from the center of the mouth
to the angle of the jaw.
Rotate airway 180 while inserting into oropharynx.
OROPHARYNGEAL AIRWAY
TRACHEA
TONGUE
ESOPHAGUS
OROPHARYNGEAL
AIRWAY
PHARYNX
Oropharyngeal airway.
Nasopharyngeal Airway
Indicated for patients with a gag
reflex, comatose with spontaneous
respirations, lockjaw.
Measure from the tip of the
patients nose to the earlobe.
The diameter should match that
of the patients pinkie.
NEVER insert in the presence
of facial trauma.
PHARYNX
NASOPHARYNGEAL
AIRWAY
TRACHEA
ESOPHAGUS
Nasopharyngeal airway.
RESP
RESP
Endotracheal Tube
Indicated for apnea, airway obstruction, respiratory failure, risk of
aspiration, combative patient (protect from further injury), or when goal of
therapy is hyperventilation.
Can be inserted through the mouth or nose.
Inflated cuff protects patient from aspiration.
Endotracheal tube.
56
57
A & P Snapshot
Arteriole Pulmonary
capillaries
Alveolar
duct
Frontal sinuses
Sphenoidal
sinuses
Nasal cavity
Nasopharynx
Soft palate
Epiglottis
Larynx and
vocal folds
Trachea
Alveolus
B
Superior lobe
Right lung
Venule
Left lung
Left
primary
bronchus
Superior
lobe
Right
primary
bronchus
Middle
lobe
Bronchioles
Inferior lobe
Inferior
lobe
Mediastinum
Cardiac notch
Diaphragm
A
Respiratory system.
RESP
Pleural
membranes
Pleural space
RESP
sp
ac
e
Pulmonary
capillary
e
Alv
ir
ra
ola
O2
pickup
O2
Hb
Hb O2
O2
O2
Systemic
capillary
O2
delivery
Plasma
Hb O2
Red blood
cells
Hb
O2
O2
in su
lls tis
Ce ral
e
iph
per
A
58
O2
59
sp
ac
Pulmonary
capillary
e
Alv
ir
ra
ola
CO2
delivery
CO2
CO2
H2CO3
H 2O
CO2
Systemic
capillary
Hb
Hb CO2
Hb
CO 2
H2CO3
H 2O
Hb
in su
lls tis
Ce ral
CO2
iph
per
CO2
RESP
CO2
pickup
NEURO
Neurological Assessment
Mental Status
See Mini Mental Status Examination.
Assess affect, mood, appearance, grooming.
Assess speech for clarity and coherence.
Assess LOCalert, lethargic, stuporous, obtunded.
Assess orientationperson, place, time.
Cranial Nerves
See Cranial Nerve Assessment in this tab.
Balance and Coordination
Gait/balance
Observe gait patterns while instructing patient to walk away from you
and then back again.
Have patient hop in place on each foot.
Have patient stand from a sitting position.
Coordination
Instruct patient to tap the tip of the thumb with the tip of the index
finger as fast as possible.
Instruct patient to touch nose and your index finger alternately several
times. Continually change the position of your finger during the test.
Sensation, Strength, Motion, Reflexes
Ask about altered sensations such as numbness and tingling.
Using your finger and a toothpick, instruct patient to distinguish between
sharp and dull sensations. Compare left side of body with right, with
patients eyes closed.
Assess motor strength of all four extremities.
Muscle Strength Grading Scale
0
No muscle movement
1
Visible muscle movement, but no movement at the joint
2
Movement at the joint, but not against gravity
3
Movement against gravity, but not against added resistance
4
Movement against resistance, but less than normal
5
Normal strength
Assess reflexes using a reflex hammer
Tendon Reflex Grading Scale
0
Absent
1
Hypoactive
2
Normal
3
Hyperactive without clonus
4
Hyperactive with clonus
60
61
Assess plantar (Babinskis) reflex by stroking the lateral aspect of the
sole of each foot with the reflex hammer. Normal response is flexion
(withdrawal) of the toes.
5
4
3
2
1
6
5
4
3
2
1
NEURO
NEURO
Name
Function
Test
Olfactory
Smell
II
Optic
Visual acuity
Visual field
III
Oculomotor
Pupillary
reaction
IV
Trochlear
Eye
movement
Trigeminal
Facial
sensation
Motor
function
VI
Abducens
Motor
function
VII
Facial
Motor
function
Sensory
Hearing
Balance
VIII
Acoustic
IX
Glossopharyngeal
Swallowing
and voice
Vagus
Gag reflex
XI
Spinal
accessory
Neck motion
XII
Hypoglossal
Tongue
movement
62
63
Mini Mental Status Examination
Task
Instructions
Scoring
Date orientation
Place
orientation
Register
three objects
Name three
objects slowly
and clearly. Ask
patient to repeat
them.
Serial 7s
Ask patient to
count backward
from 100 by 7.
Stop after five
answers (or ask
patient to spell
world
backwards).
Recall three
objects
Ask patient to
recall the objects
mentioned
above.
Naming
Repeating
a phrase
1 point if successful
on first try.
Score
NEURO
NEURO
Instructions
Scoring
Verbal commands
Written commands
Writing
Drawing
Score
1 point if
sentence has
a subject and
a verb and
makes sense.
Scoring
Total possible score: 30. Score of 24 or above is considered normal.
64
65
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
NEURO
NEURO
POSSIBLE ETIOLOGIES
Brain lesions/interruptions in blood flow, metabolic disorders (hypoglycemia, hypoxia), psychiatric disorder, toxic medication levels/drug
overdose, increasing intracranial pressure (ICP), dysrhythmia.
Levels of Consciousness
LOC
Characteristics
Full consciousness
Confusion
Lethargy
Obtundation
Stupor
Coma
66
67
Change in Mental Status/Delirium
CLINICAL PICTURE
The patient may have or be:
Confused, restless, agitated, disoriented to time and place.
Easily distracted, delusional, hallucinating.
Disturbed general appearance, motor activity, dress, and facial expression.
Agitated or obtunded with fluctuating LOC.
Rambling, disorganized speech.
Impaired cognitive function.
Reversal of sleep-wake cycle.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
NEURO
NEURO
BE PREPARED TO
POSSIBLE ETIOLOGIES
Dizziness
CLINICAL PICTURE
The patient may have or be:
Sensation of spinning (vertigo), disequilibrium, or faintness.
Weakness, nausea.
Chest pain, tightness, squeezing, or pressure.
Shortness of breath, palpitations.
Tingling, pins-and-needles, weakness of extremities.
IMMEDIATE INTERVENTIONS
68
69
FOCUSED ASSESSMENT
BE PREPARED TO
Start an IV.
Assist with diagnostic testing.
POSSIBLE ETIOLOGIES
Head Trauma
CLINICAL PICTURE
The patient may have:
Scalp lacerations, hematoma, bilateral orbital ecchymosis.
Battles sign (bruising behind the ear at the mastoid process).
Altered mental status of LOC: agitated, semiconscious, consciousness
or unconscious; may have seizures.
CSF leakage from ear or nose.
Signs of ICP:
Decreasing LOC, deterioration in GCS.
Cushings response (bradycardia, hypertension, bradypnea).
NEURO
NEURO
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
70
71
POSSIBLE ETIOLOGIES
Patient fall, trauma.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
NEURO
NEURO
BE PREPARED TO
POSSIBLE ETIOLOGIES
Seizure
CLINICAL PICTURE
The patient may have:
Repetitive, jerking movements of the upper and lower extremities.
Extreme muscle rigidity.
LOC or disorientation.
Tongue or eye deviation.
Cyanosis or apnea.
Urinary or fecal incontinence.
Blinking or repetitive behaviors (e.g., playing with buttons).
Difficulty in arousing from stuporous state (postictal).
Aura (warning or recognition that seizure may occur).
72
73
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
NEURO
NEURO
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
74
75
Assess for potential complications: neurogenic shock (hypothermia
and hypotension without tachycardia), spinal shock (urinary and bowel
retention leading to abdominal distention, ileus, and delayed gastric
emptying), autonomic hyperreflexia, respiratory compromise, nutritional
decline, skin breakdown, urinary retention, constipation.
Maintain spinal stabilization and immobilization. Move the patient
very carefully using logroll technique. Use a spine board with
restraints or other items, such as head blocks and pillows, to
maintain position.
Document findings, and communicate with physician or NP.
Assist with diagnostic studies (spine x-rays, CT, MRI).
BE PREPARED TO
POSSIBLE ETIOLOGIES
NEURO
NEURO
Changes in affect/memory/judgment.
Altered LOC, confusion, agitation.
Seizures.
Nausea/vomiting.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Assess airway, ability to clear secretions, breathing pattern, heart rate and
rhythm, oxygenation status, and blood pressure.
Assess LOC (see GCS in this tab).
If patient is conscious, assess level of orientation.
Assess pupillary response, vision, and facial symmetry.
Assess speech.
Assess motor strength and control (see Neurological Examination in
Tools tab).
76
77
BE PREPARED TO
POSSIBLE ETIOLOGIES
A & P Snapshot
Premotor area
Motor area
Frontal lobe
Motor speech
area
Auditory
association
area
Auditory area
Temporal lobe
NEURO
NEURO
OLFACTORY 1
OCULOMOTOR 3
TROCHLEAR 4
ABDUCENS 6
OPTIC 2
TRIGEMINAL 5
FACIAL 7
GLOSSOPHARYNGEAL 9
VESTIBULOCOCHLEAR 8
HYPOGLOSSAL 12
VAGUS 10
ACCESSORY 11
Cranial nerves.
78
79
Central
canal
Interneuron
Synapse
Dorsal root
Dorsal
column
Corticospinal tract
Rubrospinal
tract
Dorsal root
ganglion
Cell body
of sensor
neuron
Dendrite
of sensory
neuron
Ventral root
Receptor
Spinothalamic
tract
White matter
Gray matter
Effector muscle
Cell body of
motor neuron
NEURO
RENAL/F&E
80
81
Call physician or NP immediately with critical results.
Creatinine clearance (CrCl) compares the level of creatinine in urine
with the serum creatinine level. CrCl is used to determine safe dosing
of nephrotoxic drugs. Urine creatinine is based on a 24-hour urine
collection; blood for serum creatinine is collected at the end of the
24-hour period. However, CrCl is usually estimated by using a formula
based on age, mass, and serum creatinine. Normal values: Male:
107139 mL/min; Female: 85105 mL/min. CrCl of 1020 mL/min is
indicative of renal failure and the need for dialysis.
Other urine tests include urinalysis for screening, urine osmolality and
specific gravity for assessing renal concentrating ability, and urine culture
and sensitivity for assessing urinary tract infection (UTI).
Assess urine for cloudiness, color, and volume.
Vital signs and ABGs: In coordination with other organs (lungs, adrenal glands, hypothalamus, endocrine system), the kidneys regulate
acid-base balance, electrolyte concentrations, blood volume, and BP.
The kidneys maintain BP through the renin-angiotensin system (RAS)
and regulate hydration status by retaining sodium in response to
aldosterone secretion. Therefore, kidney disorders may be reflected
in changes in BP, fluids and electrolytes, and acid-base balance. When
assessing BP, calculate the pulse pressure, which is the difference between
the systolic and diastolic pressures. High pulse pressure (40 mm Hg) is
a risk factor for cardiac events. See Tab 3 for ABG interpretation. Briefly,
the sodium bicarbonate value represents the metabolic componet of the
ABG and is controlled by the kidneys.
Hydration status: Assess I&O, daily weights, mucous membranes,
sodium levels, BUN to creatinine ratio, urine osmolality, specific
gravity.
CVA tenderness: The angle created where the lowest ribs connect
with the vertebral column. CVA pain and tenderness with other UTI
symptoms suggests a kidney infection.
Focused assessment of the lower urinary tract includes:
Voiding patterns, including stress, urge, or overflow incontinence
and difficulties initiating stream.
Residual urine volume (amount of urine left in the bladder after
voiding).
Prostate examination in males.
RENAL/F&E
RENAL/F&E
Electrolyte Imbalances
Electrolyte imbalances are encountered frequently in patients with all types
of conditions.
See p. 86 for hyperkalemia, p. 88 for hypokalemia, p. 87 for hypernatremia,
and p. 89 for hyponatremia
Treatment
Abdominal and
muscle cramps,
lethargy, BP,
tetany, seizure,
ECG changes.
Calcium gluconate
10%*: 1 g in 50100
mL of D5W over 1 hr,
then infusion of 12
mg/kg/hr.
Nursing
Given by physician or NP on
general care units and by
RNs in ICU. Do not infuse
too rapidlyis cardiotoxic
and can cause BP.
Never given IM or
subcutaneouslycauses
severe sloughing of tissue.
Check calcium and magnesium levels.
Antidote: IV magnesium
sulfate.
Treatment
Nursing
Dehydration, renal
stones, confusion,
severe thirst, constipation, polyuria,
shortening of QT
interval BP.
D5NS at 250500
mL/hr; furosemide
2080 mg IV over 2
min to bring Ca
down with
diuresis.
82
83
Hypomagnesemia Mg 1.5 mEq/L
S&S
Treatment
Nursing
Weakness, vertigo,
muscle twitching,
tachycardia,
seizures, tetany,
PVCs.
2 g magnesium
sulfate in D5W over
1020 min, then 1
g/hr for 34 hr.
Treatment
Nursing
Nausea, vomiting,
BP, weakness,
drowsiness, hyperreflexia, HR,
coma, respiratory
failure.
Calcium gluconate
10%*: 110 mL in
50100 mL of D5W
over 1020
minutes.
Treatment
Nursing
Anorexia, weakness,
muscle pain, confusion, rhabdomyolysis, hemolysis,
cardiac and respiratory failure.
Potassium or sodium
phosphate 2 mg/kg IV
over 6 hr if PO4 level is
15 mg/dL. Oral
replacement with KPhos or Neutra-Phos if
depletion is less severe.
Too rapid IV
administration can
cause severe
hypocalcemia;
assess for tetany.
RENAL/F&E
RENAL/F&E
Treatment
Nursing
Phosphate binders,
possibly acetazolamide,
low-phosphate diet
Dehydration
CLINICAL PICTURE
The patient may have:
Increased thirst, dry mouth, and swollen tongue (see table below of Signs
and Symptoms of Progressive Dehydration).
Weakness, dizziness, palpitations.
Tachycardia, hypotension.
Confusion, sluggishness, fainting, seizure.
Decreased urine output.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
84
85
Maintain safe environment.
Provide oral care.
Chart patient status and convey to physician or NP.
BE PREPARED TO
Obtain IV access.
Obtain a nutritional/dietary assessment.
Insert urinary catheter with a urometer to monitor hourly output.
Mild
Dehydration
Moderate
Dehydration
Severe
Dehydration
LOC
Alert
Lethargic
Obtunded
Capillary refill
2 sec
24 sec
Greater than 4
sec, cool limbs
Mucous membranes
Normal
Dry
Parched, cracked
HR
Slight increase
Increased
Very increased
RR
Normal
Increased
Increased and
hyperpnea
BP
Normal
Normal, but
orthostasis
Decreased
Pulse
Normal
Thready
Faint or
impalpable
Skin turgor
Normal
Slow
Tenting
Urine output
Decreased
Oliguria
Oliguria/anuria
POSSIBLE ETIOLOGIES
RENAL/F&E
RENAL/F&E
Hyperkalemia
CLINICAL PICTURE
The patient may have:
Muscular weakness.
Cardiac dysrhythmias.
ECG abnormalities (tall, peaked T waves).
Nausea.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Obtain IV access.
Administer potassium-binding resins (Kay-exalate) orally or rectally.
Monitor cardiac rhythm, I&O, serial potassium levels, and other laboratory
tests.
Chart patient status and convey to physician or NP.
BE PREPARED TO
86
87
POSSIBLE ETIOLOGIES
Hypernatremia
CLINICAL PICTURE
The patient may have:
Sodium level 144 mEq/L
Confusion, lethargy, seizures, coma (if imbalance is severe)
Restlessness, irritability, disorientation, hallucinations
Thirst (many older adults have an impaired sense of thirst and may not
express thirst) of flushed skin, peripheral edema
Postural hypotension, tachycardia
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
RENAL/F&E
RENAL/F&E
BE PREPARED TO
POSSIBLE ETIOLOGIES
Hypokalemia
CLINICAL PICTURE
The patient may have:
Serum potassium 3.5 mEq/L.
Palpitations, ventricular dysrhythmias, bradycardia or tachycardia,
hypotension.
Malaise, fatigue, weakness, muscle cramps.
Nausea, vomiting, ileus, constipation.
Hypoventilation, respiratory distress.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
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89
Administer oral and/or IV potassium supplement. Oral supplementation
is much safer; IV rate should not exceed 200400 mEq/24 hr (based on
serum potassium level of 2.02.5 mEq/L); never give as a bolus: may
precipitate cardiac arrest. Patient should be on telemetry if receiving
treatment level amounts of potassium.
Monitor potassium and other electrolyte levels.
Monitor HR and rhythm.
Maintain safety precautions due to muscle weakness.
Nutrition/dietary education, especially if taking diuretics.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
POSSIBLE ETIOLOGIES
Hyponatremia
CLINICAL PICTURE
The patient may have:
Mild: Na 120 mEq/L: headache, nausea, vomiting, weakness, muscle
cramps.
Moderate: Na 110120 mEq/L: hallucinations, bizarre behavior,
hyperventilation, gait disturbance.
Severe: Na 110 mEq/L: coma, respiratory arrest, hypertension, dilated
pupils, seizures.
Neurological symptoms usually reflect severe, sudden drop in serum
sodium level, which causes intracerebral osmotic fluid shifts and cerebral
edema. A gradual drop in serum sodium may be tolerated because of
neuronal adaptation.
IMMEDIATE INTERVENTIONS
RENAL/F&E
RENAL/F&E
FOCUSED ASSESSMENT
Assess HR and BP lying, sitting, and standing (if possible); note changes
in BP and HR.
Assess fluid status: examine mucous membranes and skin turgor, assess
lung sounds, check for peripheral edema.
Assess recent I&O.
Assess for recent infusion of hypotonic IVF (common cause of Na
in hospitalized patients) or use of continuous bladder irrigation (CBI).
Review medication and dietary history (salt and water intake).
BE PREPARED TO
POSSIBLE ETIOLOGIES
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91
Hypotonic Hyponatremia
Inability of the kidneys to excrete free water adequately. Categorized
according to the associated intravascular volume: hypovolemic,
hypervolemic, and euvolemic. Most common cause of hyponatremia in
surgical patients is infusion of hypotonic fluids.
Intervention
Hypovolemic
hyponatremia
Type
Euvolemic
hyponatremia
Treat underlying
cause.
Restrict free
water.
Hypervolemic
hyponatremia
Restrict free
water.
Possible diuretics.
RENAL/F&E
RENAL/F&E
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
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93
Urinary Retention
CLINICAL PICTURE
The patient may have:
Difficulty initiating stream, feeling of not emptying bladder.
Inability to void.
Lower abdominal pain, bladder distention and spasm.
Voiding in frequent small amounts.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Monitor I&O.
Evaluate subsequent attempts to void and PVR.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
RENAL/F&E
RENAL/F&E
POSSIBLE ETIOLOGIES
Urinary Catheterization
Straight Catheter
Also called red rubber catheter or straight cath. Straight catheters have
only a single lumen and do not have a balloon near the tip. Straight
catheters are inserted for only as much time as required to drain the bladder
or obtain a urine specimen.
Indwelling Catheter
Also called Foley or retention catheter. Indwelling catheters have two
lumens, one for urine drainage and one for inflation of the balloon near the
tip. Three-way Foley catheters are used for continuous or intermittent
bladder irrigation. They have a third lumen for irrigation.
Procedure
1. Prepare patient: explain procedure, and provide privacy.
2. Collect appropriate equipment.
3. Place patient in supine position (female: knees up, legs apart; male:
legs flat, slightly apart).
4. Open and set up catheter kit using sterile technique.
5. Don sterile gloves, and set up sterile field.
6. If placing indwelling catheter, test patency of balloon by filling
balloon with 5 mL sterile water. Check for leaks and proper inflation.
Remove water.
7. Lubricate end of catheter; saturate cotton balls with cleansing solution.
8. With nondominant hand and using forceps to hold cotton balls: female
hold labia apart; swab from front to back, starting with the outer labia
and working inward toward the meatus. Use one swab per swipe (total of
five); maleretract foreskin; swab in a circular motion from the meatus
outward. Repeat at least three times, using a different swab each time.
9. Gently insert catheter (about 23 inches for females and 69 inches for
males) until return of urine is noted. Straight: collect specimen or drain
bladder, and remove catheter. Indwelling: insert an additional inch, and
inflate balloon.
10. Attach catheter to drainage bag, using sterile technique.
11. Secure catheter to patients leg according to hospital policy.
12. Hang drainage bag on bed frame below level of bladder.
94
95
Patient Care
Wash hands with soap and water before and after handling catheter,
tube, or bag.
Keep bag below level of patients bladder at all times.
Check frequently to be sure there are no kinks or loops in tubing and that
patient is not lying on tubing.
Do not pull or tug on catheter.
Wash around catheter entry site with soap and water twice each day and
after each bowel movement.
Do not use powder around catheter entry site.
Periodically check skin around catheter entry site for signs of irritation,
redness, tenderness, swelling, or drainage.
Offer fluids frequently (if not contraindicated by health status), especially
water or cranberry juice.
Record urine output according to physician orders.
Empty collection bag each shift; note color, clarity, and odor.
Notify physician for any of the following:
Blood, cloudiness, or foul odor.
Decreased urine output (30 mL/hr).
Irritation or leaking around catheter entry site.
Fever, abdominal or flank pain.
Removal
Don gloves.
Use a 10-mL syringe to withdraw all water from balloon.
Hold a clean 4 4 pad at meatus in the nondominant hand. With
dominant hand, gently pull catheter. If you meet resistance, stop and
reassess if balloon is completely deflated. If balloon appears to be
deflated and catheter cannot be removed gently, notify physician or
nursing supervisor for assistance.
Catheter should withdraw easily. Wrap tip in clean 4 4 pad as it is
withdrawn to prevent leakage of urine.
Provide bedpan, urinal, or assist patient to toilet. Measure spontaneous
void amount. Palpate bladder to ascertain it is empty.
Note time catheter discontinued.
RENAL/F&E
RENAL/F&E
Suprapubic pain.
Fever 101F, chills, and malaise.
Upper UTI S&S (pyelonephritis):
Fever 101F, shaking chills.
Nausea, vomiting, flank pain.
Elderly: altered mental status, delerium, anorexia, abdominal pain,
incontinence, or asymptomatic.
IMMEDIATE INTERVENTIONS
Assess VS.
Notify physician or NP of symptoms.
Obtain clean catheter urine specimen.
Offer acetaminophen (if ordered) and heating pad or hot water bottle
to relieve suprapubic pain.
Encourage patient to drink fluids to flush urinary system.
Document patient status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
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97
A & P Snapshot
Ribs
Aorta
Inferior vena
cava
Left adrenal
gland
Superior
mesenteric
artery
Left renal
artery and
vein
Diaphragm
Left kidney
Left ureter
Right
kidney
Left common
iliac artery
and vein
Lumbar
vertebra
Pelvis
Psoas
major
muscle
lliacus
muscle
Sacrum
Right
ureter
Urinary bladder
Urethra
Opening of ureter
Trigone of bladder
Symphysis pubis
Urinary system.
RENAL/F&E
RENAL/F&E
Parietal peritoneum
Ureter
Detrusor muscle
Openings of
ureters
Rugae
Ureter
B
Trigone
Prostate
gland
Prostatic
urethra
Trigone
Internal
urethral sphincter
External
urethral sphincter
Urethra
Membranous
urethra
Cavernous
(spongy)
urethra
Cavernous
(erectile)
tissue of
penis
Urethral orifice
98
99
Focused GI Assessment
A focused nursing assessment of the GI system includes:
Investigation of abdominal pain, nausea, and vomiting.
Frequency and character of bowel sounds.
Amount of abdominal distention
Frequency and character of bowel movements (constipation or
diarrhea).
Appetite, intake, swallowing, and tolerance of foods and fluids.
Abdominal pain, nausea, and vomiting:
Ask the patient about the nature of the abdominal pain. Use the PQRST
guideline in the Basics tab.
Ask about nausea, and consider any recent procedures or new
medication.
If the patient has vomited, assess quantity and characteristics of
emesis.
Use a hemeoccult slide to test for blood in the emesis.
Fecal material in the emesis is rare but is an emergency if found.
Assess bowel sounds:
Assess bowel sounds before palpating the abdomen. Listen in all four
quadrants; however, most clinicians think that it is difficult to pinpoint
the origin of bowel sounds because they can be heard even when
ausculatating the lungs.
Bowel sounds provide supporting information to the clinical picture for
the patient with an evolving GI problem.
Normal bowel sounds are small gurgles heard every few seconds,
although there is considerable variability that is still considered normal.
Absence of bowel sounds can indicate an inflammatory process such
as peritonitis or a bowel obstruction.
High-pitched, frequent, tinkling bowel sounds can be heard in the initial
stages of a bowel obstruction.
Bowel sounds are absent after abdominal surgery and may take a few
days to return. Patients are not fed when bowel sounds are absent.
When bowel sounds return, which is usually accompanied with passing
flatus, it indicates that the intestinal tract is beginning to function again.
Assess abdominal distention:
The abdomen can be distended in many bowel problems; such distention is frequently associated with abnormal or absent bowel sounds.
The abdomen can be distended from constipation, excessive
abdominal gas, severe bowel dysfunction, obstruction, or infection.
Ascites, the abnormal accumulation of fluid in the peritoneal cavity, can
cause massive distention. For patients with ascites, mark the abdomen,
and measure girth at the same level each day to assess if ascites is
decreasing or increasing.
GI
GI
100
101
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Ask patient to describe pain; use the PQRST guidelines in the Basics tab.
Assess recent bowel habits, recent laxative or enema use.
Inspect abdomen; auscultate bowel sounds.
Palpate abdomen for pulsations, tenderness, and rigidity. Assess from
area of least tenderness to area of most tenderness.
Assess hydration status and urine output (UO) by reviewing I&O record
for previous 2 days.
Check all recent laboratory values including WBC count.
Test emesis for occult blood.
Notify physician or NP of assessment findings. Document findings and
phone call.
BE PREPARED TO
Hang IVF.
Administer pain medication, antiemetics, antibiotics.
Insert an NGT, or set up suction.
Insert indwelling urinary catheter.
Order or obtain laboratory tests.
Facilitate diagnostic tests such as abdominal x-ray, CT, endoscopy,
ultrasound, and diagnostic imaging.
POSSIBLE ETIOLOGIES
GI
GI
NGT Insertion
Indications
Aspirate blood or fluids and gas from stomach.
Control nausea and vomiting.
Procedure
1. Explain procedure to the patient.
2. Position patient upright in high Fowlers position. Instruct patient to keep
chin-to-chest posture during insertion. This helps to prevent accidental
insertion into the trachea.
3. Measure tube from tip of the nose to the ear lobe, then down to xyphoid.
Mark this point on the tube with a piece of tape.
4. Lubricate tube by applying water-soluble lubricant to tube. Never use
petroleum-based jelly.
5. Insert tube through nostril until the previously marked point on the tube
is reached. Instruct patient to take small sips of water during insertion to
help facilitate passing of the tube. Withdraw tube immediately if patient
becomes cyanotic or develops breathing problems.
6. Secure tube to patients nose using tape. Be careful not to block the
nostril. Tape tube 1218 inches below insertion line. Then pin tape to
patients gown, allowing slack for movement.
7. Confirm proper location of tube.
Checking the pH of aspirate is the preferred method for
checking placement.
Pull back on plunger of a 20-mL syringe to aspirate stomach contents.
Typically, gastric aspirates are cloudy and green, or tan, off-white,
bloody, or brown in some cases. Gastric aspirate can look like
respiratory secretions.
Dip litmus paper into gastric aspirate. A reading of 13 suggests
placement in the stomach.
An alternate, but less reliable, method, is to inject 20 mL of air into tube
while auscultating the abdomen. Hearing a loud gurgle of air suggest
placement in the stomach. If no bubbling is heard, remove tube, and
reattempt. Withdraw tube immediately if patient becomes cyanotic or
develops breathing problems.
An inability to speak also suggests intubation of trachea instead of
stomach.
8. Assemble suction canister, liner, and attachment for wall suction. If using
portable suction, have ready at bedside.
Attach a connector to the end of tube.
Attach the extension tubing that comes with the suction canister to the
connector.
102
103
Connect the other end of the tubing to suction canister where indicated.
Set suction as ordered.
Patient Care
Reassess placement of tube.
Assess amount and character of drainage.
Replace collection liner before it is full (full or nearly full liner prevents
thorough suction of GI material).
Flush tube with water after each feeding and after each medication.
Assess skin around nose for irritation and breakdown, and replace tape
as needed. Change at least every other day.
Gently wash around the nose with soap and water, and dry before
replacing tape.
Provide mouth care every 2 hours and PRN.
Mouthwash, water, toothettes: clean tongue, teeth, gums, cheeks, and
mucous membranes.
If patient is performing oral hygiene, remind him or her not to swallow
any water.
Removal
1. Explain procedure to patient. Don gloves.
2. Remove tape from nose and face. Offer patient some tissues as he or she
may gag slightly as the tube is withdrawn.
3. Clamp or plug tube (prevents fluid from entering lungs), and remove tube
in one gentle, swift motion.
4. Assess for signs of aspiration.
Constipation
CLINICAL PICTURE
The patient may have:
Complaints of constipation.
Infrequent stools accompanied by discomfort, bloating, flatulence.
GI
GI
If the patient has bowel sounds, is on a solid diet, and has a PRN order
for a laxative, check how soon the laxative is designed to work, and
administer it at the appropriate time (e.g., some magnesium-containing
laxatives work very quickly; some are designed to work over 8 hrs).
If there is an order for a small-volume enema that can be selfadministered or an oral laxative, ask the patient which he or she would
prefer. Explain how to use the enema if the patient chooses that option.
BE PREPARED TO
Check for impaction; administer saline enemas.
POSSIBLE ETIOLOGIES
Medications such as diuretics, loperamide, opioids, antidepressants, and
medications containing iron, calcium, or aluminum; insufficient intake of
dietary fiber; dehydration; hypothyroidism; hypokalemia; injury to the anal
sphincter; diminished or absent peristalsis related to surgery, cancer,
diverticula, irritable bowel syndrome, functional incapacity.
Diarrhea
CLINICAL PICTURE
The patient may have:
Frequent loose, watery, bowel movements.
Loose stools containing blood, pus, or mucus.
Abdominal pain, cramps, flatulence.
Nausea, vomiting, dehydration.
Fatigue, temperature elevation.
IMMEDIATE INTERVENTIONS
104
105
Notify physician or NP of symptoms.
Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
Insert IV, and administer IVF (D5 1/2 NS with KCl) if dehydrated or unable
to tolerate oral fluids (with order).
Encourage fluids if able to tolerate.
Monitor I&O.
Administer appropriate antibiotic/anti-infective agent promptly and on
schedule.
Avoid use of antimotility drugs (diphenoxalate, loperamide) or opiates if
infectious diarrhea suspected.
Monitor for relief of symptoms or complications (toxic megacolon if PMC,
dehydration, electrolyte imbalance, skin breakdown).
Document patients status in medical record, and communicate to
physician or NP.
BE PREPARED TO
POSSIBLE ETIOLOGIES
GI
GI
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
106
107
Feeding Tubes: Preventing and Managing Complications
Complication/Cause
Interventions
Tube migration:
Internal balloon deflates
or external tube suture,
bumper, or disc falls out.
Reposition tube.
Extubation:
Internal balloon deflates or suture,
bumper, or disc falls out.
Stomal infection:
Leakage around tube.
Inadequate stomal care.
Allergic reaction to soap.
Gastroesophageal reflux/
large residuals:
Delayed gastric emptying.
GI
GI
Interventions
Diarrhea:
Too rapid increase in amount of
feeding, too rapid administration, feeding too cold,
lactose intolerance, tube
migration from stomach
to small intestine
108
109
Obtain all medications in liquid form. If liquid form is not available, check
with pharmacist to see if medication can be crushed.
Administer each medication separately, and flush with 510 mL of water
between each medication.
Do not mix medications with feeding formula.
Management
Check the feeding tube for kinks.
Inject a small amount of air into tube.
Change patients position.
If no obvious kink is found, place flushing syringe (30 mL) into the tube
end, and gently pull back on the plunger to dislodge the occluding plug.
If tube still blocked, instill warm water into the tube. Gently depress, and
withdraw syringe plunger to remove obstruction. If unsuccessful, leave
instilled warm water in tube, clamp tube for 1015 min, and try again.
Milk the tube with fingers from the insertion site out.
Do not instill meat tenderizercan cause metabolic complications and
allergic reactions.
Commercial products that use thin plastic devices for clearing feeding
tubes or products that use a catheter and chemical declogging powder are
available; however, a physician or NP usually must perform the
procedure.
To prevent tube damage, do not use force to unclog, or use a syringe
smaller than 30 mL.
Hematemesis/Upper GI Bleed
CLINICAL PICTURE
The patient may have:
Bright red or dark coffee groundappearing emesis.
Distended, rigid, and/or tender abdomen.
Nausea, black stools.
Tachycardia, hypotension.
Dizziness, weakness, SOB.
Anxiety.
IMMEDIATE INTERVENTIONS
GI
GI
FOCUSED ASSESSMENT
Assess BP, HR, and RR. Check blood pressure supine and standing (if
feasible), and document difference.
Check oxygen saturation via pulse oximetry. Assess LOC.
Assess skin color and temperature, capillary refill.
Assess respiratory status and lung sounds.
Assess abdomen for distention, tenderness, guarding, peristalsis, and
rigidity.
Hematest emesis; assess amount and characteristics.
Assess for use of anticoagulants, NSAIDs, or steroids.
Check if patient has been previously typed and cross-matched and if any
blood products are available in the blood bank.
BE PREPARED TO
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111
POSSIBLE ETIOLOGIES
Lower GI Bleed/Melena
CLINICAL PICTURE
The patient may have:
Frankly bloody or melanotic stool or stool tests positive for occult blood.
Abdominal cramping.
Signs and symptoms of hypovolemic shock (acute bleed): hr 110
beats/min, SBP 100 mm Hg, orthostatic drop in systolic BP of 16 mm,
oliguria, cold clammy extremities, mental status changes.
Anemia, fatigue, pallor, dizziness, chest pain (chronic bleed).
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
GI
GI
BE PREPARED TO
POSSIBLE ETIOLOGIES
Nausea
CLINICAL PICTURE
The patient may have:
Sensation/urge to vomit.
Tachycardia, bradycardia.
Diaphoresis, skin pallor.
Decreased or high-pitched bowel sounds.
Abdominal pain.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
112
113
STABILIZING AND MONITORING
BE PREPARED TO
POSSIBLE ETIOLOGIES
Vomiting
CLINICAL PICTURE
The patient may have:
Small or large amounts of emesis.
Tachycardia, bradycardia, diaphoresis, skin pallor.
Abdominal pain, decreased or high-pitched bowel sounds.
IMMEDIATE INTERVENTIONS
GI
GI
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
114
115
A & P Snapshot
Tongue
Teeth
Parotid gland
Pharynx
Sublingual
gland
Esophagus
Submandibular
gland
Liver
Left lobe
Stomach (cut)
Spleen
Right lobe
Gall bladder
Bile duct
Duodenum
Pancreas
Transverse
colon (cut)
Descending
colon
Small intestine
Ascending
colon
Cecum
Rectum
Anal canal
Vermiform
appendix
Digestive system.
GI
ENDO
116
117
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
ENDO
ENDO
Hyperglycemia*
CLINICAL PICTURE
The patient may have:
Blood glucose level 180300 mg/dL on routine fingerstick.
Usually there are few or no symptoms or signs other than blood glucose
level
Can have:
Flushed, dry skin; poor skin turgor, and dry mucous membranes.
Fruity breath odor (like acetone).
Blurred vision, generalized weakness, and dizziness.
N&V, cramping, increased urination.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
118
119
POSSIBLE ETIOLOGIES
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
ENDO
ENDO
BE PREPARED TO
Obtain ABGs.
Facilitate blood tests and other diagnostic tests.
Assist with intubation.
Assist with insertion of a central venous catheter.
Insert a nasogastric tube.
Transfer to ICU.
Teach patient about process of HHNC to avoid recurrence.
POSSIBLE ETIOLOGIES
Hypoglycemia
CLINICAL PICTURE
The patient may have:
Cool, pale, and diaphoretic skin.
Agitation, disorientation, slurred speech, blank stare.
Headache, palpitations/tachycardia, trembling, hunger.
LOC progressing to coma and/or seizures if not treated.
IMMEDIATE INTERVENTIONS
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121
If patient has LOC, give 1 amp (25 g in 50 mL) of 50% dextrose IV push
(with order).
Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
Assess time the insulin or oral hypoglycemic agent was taken and amount.
Ascertain that dose/type of insulin/oral hypoglycemic given was accurate.
Assess if patient has eaten.
Assess other medications for potential to affect glucose control.
Assess response to oral or IV administration of glucose.
BE PREPARED TO
POSSIBLE ETIOLOGIES
Myxedema Coma
CLINICAL PICTURE
The patient may have:
Low body temperature, cold intolerance.
Confusion, depression.
Hypoventilation.
Weakness.
Edema.
ENDO
ENDO
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
New infection in an otherwise well-controlled hypothyroid patient; medications such as diuretics, opioids, beta blockers, tranquilizers, and others
in a hypothyroid patient; GI bleed; stroke; surgery; trauma.
Thyroid Storm
CLINICAL PICTURE
The patient may have:
Tachycardia, palpitations, widened pulse pressure, atrial fibrillation.
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123
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
ENDO
ENDO
A & P Snapshot
PITUITARY (HYPOPHYSIS) GLAND
Anterior: GH, TSH, ACTH
FSH, LH, Prolactin
Posterior: ADH, Oxytocin
HYPOTHALAMUS
Releasing hormones
for anterior pituitary
PINEAL GLAND
Melatonin
THYROID GLAND
Thyroxine and T3
Calcitonin
PARATHYROID GLANDS
PTH
THYMUS GLAND
Immune hormones
ADRENAL (SUPRARENAL)
GLANDS
Cortex: Aldosterone
Cortisol
Sex hormones
Medulla: Epinephrine
Norepinephrine
PANCREAS
Insulin
Glucagon
OVARIES
Estrogen
Progesterone
Inhibin
TESTES
Testosterone
Inhibin
The endocrine system.
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Focused Assessment of Musculoskeletal System
Assess the musculoskeletal system on all patients with an orthopedic
problem or recent trauma, patients with arthritis or who have been on
bedrest, and patients with neurological (e.g., stroke) or neuromuscular
disease.
Clinicians usually assess the peripheral nervous system simultaneously.
Assessment includes evaluation of dressings and wound drainage
systems.
Assessment of musculoskeletal status includes:
Gait.
Joint mobility.
Neurovascular status (CMS: circulation, motion, sensation); an
assessment of circulatory compromise and/or nerve damage.
Pain.
Fall risk.
Gait
Assess patients ability to ambulate independently.
Assess need for assistive devices. If the patient uses an assistive
device, asses if he or she is using it safely.
Joint range of motion (ROM)
Ask patient to put shoulders, elbows, wrists and fingers, hips, knees,
and ankles through full range of joint motion as indicated. Neck and
back can be included if appropriate.
As a nursing assessment, joint ROM evaluation may be necessary only
with initial assessment. If the patient is receiving physical therapy to
increase that joints ROM, then the physical therapist will assess the
extent to which the joint can move.
If the patient is not able to move or participate, passively move the
joints to assess ROM.
Do not push a joint past its range, even if limited.
Do not push the joint if the patient has pain.
Neurovascular status (CMS: Circulation, Motion, Sensation)
Palpate peripheral pulse and check capillary refill.
Note skin color of extremity; compare with that of opposite extremity.
Have patient move hands and fingers, flex and extend feet. Focus on
the extremity of interest, but initially compare with the contralateral
arm, hand, leg, or foot.
Assess strength by having patient push or pull against resistance.
Ask about paresthesias (numbness and tingling, odd sensations);
lightly trace your finger over different surfaces of the at-risk area
MSKEL/
INTEG
MSKEL/
INTEG
to assess sensation. Have the patient close his or her eyes while
you do this.
Ask about pain. (See Pain Assessment in Basics tab.)
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Pressure points
Assess pressure points; do not massage reddened areas.
Use position changes, pillows, and preventive mattresses to alleviate
pressure.
Pressure ulcers
Perform and document a thorough wound assessment and staging (see
pressure ulcer later in this tab).
Assess healing. Note that ulcers may progress to a later stage but do
not regress as they heal. The correct term, for example, is healing
stage 3 ulcer, with a description of signs of healing (granulation tissue,
decreased circumference).
Compartment Syndrome
Muscle groups are contained within a tough, inelastic tissue called fascia.
This envelope of tissue creates a compartment that contains muscles,
nerves, veins, and arteries.
After injury or surgery, swelling of the muscles in the fascial compartment
causes increased pressure because the fascia cannot expand with the
swelling. The increased pressure closes off capillaries, arterioles and,
eventually, arteries, causing ischemia that will progress to necrosis if not
treated.
Compartment syndrome is more common in the extremities, particularly
the anterior or posterior compartments of the lower leg, but is possible at
other sites of injury such as the abdomen. This discussion is focused on
the arm or leg.
CLINICAL PICTURE
MSKEL/
INTEG
MSKEL/
INTEG
IMMEDIATE INTERVENTIONS
The extreme pain is the first warning sign. When pain is more severe than
expected, immediately consider compartment syndrome, and notify
physician or NP.
Although pain medication should not be delayed or withheld, do not
simply medicate and return later to see if the medication is working.
Stay with the patient, and perform a focused assessment.
Elevate the extremity to the level of the heart to prevent further swelling
and increase venous return.
Do not put ice bags on the extremity.
Document phone call to physician or NP and physician or NP response.
FOCUSED ASSESSMENT
BE PREPARED TO
POSSIBLE ETIOLOGIES
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Hip Fracture
CLINICAL PICTURE
The patient may have:
Groin, knee, or hip pain.
Inability to bear weight on affected extremity.
Shortened and externally rotated leg.
Inability to move affected leg.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
MSKEL/
INTEG
MSKEL/
INTEG
BE PREPARED TO
Start an IV.
Obtain laboratory work, x-rays, possible CT or MRI.
Assist with set-up and application of traction.
POSSIBLE ETIOLOGIES
Osteoporosis, trauma.
CLINICAL PICTURE
The patient may have or be:
Minor skin disruption, no disruption at all, or major disruption (e.g.,
surgical incision).
Severe or worse than expected pain at site, which gets progressively
worse.
Cellulitis-like appearance of affected area, which is hot and painful to the
touch.
Swollen, purplish, blistered tissue with foul-smelling, watery discharge.
High fever with flu-like symptoms.
Dehydrated and hypotensive.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
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STABILIZING AND MONITORING
BE PREPARED TO
Assist with bedside dbridement, or get the patient ready for the OR.
Obtain x-rays or CT.
Start a heparin drip (to decrease risk of vasculitis and thrombosis).
Transfer the patient to ICU.
POSSIBLE ETIOLOGIES
Infection with Group A beta-hemolytic streptococcus alone or in combination with S aureus; infection with Clostridium, Peptococcus, E. coli,
Pseudomonas, S. pyogrenes, S. aureus, or S. marcescens.
Pathological Fracture
CLINICAL PICTURE
The patient may have:
Sudden pain in leg/hip/back/shoulder/arm while moving in bed,
transferring to wheelchair or stretcher, or ambulating. Audible crack may
be heard.
Abnormal or limited motion of extremity.
Back pain (with spinal compression fracture).
Unexplained ecchymosis, edema over bone or joint.
Obvious deformity of extremity.
IMMEDIATE INTERVENTIONS
MSKEL/
INTEG
MSKEL/
INTEG
FOCUSED ASSESSMENT
Assess VS.
Assess extremity for swelling or hematoma.
Assess sensation and mobility of fingers or toes distal to injury if
extremity fracture is suspected.
Assess mobility and sensation of arms and legs if spinal fracture
suspected.
Assess history of falls or fractures.
BE PREPARED TO
POSSIBLE ETIOLOGIES
Patient Fall
CLINICAL PICTURE
The patient may have or be:
Found on floor, unexplained abrasions, or reported falling.
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IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
MSKEL/
INTEG
MSKEL/
INTEG
BE PREPARED TO
POSSIBLE ETIOLOGIES
Sedation, debilitation, unfamiliar surroundings, side rails left down, callbell malfunction or not left within easy reach, drug reaction, improper use
of restraints, dysrhythmias, altered LOC, altered proprioception, spill on
the floor.
Nursing Intervention
Polypharmacy
Deconditioning
Postural hypotension;
change in proprioception
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Pressure Ulcer
CLINICAL PICTURE
The patient may have:
Reddened, blistered, open skin over pressure point such as sacrum, coccyx,
scapula, trochanter, or heel.
History of immobility, decreased sensorium, incontinence.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Perform dressing changes as ordered. (See Wound Care Products for Pressure
Ulcers in this tab.)
Turn and reposition patient at least every 2 hours.
Keep wound free of contamination from urine and stool.
Assess nutritional status; consult dietitian.
BE PREPARED TO
POSSIBLE ETIOLOGIES
MSKEL/
INTEG
MSKEL/
INTEG
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Wound Assessment and Documentation Guide
Measure length, width, and depth using a centimeter ruler.
Assess characteristics of wound edges (i.e., attached, not attached,
fibrotic).
Assess for undermining: Insert a cotton-tipped applicator under the
wound edge; gently advance it until resistence is met. Using a felt-tipped
pen, mark the skin where applicator is felt. Continue around the wound.
Describe necrotic tissue type:
White/gray.
Nonadherent yellow slough.
Loosely adherent yellow slough.
Adherent, soft black eschar.
Firmly adherent, hard black.
Describe exudate type:
Bloody.
Serosanguineous.
Serous.
Purulent.
Foul purulent.
Describe exudate amount:
Nonewound tissues dry.
Scantwound tissues moist; no measurable exudates.
Smallwound tissues wet; drainage involved 25% of dressing.
Moderatewound tissues saturated; drainage involved 25%75% of
dressing.
Largewound tissues bathed in fluid; drainage involves 75% of
dressing.
Assess and describe skin color surrounding wound: Assess tissues
within 4 cm of wound edge. For light-skinned persons, note if skin is
reddened. For dark-skinned persons, note if skin is reddened or darker or
purplish around wound edges.
Assess wound edge for tissue edema: Note if edema is pitting or
nonpitting and if wound is crepitant (crackly noises when tissue is palpated).
Notify physician immediately if wound is crepitant: may indicate gas
gangrene.
Assess amount of induration: Induration is abnormal firmness of tissues
with margins. Assess by gently pinching the tissue distal to wound edge; if
indurated, you will be unable to pinch a fold of skin.
Assess for granulation tissue: Granulation tissue is present in the
healing wound. It is the regrowth of small blood vessels and connective
tissue. Healthy granulation tissue is bright, beefy red, shiny, and granular.
Poorly vascularized tissue supply appears pale pink, dull, or dusky red.
Stage the pressure ulcer: (see the following table).
MSKEL/
INTEG
Stage
Ulcer Characteristics
Interventions
II
III
IV
138
MSKEL/
INTEG
Copyright 2008 by F. A. Davis.
139
Product
Characteristics
Transparent
Films
Tegaderm
CarraFilm
OpSite
BIOCLUSIVE
Semipermeable
membrane.
Waterproof.
Permeable to oxygen and
water vapor.
Provide moist healing
environment and prevent
bacterial contamination.
Hydrogels
Hypergel
CarraSorb
Nu-gel
Curafil
Water- or glycerin-based
gels, impregnated gauzes,
or sheet dressings.
Provides moist wound
environment. Helps clean
and dbride by supplying
liquid to dry, sloughy
wounds.
Occlusive and adhesive
wafer dressings, or
hydrocolloid powders and
pastes.
Facilitate rehydration and
autolytic dbridement of
dry, sloughy, or necrotic
wounds.
Hydrocolloid
dressings
Tegasorb
Comfeel
DuoDERM
Restore
Indications
Nursing Considerations
MSKEL/
INTEG
Product
Alginates
CURASORB
AlgiDERM
Sorbsan
Algosteril
Foam dressings
Flexzan
CURAFOAM
Mepilex
Enzymatic
dbriding
agents
Panafil
Santyl
Accuzyme
Characteristics
Indications
Nursing Considerations
Highly absorbent, therefore
good for packing exudating
wounds.
Require secondary dressing.
Usually changed once daily.
Highly absorbent foam may
allow less frequent dressing
changes.
Can be left undisturbed for
34 days.
Decrease maceration of
surrounding tissue.
Comfortable and
conformable.
Usually changed up to three
times/week.
Surgical dbridement may
be avoided in some cases
with use of enzymatic
dbriding agents.
Require prescription.
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MSKEL/
INTEG
141
Surgical Site Infection/Complication
CLINICAL PICTURE
The patient may have:
Warm, reddened, tender, swollen, painful wound.
Low-grade fever.
Separation of wound edges with serous-sanguineous or purulent drainage
from wound.
Purulent discharge from wound drain.
Feeling of wound tearing or opening.
Exposure or protrusion of abdominal contents through open wound.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
MSKEL/
INTEG
MSKEL/
INTEG
BE PREPARED TO
POSSIBLE ETIOLOGIES
Wound Vacuums
Vacuum-assisted closure (VAC) units are negative pressure devices that help
promote wound healing by removing exudate and other fluids with
continuous and/or intermittent subatmospheric pressure; in other words, by
suction. The suction, in conjunction with the system, also helps pull the
wound edges together, stimulates granulation tissue, and improves blood
flow to the wound bed.
Setting up the wound VAC:
Wash your hands, don gloves, and clean the wound using aseptic
technique.
Apply skin preparation to peri-wound area to help secure the dressing.
Cut foam to fit wound, and place in the wound; do not push it in, just
place it on the wound.
Apply Tegaderm-like plastic sheet over foam and onto healthy skin; put it
on in patches, if necessary.
Cut a small hole in the plastic sheet over the foam. This is essential for
suction to reach wound bed.
Apply suction disc over the hole in the plastic dressing.
Connect suction tubing, remove kinks, and set suction as ordered.
Remove gloves, discard old dressing properly, wash hands.
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MSKEL/
INTEG
MSKEL/
INTEG
A & P Snapshot
Skull (cranium)
Zygomatic arch
Cervical vertebrae
Maxilla
Thoracic vertebrae
Mandible
Clavicle
Scapula
Sternum
Humerus
Ribs
Lumbar
vertebrae
Radius
Ulna
Ilium
Sacrum
Carpals
Metacarpals
Coccyx
Phalanges
Pubis
Ischium
Femur
Patella
Tibia
Fibula
Tarsals
Metatarsals
Phalanges
Skeletal system.
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Receptor
for touch
(encapsulated)
Pore
Epidermis
Papillary
layer with
capillaries
Dermis
Pilomotor
muscle
Sebaceous
gland
Hair
follicle
Receptor
for pressure
(encapsulated)
Nerve
Arteriole
Venule
Stratum
germinativum
Stratum
corneum
Fascia of
muscle
Adipose
tissue Subcutaneous
Eccrine
tissue
sweat gland
Free nerve ending
Skin structure.
MSKEL/
INTEG
INFECT
Standard Precautions
Use standard precautions for the care of all patients. Add contact, droplet,
or airborne precautions, depending on the mode of transmission.
Handwashing:
Wash hands.
After touching blood, body fluids, secretions, excretions, and
contaminated items.
Immediately after gloves are removed.
Between patient contacts.
To avoid transfer of microorganisms to other patients or environments.
Between tasks and procedures on the same patient to prevent cross
contamination of different body sites.
Gloves:
Wear clean, nonsterile gloves:
When touching blood, body fluids, secretions, excretions, and
contaminated items.
Before touching mucous membranes and nonintact skin.
Change gloves between procedures on the same patient after contact
with contaminated material.
Remove gloves promptly after use and before touching noncontaminated
items and environmental surfaces. Wash hands immediately.
Mask, Eye Protection, Face Shield:
Wear mask and eye protection or face shield when patient-care activities
are likely to generate splashes or sprays of blood, body fluids, secretions,
or excretions.
Gown:
Wear a clean, nonsterile gown when patient-care activities are likely
to generate splashes or sprays of blood, body fluids, secretions, or
excretions.
Patient-Care Equipment:
Prevent skin, mucous membrane, and clothing exposure to contaminated
equipment.
Do not use reusable equipment for another patient until cleaned
appropriately.
Discard single-use items properly.
Linen:
Prevent skin, mucous membrane, and clothing exposure to contaminated
linen.
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Preventing Needle and Sharps Injuries
Never recap used needles or manipulate them using both hands.
Do not direct needle point toward self.
Use one-handed scoop technique.
Do not remove used needles from disposable syringes by hand; do not
bend, break, or manipulate used needles by hand.
Place used disposable syringes and needles, scalpel blades, and other
sharp items in appropriate puncture-resistant containers.
Airborne Precautions
For patients who are or may be infected with microorganisms transmitted
by airborne droplet nuclei.
Private room with:
Monitored negative air pressure in relation to the surrounding
area.
6 to 12 air changes per hour.
Monitored high-efficiency filtration of room air.
Door closed.
Keep patient in room.
Droplet Precautions
For patients who are or may be infected with microorganisms transmitted
by large-particle droplets that occur with coughing, sneezing, talking.
Private room or in room with patient who has active infection with same
microorganism but no other infection.
If private room not possible, maintain at least 3 ft of space between
infected patient and other patients and visitors.
Door may be open.
Wear a mask when working within 3 ft of patient.
Place mask on patient when leaving the room, if possible.
INFECT
INFECT
Contact Precautions
For patients who are or may be infected or colonized with microorganisms
transmitted by direct contact with the patient or indirect contact with
environmental surfaces or patient-care items.
Private room or in room with patient who has active infection with same
microorganism but with no other infection.
Wear clean, nonsterile gloves when entering the room.
Remove gloves before leaving patient room, and immediately wash hands
with antimicrobial or waterless antiseptic agent.
Do not touch potentially contaminated surfaces once gloves are removed
and hands washed.
Wear clean, nonsterile gown when entering room if clothing will have
contact with patient, surfaces, or items in the room or if patient is
incontinent, has diarrhea, an ileostomy, a colostomy, or wound drainage
not contained by a dressing.
Remove the gown before leaving room.
Clostridium-Associated Diarrhea
(CDAD, Psuedomembranous Colitis)
CLINICAL PICTURE
The patient may have:
Frequent, watery diarrhea, possibly with blood.
Fever.
Loss of appetite, nausea.
Abdominal cramping, pain, and tenderness.
IMMEDIATE INTERVENTIONS
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149
FOCUSED ASSESSMENT
Make sure all visitors wear gloves when touching the patient, and
wash their hands with soap and water each time before they leave
the room.
Administer oral metronidazole or Vancomycin as ordered.
Collect stools for testing as orderedusually three stools from three
separate bowel movements on consecutive days.
Provide incontinence care, if needed, and monitor perianal skin for
breakdown.
Monitor hydration status and food intake
Monitor electrolytes, albumin, WBC count.
Assess for complications of severe infection including anasarca,
dehydration, toxic megacolon, and colonic perforation.
BE PREPARED TO
POSSIBLE ETIOLOGIES
Fever
CLINICAL PICTURE
The patient may have:
Temperature elevation (low-grade fever: T 101F; high-grade 101F).
Fatigue, weakness.
Flushed, dry skin.
IMMEDIATE INTERVENTIONS
Assess VS.
Offer cool compress for forehead.
INFECT
INFECT
FOCUSED ASSESSMENT
BE PREPARED TO
Obtain sputum, blood, or urine sample for Gram stain, culture, and
sensitivity.
Obtain or change IV access.
Order a chest x-ray.
Order or obtain laboratory tests.
POSSIBLE ETIOLOGIES
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Systemic Inflammatory Response Syndrome (SIRS): Systemic
inflammatory response to severe clinical insults, including infection,
pancreatitis, trauma, and burns. This response is manifested by two
or more of the following conditions:
Core temperature 38C (100.4F) or 36C (96.8F).
HR 90 beats/min.
RR 20 breaths/min or PaCO2 32 mm Hg.
WBC count 12,000/mm3, 4000/mm3, or the presence of 10%
immature neutrophils.
Sepsis: A systemic inflammatory response to infection that initiates a
cascade of biochemical events resulting in hypotension, coagulopathy,
suppression of fibrinolysis, and multisystem organ dysfunction. Sepsis is
diagnosed when there is a documented infection with at least two of the
four systemic inflammatory response criteria.
Severe sepsis: Sepsis with dysfunction of one or more organ systems,
hypoperfusion, or hypotension.
Septic shock: Sepsis with hypotension (systolic BP 90 mm Hg or a
reduction of 40 mm Hg from baseline) despite adequate fluid resuscitation
and with perfusion abnormalities that include lactic acidosis, oliguria, or
change in mental status.
Multiple organ dysfunction syndrome: Altered organ function in an
acutely ill patient such that homeostasis cannot be maintained without
intervention.
CLINICAL PICTURE
The patient may have:
Temperature 38C (100.4F) or 36C (96.8F).
Chills, sweating.
Tachypnea, respiratory alkalosis.
Tachycardia.
Elevated or depressed WBC count.
Change in mental status.
Abdominal or flank pain.
Rash; warm, dry, flushed skin.
Progressive Indications:
Restlessness, confusion, altered LOC.
Hypotension, widening pulse pressure.
Oliguria.
Rapid thready pulse, delayed capillary refill.
Decreased urinary output.
INFECT
INFECT
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
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153
Assist with intubation and airway management.
Call a code.
Transfer patient to ICU or monitored unit.
POSSIBLE ETIOLOGIES
Hepatitis
Inflammation of liver cells that results in necrosis and obstruction of bile.
There are many forms of hepatitis, including viral, bacterial, alcoholic, and
drug-induced hepatitis.
The various forms of viral hepatitis are named with a letter of the alphabet,
using A through G.
CLINICAL PICTURE
The patient may have:
Fever, loss of appetite, nausea, and vomiting
Fatigue, headache.
Tea-colored urine, clay-colored stools, jaundice.
Right upper quadrant abdominal pain.
POSSIBLE ETIOLOGIES
Viral infection.
INFECT
INFECT
Route of
Transmission
HAV
Fecal-oral route;
exposure to
contaminated
food or water
HBV
HCV
Parenteral:
blood-to-blood
contact
HDV
HEV
Precautions
Standard precautions plus contact precautions.
Found in feces; spread under poor sanitary
conditions and poor personal hygiene. Can
also be transmitted through oral and anal
sexual activity, drinking contaminated water,
eating raw shellfish taken from contaminated water, or eating fruits and vegetables
contaminated during handling.
Standard precautions.
Spread by blood-to blood contact via
punctures of the skin with bloodcontaminated needles or scalpels, blood
splashes to open skin or mucous
membranes, or indirectly when dried blood
on a surface or instrument gets transferred
to open skin or mucous membranes.
Saliva can contain very low concentrations of
hepatitis B virus, thus disease can be spread
by a bite. Spread by sharing needles and
through unprotected sexual contact.
Feces, nasal secretions, sputum, sweat, tears,
urine, and emesis do not spread hepatitis B
unless visibly contaminated with blood.
Not transmitted by casual contact.
Standard precautions.
Spread by blood-to-blood contact or exposure
of contaminated blood to open skin or
mucous membranes.
People may get hepatitis C by sharing needles
to inject drugs or through exposure to blood
in the workplace. Can be sexually transmitted. Not spread by casual contact or
through food or water.
Standard precautions.
See Hepatitis B.
Standard precautions plus contact precautions.
See Hepatitis A.
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Meningitis
Inflammation of the meninges, which cover the brain and spinal cord. May
be septic meningitis, which is caused by bacteria, or aseptic, which is viral or
secondary to a lymphoma, leukemia, or a brain abscess. Bacterial meningitis
is much more severe than viral meningitis and will be fatal if not treated
promptly.
CLINICAL PICTURE
The patient may have:
Fever, headache, nausea and vomiting.
Confusion, delirium, seizure.
Neck stiffness, lethargy, rash.
Photophobia, sore throat, weakness.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Assess cranial nerves for possible complication (hearing loss, visual impairment, nerve palsy). See cranial nerve assessment in Neurological tab.
Assess for Brudzinskis sign (hip and knee flexion in response to forced
flexion of the neck).
Assess for Kernigs sign (inability to completely extend the legs).
Initiate seizure precautions.
BE PREPARED TO
POSSIBLE ETIOLOGIES
INFECT
INFECT
Pneumonia
Acute infection of the lungs. Alveoli become inflamed and fluid-filled.
The patient may have:
Cough, chest pain, fever, tachycardia.
Shortness of breath, cyanosis, tachypnea, hemoptysis.
Joint pain, muscle aches.
Loss of appetite, fatigue.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Assess
Assess
Assess
Assess
Assess
Assess
Assess
BE PREPARED TO
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157
POSSIBLE ETIOLOGIES
CLINICAL PICTURE
The patient may have:
Small red pimple-like bumps that may look like boils or spider bites.
Erythema, swelling, and warmth around bumps; purulent drainage.
Fever, SOB, chest pain, muscle aches.
Painful skin abscesses.
Infection of bone, joints, incisions, blood, cardiac valves, lungs.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
INFECT
INFECT
BE PREPARED TO
POSSIBLE ETIOLOGIES
Tuberculosis
CLINICAL PICTURE
The patient may have:
Productive cough, worse in the morning.
Hemoptysis.
Chest pain, SOB.
Fever, night sweats.
Extreme weight loss if disease is advanced.
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159
STABILIZING AND MONITORING
BE PREPARED TO
POSSIBLE ETIOLOGIES
Mycobacterium tuberculosis.
INFECT
EMERG
Assessment in an Emergency
This assessment guideline was developed for the multiple trauma patient
brought into the emergency department (ED). However, the basic primary
surveythe ABCs (airway, breathing, circulation)take precedent in
any emergency situation, whether in the ED, ICU, or general care floor. The
primary survey should be accomplished within the first few minutes.
Put on gloves and face mask with visor.
Check that needed equipment is readily available.
Ensure that needed staff is available.
A: Airway
Assessment (with cervical spine immobilized):
Ask are you all right? Can the patient speak? If so, ABC is functional to
some extent. If there is no answer, rapidly begin more in-depth airway
and breathing assessment.
Look in the oropharynx for foreign objects, blood, teeth, vomitus, etc.
You may hear abnormal sounds such as wheezing or stridor.
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161
Interventions:
Immobilize cervical spine.
Establish patent airway with:
Jaw thrust/chin lift maneuver.
Consider a nasal airway. Do not use an oral airway in a conscious
patient as it may induce vomiting and aspiration.
Suction fluid from oropharynx.
If patient is not breathing or the airway cannot be cleared, endotracheal
intubation will be attempted. This will help:
Protect airway and ensure patency.
Correct hypoxemia.
Provide access for some medications.
If the patient cannot be intubated, a tracheotomy will be performed.
B: Breathing
Assessment:
Some patients are not breathing in an emergency (see CPR Quick
Reference in this tab). In a hospital, the code team will take over, and an
anesthesiologist, respiratory therapist, or other highly skilled individual
will assess the airway.
If the patient is breathing and you hear any noises with breathing, open
the mouth, and inspect the airway. Remove any obstructing material by
sweeping with a gloved finger.
Assess rate and ease of breathing. Check nailbed and circumoral area
for cyanosis.
Is the patient restless, thrashing about, extremely anxious? You will see
this in an emergency unless the patient has had a head injury and is
unconscious.
Feel trachea, examine the chest, and auscultate lungs.
Evaluate ABG results.
Interventions:
Provide high-flow supplemental O2; manually ventilate if necessary.
Identify and treat major thoracic injuries:
Pneumothorax (simple, open, or tension).
Hemo-pneumothorax.
Rib fractures.
Flail chest.
EMERG
EMERG
C: Circulation
Assessment:
Check cardiac rate and rhythm and BP. Recheck every few minutes.
Check peripheral perfusion.
Interventions:
Control external bleeding.
Insert two large-bore IV accesses.
Send blood for laboratory tests, and type and crossmatch.
Infuse a warmed crystalloid.
D: Disability
Assessment:
Initial neurological assessment is limited to checking pupils and assessing
LOC (responsiveness) using the AVPU scale:
A Alert
V responds to Voice
P responds to Pain
U Unresponsive
Any change in AVPU requires reassessment of ABC.
E: Exposure
Remove clothing (expose), and inspect for obvious injuries.
Cover patient to reduce heat loss.
Secondary Survey
Follows primary survey and resuscitation.
Involves head-to-toe systematic assessment to detect injuries.
Includes AMPLE history (allergies, medications, past medical history, last
meal eaten, events prior).
Includes continuous reassessment of primary survey.
Provides for assessment of each body area for signs of deformity,
contusion, abrasion, hemorrhage, penetrating injury, altered perfusion,
and altered function.
Inspect and palpate head and face for lacerations, contusions, fractures, or
other injury.
Eyes (injury, hemorrhage, contact lens, dislocation of lens).
Ears and nose for CSF.
Mouth.
Cranial nerves.
162
163
Cervical Spine and Neck
Chest
Abdomen
Extremities
Perineum
Back
Fractures
Neurological
EMERG
EMERG
Diagnostic Studies
164
165
patients chance of survival. The nurses role is critical in getting the right
help for the patient. Many hospitals have rapid response teams that can
be and should be called when the patients condition changes, even if you
cannot say for sure what it is (somethings different/wrong). The rapid
response team may consist of:
Resident, NP, or physicians assistant.
ICU nurse.
Nurse anesthetist or respiratory therapist.
The staff nurse is usually responsible for:
Calling the rapid response team.
Calling the attending physician.
Providing the recent history and background information.
Continuing to assess the patient.
Obtaining and administering medications.
Providing other noncritical care.
If your facility does not have a rapid response team, notify the nurse
manager or nursing supervisor, who can help you get the resources
needed.
EMERG
EMERG
Check for a pulse. If the patient has no pulse, begin one-person CPR until
another person or the code team arrives (see CPR Quick Reference in this
tab).
When another nurse arrives to help:
Bring the crash cart into the room.
Get an IV of NS running.
Switch to bag-valve-mask ventilations by:
Inserting an oral airway.
Connecting the bag-valve-mask to oxygen tubing.
Setting up the flowmeter.
Turning on the oxygen to 1215 L/min.
Make sure the seal around the patients airway is tight, and resume CPR.
Once the code team arrives, someone will relieve you and begin other
resuscitative interventions.
Once you are relieved:
Make sure one nurse is documenting and another nurse is retrieving
medications and supplies as needed from the code cart.
Stay in the room to be available to the team.
Many other tasks may be required of you in a code situation, including
obtaining laboratory tests and transporting them to the laboratory,
inserting an IV or Foley catheter, suctioning the airway, administering
medications, calling the attending physician, arranging for a bed in the
ICU, etc. Do not practice beyond your level of expertise.
Offer support to any visitors who are present.
Document all events up to and including time code was called. Document
after time the code ended. Check that the code record is complete and on
the chart.
If the patient survives, write a transfer note, and give report to
receiving unit. If you work in an ICU and the patient is not being moved,
detail the events in your end-of-shift report, and document on the ICU
flowsheet.
If the patient does not survive, leave all tubes in place, and check with
your supervisor to determine what can be removed. If an autopsy will be
performed, you will not remove anything.
Clean and cover the patient, and straighten the room before the family
views the body. If family members were present at the time the patient
coded, sensitively ask them if they would like you to do this first. It may
be unbearable for them to wait. ALWAYS consider the familys needs first.
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167
Adult/Child CPR, Hemlich, and Recovery Positions
Headtilt, chinlift.
Hand placement.
Heimlich maneuver.
Heimlich maneuver:
abdominal thrusts if
unresponsive.
EMERG
Recovery position.
EMERG
Headtilt, chinlift.
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169
CPR Quick Reference
Determine unresponsiveness
Open airway
If pulse is present but patient is not breathing, begin rescue breathing (see
table below).
If no pulse after 10 seconds, start chest compressions.
Newborn
Ventilations
1012/min
1220/min
4060/min
Pulse check
location
Carotid
Child: Carotid
Infant: Brachial
Brachial
Umbilicus
Compression
rate
100/min
100/min
120/min
Ratio of compressions
to breaths
30:2 (1 or
2 rescuers)
30:2 (15:2 if
2 rescuers)
3:1 (1 or
2 rescuers)
Compression
depth
11/22 inches
1/21/3
1/3
the depth
of the chest
the depth
of the chest
If a defibrillator is available
Power on, and follow voice prompts (AED)
Perform 2 minutes of CPR between each shock.
Adults: Do not use pediatric pads.
Child: Use after 2 min (5 cycles) of CPR (may use adult pads if pediatric pads
are unavailable).
Note: Recheck pulse every 2 minutes and after each shock. Check without
interrupting chest compressions.
EMERG
EMERG
Adult or child: Ask victim if he/she is choking; can he/she speak or make
any sounds?
Infant: Cannot cry or ineffective cough.
Unresponsive Patient
3. Determine unresponsiveness
4. Open airway
Headtilt, chinlift.
If trauma suspected, use the jaw-thrust method.
Adult, child, and infant: Use a tongue-jaw lift while opening the airway
during CPR.
Perform a finger sweep only to remove a visible foreign body.
7. Repeat manuevers
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Automatic External Defibrillators (AEDs)
Assessment: Determine unresponsiveness and assess ABCs.
Children 18 years: get help/AED after 2 min of CPR.
Adults 8 years: get help/AED immediately.
Perform CPR until AED arrives.
Power: Turn on the AED, and follow voice prompts.
Attach pads: Stop CPR, attach appropriate-size pads to patient, and plug
pad cable into the AED unit if needed.
Upper right sternal border and cardiac apex.
Analyze: Press the Analyze button, and wait for instructions (do not
make contact with patient while AED is analyzing rhythm).
Shock: Announce Shock indicated, stand clear, and assure that no one
is in contact with the patient.
Fully automatic units analyze rhythm and shock if indicated.
Semiautomatic units analyze rhythm, and then instruct the operator to
press the shock button if indicated.
PACING MODES
Demand (synchronous) mode senses the patients heart rate and paces
only when the HR falls below the clinician-set rate.
Fixed (asynchronous) mode does not sense the HR, but rather paces at the
rate set by the clinician.
PROCEDURE
EMERG
EMERG
Emergency Conditions
INJURY AND ILLNESS
Air embolism
Aortic aneurysm (ruptured)
Aortic dissection
Cardiac arrest
Cardiac arrhythmia
Cardiac tamponade
Hemorrhage
Hypertensive emergency
Myocardial infarction
Subarachnoid hemorrhage
Subdural hematoma, acute
Ventricular fibrillation
METABOLIC
Lactic acidosis
Thyroid storm
NEUROLOGICAL
OPHTHALMOLOGICAL
RESPIRATORY
Acute asthma
Agonal breathing
Asphyxia secondary to
angioedema, choking. drowning,
smoke inhalation
Epiglottitis or severe croup
Pneumothorax
Pulmonary embolism
Respiratory failure
SHOCK
Anaphylaxis
Cardiogenic shock
Hypovolemic or hemorrhagic shock
Neurogenic shock
Septic shock
UROLOGICAL, GYNECOLOGICAL,
AND OBSTETRIC
Eclampsia
Ectopic pregnancy
Gynecological hemorrhage
Obstetrical hemorrhage
Paraphimosis
Priapism
Testicular torsion
Urinary retention
172
173
Anaphylaxis
CLINICAL PICTURE
The patient may have:
Angioedema, hives, itching.
Feelings of impending doom, anxiety, restlessness.
Bronchospasm, laryngeal edema, respiratory distress.
Hypotension, dysrhythmia.
Nausea, vomiting, diarrhea.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
Assess airway status, LOC, and VS (HR, RR, BP) on a continuous basis.
Assess SaO2 via pulse oximetry.
Assess skin for color, temperature, turgor, moistness, and capillary refill.
BE PREPARED TO
POSSIBLE ETIOLOGIES
Exposure to antigen.
EMERG
EMERG
Transfusion Reaction
CLINICAL PICTURE
The patient may have:
Fever, chills, tachycardia, hypotension.
Chest pain, SOB.
Apprehension, restlessness.
Burning at infusion site.
Nausea, vomiting, diarrhea.
Urticaria, pruritus, skin erythema.
Flank, back, or joint pain.
Hematuria.
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
BE PREPARED TO
174
175
Insert indwelling catheter to monitor hourly urine output.
Administer medications such as:
Antihistamine, antipyretic, steroids, and furosemide (Lasix) IV.
Acute hemolytic reaction: IV normal saline with diuretics to maintain
urine output of 100 mL/hr.
Allergic response: corticosteroids such as Solu-Medrol.
Urticaria: diphenhydramine 2550 mg IV, deep IM.
Fever: acetaminophen.
Septicemia: antibiotics, IV fluids, vasopressors.
Kidney failure and shock: IV fluids and vasopressors.
Obtain or order STAT laboratory tests.
Titrate O2 to keep SaO2 90%.
Obtain two large-bore IV accessories.
POSSIBLE ETIOLOGIES
Types of Reactions
Type
Cause
Acute hemolytic
ABO incompatibility
reaction to RBC
antigens.
Febrile
nonhemolytic
Sensitization to donor
WBCs, platelets, or
plasma proteins.
Anaphylactic
Administration of
donors IgA proteins to recipient with
anti-IgA antibodies.
Restlessness, urticaria,
wheezing, shock, cardiac
arrest.
Allergic
Sensitivity to foreign
proteins.
Bacteremia
EMERG
EMERG
Shock
CLINICAL PICTURE
The patient may have:
Anxiety (early), lethargy and coma (later).
Hypotension.
Decreased urine ouput.
Tachycardia (bradycardia in neurogenic shock).
Delayed capillary refill (3 sec), diminished peripheral pulses (2).
Cool, pale, mottled, or cyanotic skin (hypovolemic shock).
Tachypnea.
Diaphoresis.
Throat tightness, stridor, flushing, urticaria (anaphylactic shock).
IMMEDIATE INTERVENTIONS
FOCUSED ASSESSMENT
176
177
Cardiogenic: O2; IVF; vasopressors, cardiotonics, antidysrhythmics (i.e.,
dopamine, dobutamine, lidocaine); correct dysrhythmias; arterial line
placement and hemodynamic monitoring.
Septic: O2; IVF; volume replacement; antibiotics, vasopressors,
antipyretics; arterial line placement.
Anaphylactic: O2; IVF; epinephrine, antihistamines (Benadryl/Atarax),
steroids; intubation and airway management; arterial line placement.
Neurogenic: O2; IVF; spinal stabilization; vasopressors; intubation and
airway management; arterial line placement; insert Foleys catheter.
Provide emotional support to family/patient.
Record patients status in chart, and communicate to physician or NP.
BE PREPARED TO
Call a code.
Assist with intubation and airway management.
Assist with obtaining central venous access.
Administer fluids, blood products, and medications as ordered.
Order or obtain specific laboratory tests to be drawn STAT (Hgb, Hct,
WBC, cardiac markers, electrolytes, ABG, UA).
Transfer to ICU.
POSSIBLE ETIOLOGIES
Pathophysiology
Anaphylactic:
Acute, lifethreatening
allergic reaction
to a specific
antigen.
Signs and
Symptoms
Respiratory distress (stridor);
BP; edema;
rash, hives;
cool, pale skin;
possible
seizure activity,
tight chest.
Interventions
O2, airway
management,
epinephrine,
antihistamines,
steroids, IV
fliuds.
EMERG
EMERG
Signs and
Symptoms
Pathophysiology
Cardiogenic:
Pump failure
due to MI, PE,
cardiac tamponade, heart failure,
aneurysm.
Interventions
Hypotension,
weak pulse,
tachycardia,
clammy skin,
altered LOC;
dysrhythmias.
O2, IV fliuds,
vasopressors,
cardiotonics,
antidysrhythmics.
Hypotension;
tachycardia;
weak pulse;
capillary refill;
cyanosis;
dysrhythmias;
altered LOC;
cool, clammy,
pale skin.
Hypotension,
bradycardia,
or tachycardia;
tachypnea;
possible
flaccid
paralysis and
absent
reflexes.
O2, control
bleeding,
fluid replacement with
crystalloids,
colloids,
volume
expanders,
blood.
O2, IV fluids,
airway
management,
spinal
stabilization,
possible
vasopressors.
Fever or low
temperature;
bounding
pulse; urine
output;
flushed, warm,
moist to
diaphoretic
skin; increased
HR/RR.
O2, IV fluids,
blood
cultures, UA,
sputum C&S
antibiotics,
vasopressors.
178
179
Cardiogenic Shock
Ineffective Pump
Ventricular Emptying
Stroke Volume
End-diastolic Volume
Cardiac Output
Filling Pressures
Tissue Perfusion
Cardiogenic shock.
Hypovolemic Shock
Volume
Venous Return
Filling Pressures
Stroke Volume
Cardiac Output
Tissue Perfusion
Hypovolemic shock.
EMERG
EMERG
Neurogenic Shock
Massive Vasodilation
Venodilation
Arteriolar Dilation
Venous Return
Peripheral Resistance
Filling Pressures
Stroke Volume
Cardiac Output
Blood Pressure
Tissue Perfusion
Neurogenic shock.
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181
High-Alert Medications
High-alert medications are those medications that have a high risk of causing
injury or death when improperly handled or administered. Many of these
drugs are used commonly in the general population or are used frequently
in urgent clinical situations. The Joint Commission monitors the five most
often prescribed high-alert medications: insulin, opiates and narcotics,
injectable potassium chloride (or phosphate) concentrate, IV anticoagulants
(heparin); and sodium chloride solutions above 0.9%. Exercise extreme
caution when administering these medications:
Adrenergic agonists (e.g., epinephrine, isoproterenol, norepinephrine).
Cardioplegic solutions.
Chemotherapeutic agents.
Chloral hydrate (in pediatric patients).
Colchicine injection.
High-concentration dextrose (greater than 10% dextrose).
Hypoglycemic agents (oral).
Hypertonic sodium chloride injection (0. 9% concentration).
Insulin.
IV adrenergic antagonists (propranolol, esmolol, metoprolol).
IV calcium.
IV digoxin.
IV magnesium sulfate.
IV potassium (phosphate and chloride).
Lidocaine/benzocaine; other topical anesthetics.
Midazolam.
Neuromuscular blocking agents.
Opiates (opioids).
Thrombolytics, heparin, warfarin.
MEDS/LABS
MEDS/LABS
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183
Make sure to tell the patient:
The brand and generic names of the medication.
The purpose of the medication.
The strength and dose and when to take the medication.
Possible side effects and what to do if they occur.
How long to take the medication.
What medications or foods to avoid and why they should be avoided.
How to store the medication.
What to do if a dose is missed.
What activities, if any, should be avoided while on the medication.
Signs and symptoms of adverse drug reactions.
Symbols
(dram)
(minim)
@ (at)
& (and)
(hour)
/ (slash)
(plus)
(minus)
(greater than)
(less than)
Apothecary symbols
Drug Names
ARA A
AZT
CPZ
DPT
DTO
HCl
HCT
HCTZ
IV Vanc
MgSO4
MEDS/LABS
MTX
Nitro drip
Norflox
PCA
PTU
T3
TAC
TNK
ZnSO4
General Tips
Avoid using a zero
after a decimal point.
Use a zero before a
decimal point.
Use commas for
dosing units at or
above 1,000.
Place adequate
space between a
drug name, dose,
and the unit of
measure.
MEDS/LABS
TKO
50
75
100
125
200
250
10 gtt/
mL set
13
17
21
150 175
25
29
33
42
12 gtt/
mL set
10
15
20
25
30
35
40
50
15 gtt/
mL set
13
19
25
31
37
44
50
62
20 gtt/
mL set
10
17
25
33
42
50
58
67
83
60 gtt/
mL set
30
50
75
100
125
150
175
200
250
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185
Adenosine (Adenocard) (Antidysrhythmic)
Indications: Narrow complex PSVT.
Dose: 6 mg IV. Repeat with 12 mg IV in12 min if needed. A third dose
of 12 mg may be given in 12 min. Max: 30 mg.
Contraindications: Drug- or poison-induced tachycardia.
Side Effects: Flushing, chest pain, tightness, bradycardia, heart block,
asystole, ventricular ectopy, VF.
Precautions: Ineffective in treating atrial fibrillation, atrial flutter, or VT.
Avoid in patients on dipyridamole or with a history of MI or cerebral
hemorrhage.
MEDS/LABS
MEDS/LABS
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187
Dose: 0.40.5 mg/kg IV bolus, may repeat subsequent boluses of 0.1 g/kg
q 1520 min or an infusion of 59 g/kg/min.
Contraindications: Myasthenia gravis, asthma, Eaton-Lambert syndrome,
severe electrolyte imbalances.
Side Effects: Bronchospasm, flushed skin, hypotension, tachycardia,
urticaria, hypersensitivity.
Precautions: Ensure intubation and suction equipment available, set up,
and in working order; multiple drug interactions.
Time Action Profile: Onset 22.5 min; peak 12 min; duration 3040 min.
Atropine (Anticholinergic)
Indications: Sinus bradycardia, asystole, PEA with rate 60, organophosphate and neurotoxin (nerve gas) exposure, antidote to cholinergic drug
toxicity and mushroom poisoning.
Dose: Bradycardia: 0.51 mg IV (may give via ET tube at double the dose)
q 35 min, maximum 0.04 mg/kg; cardiac arrest: 1 mg q 35 min, maximum
0.04 mg/kg; nerve gas and organophosphate exposure: 26 mg IV or IM
depending on severity of symptoms, may repeat in 2-mg increments q 3 min
titrated to relief of symptoms.
Contraindications: Atrial fibrillation, atrial flutter, glaucoma.
Side Effects: Tachycardia, HA, dry mouth, dilated pupils, VF/VT.
Precautions: Use caution in hypoxia. Avoid in hypothermic bradycardia and
2nd-degree (Mobitz) type-II HB.
MEDS/LABS
MEDS/LABS
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189
Contraindications: Drug or poison induced tachycardia, wide-complex
tachycardia of uncertain type, WPW syndrome, cardiogenic shock, pulmonary
edema.
Side Effects: Hypotension, BBB, ventricular extrasystoles.
Precautions: Severe hypotension in patients on beta blockers; do not
withdraw abruptly.
MEDS/LABS
MEDS/LABS
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191
Dose: Cardiac arrest: 1 mg IV of 1:10,000 solution q 35 min; double the
dose if administering via ET tube; anaphylaxis: 0.11 mg SQ or IM of 1:1000
solution; asthma: 0.10.3 mg SQ or IM of 1:10,000 solution; refractory
bradycardia and hypotension: 210 g/min (1 mg of 1:1,000 solution in 500
mL of saline and start at 15 mL/min).
Contraindications: Hypersensitivity to adrenergic amines, narrow-angle
glaucoma.
Side Effects: Angina, HTN, tachycardia, VT, VF, nervousness, restlessness,
tremors, pallor, cerebral or subarachnoid hemorrhage and aortic rupture,
suicidal/homicidal tendencies.
Precautions: Use caution in HTN, tachydysrhythmias, cardiac disease,
hyperthyroidism, glaucoma, DM, elderly, pregnancy, multiple drug
interactions.
Glucagon (Hormone)
Indications: Antidote to beta-blocker and calcium channel blocker overdose;
hypoglycemia when IV access unavailable and patient cannot protect airway
(cannot take oral glucose); used to decrease GI motility during GI
procedures.
Dose: Antidote to calcium channel blocker: 2 mg IV; antidote to beta
blocker: 50150 g/kg IVP followed by a 15 mg/hr infusion; hypoglycemia:
0.51 mg IV, IM, SC; to decrease GI motility: 0.251 mg slow IVP or up to
2 mg IM.
Contraindications: Known allergy to beef or pork protein.
Side Effects: N&V.
Precautions: Use caution in patients with insulinoma or
pheochromocytoma.
MEDS/LABS
MEDS/LABS
Dose: See individual order and drug for route and dosages.
Contraindications: Active internal bleeding within 30 days, history of
neurovascular event within 1 month (within 2 years of surgery or trauma
within 1 month) aortic dissection, severe (uncontrolled) HTN, within 6 weeks
of a known GI or GU bleed, known bleeding disorder.
Side Effects: Increased bleeding and bruising, GI irritation.
Precautions: Increased chance of bleeding; use with caution in elderly, in
patients with history of GI disease, or those receiving thrombolytics; multiple
herb interactions.
Heparin (Anticoagulant)
Indications: Acute pulmonary/peripheral embolism, atrial fibrillation with
emoblization, treatment of DIC.
Dose: Per order.
Contraindications: Active bleeding, blood dyscrasias, thrombocytopenia,
liver disease, suspected intracranial hemorrhage, ulceration of the GI tract,
subendocarditis, shock, threatened abortion, severe HTN, hypersensitivity.
Side Effects: Minor to major hemorrhage, thrombocytopenia, anaphylaxis.
Precautions: Use with caution in menstruating women, post-partally,
following CVA, and in the elderly; multiple herb interactions.
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193
Inamrinone (Inocor) (Inotropic)
Indications: Short-term treatment of CHF unresponsive to traditional
therapies.
Dose: Per order.
Contraindications: Hypersensitivity to bisulfates, IHSS.
Side Effects: Dyspnea, dysrhythmias, hypotension, N&V, diarrhea,
hepatotoxicity, hypersensitivity, tachyphylaxis.
Precautions: Use cautiously in atrial fibrillation or atrial flutter, electrolyte
imbalances, renal impairment, and geriatric patients.
MEDS/LABS
MEDS/LABS
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195
Side Effects: Altered LOC, HA, blurred vision, N&V, tachycardia, hypotension or HTN, chest pain, CHF, seizures.
Precautions: Elderly, cardiovascular and renal disease.
MEDS/LABS
MEDS/LABS
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197
Side Effects: Hypotension, widening QT, asystole, HA, N&V, flushed skin,
seizure, ventricular dysrhythmias, partial or complete HB.
Precautions: Stop administration for hypotension or when QT interval
begins to widen. Use cautiously in patients with CHF, cardiomyopathy, or
acute ischemic heart disease, and in patients with liver or renal disease.
Multiple drug interactions.
MEDS/LABS
MEDS/LABS
Thrombolytics
Common Agents: Activase (Alteplase, recombinant; t-PA); Retavase
(Reteplase), Streptase (Streptokinase)
Indication: Acute MI 12 hr from onset of symptoms and acute ischemic
stroke.
Dose: See individual order and drug for route and dosages.
Contraindications: Active internal bleeding within 21 days (except
menses), history of neurovascular event within 3 months, major surgery or
trauma within 2 weeks, aortic dissection, severe (uncontrolled) HTN,
bleeding disorder, prolonged CPR, LP within 1 week.
Side Effects: Hypotension, reperfusion arrhythmias, HA, increased bleeding
time, hemorrhage, flushing, urticaria.
Precautions: Patients with severe renal or hepatic disease.
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199
Side Effects: Drowsiness, GI bleed or perforation, nausea, HA, increased
bleeding time, anaphylaxis, bronchospasm.
Precautions: GI bleed; renal, hepatic, or CV disease.
MEDS/LABS
MEDS/LABS
esmolol
conjugated
estrogens
ethacrynate sodium
etoposide
famotidine
fentanyl
filgrastim
fludarabine
fluorouracil
furosemide
gatifloxacin
gemcitabine
granisetron
heparin
hydralazine
idarubicin potassium
indomethacin
insulin
isoproterenol
kanamycin
labetalol
lidocaine
linezolid
lorazepam
magnesium sulfate
melphalan
menadiol
meperidine
methoxamine
methylergonovine
midazolam
minocycline
morphine
neostigmine
norepinephrine
ondansetron
oxacillin
oxytocin
paclitaxel
penicillin G potassium
pentazocine
phytonadione
piperacillin/tazobactam
procainamide
prochlorperazine edisylate
propofol
propranolol
pyridostigmine
ranitidine
remifentanil
sargramostim
scopolamine
sodium bicarbonate
succinylcholine
tacrolimus
teniposide
theophylline
thiotepa
tirofiban
trimethaphan
trimethobenzamide
vinorelbine
warfarin
zidovudine
chloramphenicol
sodium succinate
chlorpromazine HCl
diazepam
ergotamine tartrate
methicillin sodium
200
phenytoin
phenytoin sodium
sulphadiazine sodium
suxamethonium chloride
thiopentone sodium
201
Reference Ranges for Common Laboratory Tests
Arterial Blood Gases (ABGs)
Normal ABG Results (U.S. System of Measurements)
pH
PaO2
PaCO2
7.357.45
80100
3545
mm Hg
mm Hg
Normal ABG Results (SI Units)
O2 sat
HCO3
Base Excess
95%100%
2128
mEq/L
2 to 2 mEq/L
pH
PaO2
PaCO2
O2 sat
HCO3
7.357.45
10.612.6
kPa
4.665.98
kPa
95%100%
2128
mmol/L
Base Excess
2 to 2
mmol/L
Critical Levels:
pH: 7.25 or 7.55
PaO2: 45
PaCO2: 20 or 60
HCO3: 15 or 40
Base Excess: 3 mEq/L
Chemistries
Test
Conventional
Albumin
Alkaline phosphatase
ALT
AST
BUN
Bilirubin, direct
Bilirubin, total
Calcium
Chloride
Cholesterol, total
CO2
Creatinine
Gamma-GT
Glucose
Lactic acid
3.95.0 g/dL
44147 units/L
659 units/L
1034 units/L
720 mg/dL
0.00.3 mg/dL
0.21.9 mg/dL
8.510.9 mg/dL
101111 mmol/L
100240 mg/dL
2029 mEq/L
0.81.4 mg/dL
051 units/L
64128 mg/dL
0.51.5 mEq/L or
8.115.3 mg/dL
SI Units
3550 g/L
40120 U/L
2065 U/L
1545 U/L
2.98.9 mmol/L
08 mol/L
020 mol/L
2.152.5 mmol/L
98106 mmol/L
25.19 mmol/L
2029 mmol/L
70120 mol/L
1058 U/L
3.311 mmol/L
SI units: 0.51.5 mmol/L
(Continued on the following page)
MEDS/LABS
MEDS/LABS
Chemistries (continued)
Test
LDH
Magnesium
Phosphorus
Potassium
Protein, total
Sodium
Uric acid, serum
Conventional
105333 units/L
1.52 mEq/L
2.44.1 mg/dL
3.55 mEq/L
6.37.9 g/dL
136144 mEq/L
Male: 4.08.5 mg/dL
Female: 2.87.3 mg/dL
SI Units
300600 mmol/L
0.71.05 mmol/L
0.81.4 mmol/L
3.55 mmol/L
6080 g/L
136144 mmol/L
0.240.51 mmol/L
0.160.43 mmol/L
Coagulation Profile
Test
INR
PT
PTT/aPTT
D-dimer
FDP (fibrin degradation products)
Fibrinogen
Conventional
SI Units
0.91.2
1014 sec
2137 sec
0.5 g/mL
5 g/mL
0.91.2
1014 sec
2137 sec
150400 mg/dL
1.74.1 g/L
Cardiac Markers
Test
Conventional
SI Units
85 U/mL
85 U/mL
0100 pg/mL
100 ng/L
CK isoenzymes
CK-MB: 0%3%
00.03
Cardiac troponin
T: 0.2 ng/mL
Cardiac troponin
I: 0.03 ng/mL
Cardiac troponin
T: 0.2 ng/mL
Cardiac troponin
I: 0.03 ng/mL
202
203
Cardiac Markers (continued)
Test
Conventional
SI Units
Myoglobin, serum
Lactate dehydrogenase
(LD, LDH), LDH isoenzymes
Aspartate aminotransferase
90 g/L
100190 U/L
90 g/L
100190 U/L
035 U/L
0-0.58 kat/L
Hematology
Test
Conventional
MEDS/LABS
SI Units
8085 mL/kg
4.66.2 1012/L
4.25.9 1012/L
8.111.2 mmol/L
7.49.9 mmol/L
0.450.52
0.370.48
4.310.8 109/L
0.030.08
00.01
0.010.04
0.250.40
0.100.20
0.600.80
0.020.08
0.540.75
150350 109/L
113 mm/hr
120 mm/hr
150450 109/L
MEDS/LABS
A & P Snapshot
IM injection sites.
204
205
MEDS/LABS
INDEX
SA node
Left bundle
branch
Intra-atrial
pathways
AV Node
Purkinje
fibers
Bundle of His
Right bundle
branch
on the right
(negative)
and...
Smoke
(Ground)
Over
Fire
Chest lead
and
Right leg lead
Included for seven
channel monitoring
(positive)
206
207
Lead Placement and Normal Deflection of PQRST Waves
Midclavicular
line
Anterior
axillary line
Midaxillary
line
V6
V5
V 1 V2
V3
V4
Right
lung
Left
lung
V6
V5
V4
V1
V2
V3
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PR
Q
S
Atrial
Ventricular
Ventricular
depolarization depolarization repolarization
208
209
Heart Sounds
QRS
P
QRS
T
S1
S2
S1
S2
Aortic
valve
Pulmonic
valve
S1
S2
S2
S1
Tricuspid
valve
Heart sounds.
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Mitral
valve
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Irregular
rhythms
should be
counted for
an entire
minute.
1st R wave
60
50
43
210
211
Normal Cardiac Cycle and Measurements
QRS
P-R interval
Normal
Rate bpm
60100 bpm
Normal Rate
60100
Normal P-RNormal
0.120.20
0.120.20 sec
P-R sec
Normal QRS 0.080.12 sec
P wave atrial depolarization; QRS ventricular
depolarization; T wave ventricular repolarization
0.04 sec
0.20 sec
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212
213
Sinus Tachycardia
Sinus Bradycardia
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Atrial Fibrillation
Rate..............................................................................................................Variable
Rhythm ....................................................................................Irregularly-irregular
P waves ...............................................................................None (nondiscernible)
P-R....................................................................................................Nondiscernible
QRS.....................................................................................Narrow (0.080.12 sec)
Atrial Flutter
Flutter
waves
214
215
Junctional Rhythm
No P waves
Rate.....................................................................................................100220 bpm
Rhythm ...........................................................................................Usually regular
P waves.................................................................................................Not present
P-R .........................................................................................................Not present
QRS ..........................................................................Wide and bizarre (0.12 sec)
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Ventricular Fibrillation
Asystole
Rate...............................................................................................................No rate
Rhythm ...................................................................................................No rhythm
P waves............................................................................................................None
P-R .........................................................................................................Not present
QRS......................................................................None (occasional agonal beats)
216
217
1 AV Block
Prolonged
P-R interval
Dropped
QRS
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Blocked
P waves
No correlation
between atria
and ventricles
218
219
PVC (Premature Ventricular Complex)
Compensatory
Pause
Rate .....................................................................................................................N/A
Rhythm..................................Temporary delay caused by compensatory pause
P waves............................................................................................................None
P-R .......................................................................................................................N/A
QRS ..........................................................................Wide and bizarre (0.12 sec)
PAC
No
P
PJC
Rate..........................................................................................................Premature
Rhythm....................................................................................................Premature
P waves ..................................Present in PAC, but may be hidden in the T wave
P-R .......................................................................................Not present in the PJC
QRS ..............................................................................................................Normal
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Starting an IV
Prepare the patient: explain procedure, answer any questions, and give
reassurance.
Gather equipment: IV bag with primed tubing, sharps container, catheter,
tape, dressing, tourniquet, antiseptic swabs, gloves, IV catheter of appropriate size.
Organize supplies: tear tape, hang IV solution with primed tubing close by,
sharps container within easy reach, 2 2 or other dressing open.
Apply tourniquet: proximal to intended insertion site, either mid-forearm
or above the elbow; don gloves.
Locate vein: palpate with finger tips; to further enhance dilation, gently tap,
apply heat/warm soak, have patient make a fist, or dangle arm below heart.
Cleanse site: using moderate friction, cleanse in a circular motion, moving
outward from intended site.
Put on gloves: while waiting for cleansed area to dry, avoid touching site
once it has been prepared.
Apply traction (opposite the direction of the catheter).
Position needle: bevel side up, 1530 Note: hold the needle with the
thumb and pointer finger in a way that allows for visualization of the flash
chamber.
Insert needle, and observe for flash back in flash chamber. Lower catheter
almost parallel to the skin, and insert the needle 12 additional mL to ensure
catheter has also entered the vein.
Advance the catheter: thread catheter into vein while maintaining skin
traction and pulling back on needle.
Release the tourniquet, and apply digital pressure just above the end of
the catheter tip while gently stabilizing the hub of the catheter.
Remove needle, and discard into approved sharps container.
Connect IV tubing, open clamp, and observe for free flow of IV fluid.
Secure catheter, and apply sterile dressing per hospital policy/procedure.
Clean up, and document per hospital policy/procedure.
220
221
Peripheral Access IV Lines
Change site every 72 hours.
Assess for signs of infiltration (swelling, tenderness, redness, burning
with infusion, decreased or no infusion rate, blanching of skin, site cool
to touch) or phlebitis (vein feels firm and appears red; warmth, swelling,
and tenderness); discontinue IV, and restart in a new site.
CVC: External Access Port(s) (Groshong)
Avoid touching the exit site with fingers.
Change the end cap(s) every 7 days or sooner if any blood, cracks, or
leaks are seen.
Change the dressing, and clean the exit site every day.
If using a transparent film, change and clean the exit site dressing once
a week.
Clean with alcohol. Never use iodine!
Tunneled CVC: External Access Ports (Hickman, Broviac, Leonard,
or Ventra Catheters)
Keep tubes clamped when not being used.
Change the end cap(s) every 7 days or sooner if any blood, cracks, or
leaks are seen.
Change the dressing, and clean the exit site every 2 days. If using an opsite, change and clean the exit site dressing once a week.
Implanted Port Catheters: Groshong
Wash skin around area of port daily with soap and water. If recently
inserted, provide aseptic incision care until healed.
Comparison of Crystalloids
Type of Solution
Saline solutions
NS, 0.9% NaCl, sodium
chloride, saline, 3%
and 5% saline
Components
Na and Cl
Indications
Alkalosis
Fluid loss
Sodium depletion
(Continued on the following page)
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Components
Indications
Dextrose solutions
D5W, D10W
Dextrose in
water
Dextrose and
saline mixtures
D5NS, D51/2NS, D10NS
Dextrose in
saline
Promote diuresis
Correct moderate fluid loss
Prevent alkalosis
Provide calories and sodium chloride
Multielectrolyte
solutions
Lactated Ringers,
Ringers lactate
Combination
of Na, Cl,
K, Ca, and
lactate
Components
Human plasma
protein
Indications
5%: Rapid volume expansion
and mobilize interstitial edema
25%: Hypoproteinemia
To increase serum colloid
osmotic pressure
Dextran
40% and 70%
Volume expansion
Synthetic colloid
made of glucose Mobilize interstitial edema
polysaccharides
Hetastarch:
Hespan
Synthetic colloid
made from corn
Volume expansion
Mobilize interstitial edema
222
223
Comparison of Blood Products
Blood Product
Components
Indications
Whole blood
Fresh frozen
plasma
Cryoprecipitate
Clotting factors
Hemophilia, fibrinogen
deficiency, DIC
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DX/S/P
Time
Vital Signs
BP
HR
RR
Notes
O2 sats
Temp
on
on
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on
on
on
on
on
224
on
Labs/Diagnostics
Time
General Chemistry
Na
Cl
Ca
Hct
ACT
PT
Mg
Glu
BUN
Platelets
Troponin-I
Troponin-T
Thrombin
time
pH
PO2
Cardiac Enzymes
CPK-MB
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225
Hematology
Creat.
Coagulation
INR
PTT
Blood Gases
PCO2
HCO3
BE
CO2 SaO2
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Amount In
Output
IVF
Urine
IVPB
NG drainage/emesis
Blood/colloid
Oral intake
Liquid stool
Other
Total In
Total Out
226
Amount Out
227
Selected References
Crimlisk JT, Grande MM. Neurologic assessment skills for the acute medical surgical
nurse. Orthop Nurs 2004 Jan-Feb; 23(1):39.
Deglin JH, Vallerand AH: Daviss Drug Guide for Nurses, ed. 10. FA Davis, Philadelphia,
2006.
Gallimore D. Caring for patients after mechanical ventilation. Part 1: Physical and
psychological effects. Nurs Times 2007 Mar 1319;103(11):2829.
Gallimore D. Caring for patients after mechanical ventilation. Part 2: Nursing care to
prevent complications. Nurs Times 2007 Mar 2026;103(12):2829.
Garner JS. Hospital infection control practices advisory committee: Guideline for
isolation precautions in hospitals. Am J Infect Control 1996; 24:2452.
Halvorsan L, et al. Building a rapid response team. Adv Crit Care Nurse 2007 AprJun;18(2):12940.
Jackson, M. Critical thinking models and their application. In M Jackson, DD
Ignatavicius, B Case (eds.), Conversations in Critical Thinking and Clinical Judgment.
Pohl Publishing, Pensacola, FL, 2004, pp. 4967.
Jaul E, Singer P, Calderon-Margalit R. Tube feeding in the demented elderly with severe
disabilities. Isr Med Assoc J 2006 Dec;8(12):87074.
Offner PJ, Heit J, Roberts R. Implementation of a rapid response team decreases
cardiac arrest outside of the intensive care unit. J Trauma 2007 May;62(5):122327;
discussion 122728.
Sagarin M, McAfee A. Hyperosmolar hyperglycemic, nonketotic coma
http://www.emedicine.com/emerg/topic264.htm. Accessed March 2007.
Scheffer BK, Rubenfeld MG. A consensus statement on critical thinking in nursing.
J Nurs Educ 2000 39(8):35259.
Sole ML, et al. Introduction to Critical Care Nursing. Elsevier Saunders, Philadelphia,
2005.
Varughese S. Management of acute decompensated heart failure. Crit Care Nurs Q.
2007 Apr-Jun;30(2):94103. Review.
Venes D, Thomas CL, Taber CW (eds): Tabers Cyclopedic Medical Dictionary, ed. 19. FA
Davis, Philadelphia, 2001.
Wilkinson JM, Van Leuven K. Fundamentals of Nursing. FA Davis, Philadelphia, 2007.
Illustration Credits
Pages 17, 59, 167168, 206 from Myers E: RNotes: Nurses Clinical Pocket Guide,
FA Davis, Philadelphia, 2003; pages 53, 55 from Williams L and Hopper
P: Understanding Medical Surgical Nursing, ed 2. FA Davis, Philadelphia, 2003;
pages 5556 from Tabers Cyclopedic Medical Dictionary, ed 19. FA Davis,
Philadelphia, 2001; pages 35, 36, 57, 7779, 9798, 115, 124, 144145 from Scanlon VC
and Sanders T: Essentials of Anatomy and Physiology, ed 4. FA Davis, Philadelphia,
2003. Page 9 from Hockenberry MJ, Wilson D, Winkelstein ML: Wongs Essentials of
Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. Copyright,
Mosby.
Adapted from Folstein et al, Mini Mental State, J Psych Res 12:196198 (1975)
*Reference ranges vary according to brand of laboratory assay materials used; check
normal reference ranges from your facilitys laboratory when evaluating results.
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Index
Note: Page numbers followed by f refer to figures (illustrations).
A
Abdomen, assessment of, in emergency, 163
distention of, 100101
pain in, 100101
thrusts to, in Heimlich maneuver, 167f
ABG (arterial blood gas) values, 201
assessment of, 3738, 5152
AC (assist-control) ventilation, 47
ACE (angiotensin-converting enzyme) inhibitors,
184
Acetylsalicylic acid (aspirin), 186
Acidosis, diabetic, 116117
Activase (alteplase, t-PA), 185
Activated charcoal, 184
Acute hemolytic reaction, to transfusion, 175
Acute renal failure, 92
Adenosine (Adenocard), 185
Adrenalin (epinephrine), 190191
Adrenergic agonists, 185, 190
Adult, choking in, 170
CPR in, 167f, 169
Heimlich maneuver in, 167f
Advance directives, 164
AEDs (automated external defibrillators), 169,
171
Airborne precautions, in infection prevention, 147
Airway(s), artificial, 5556, 55f56f
assessment of, in emergency, 160
methods of opening, 167f, 168f, 169, 170
Alarms, ventilator, 4849
Albumin, reference range for, 201
Albumin solution, 222
Albuterol (Ventolin), 185
Alginates, for pressure ulcer, 140
Alkaline phosphatase, reference range for, 201
Allergic reaction, to transfusion, 175
ALT, reference range for, 201
Alteplase (Activase, t-PA), 185
Alupent (metaproterenol), 185
Ambu bag, oxygen delivery via, 54, 54f
Aminophylline (Truphylline), 185186
Amiodarone (Cordarone), 186
Amyl nitrate, 186
Analgesics, 186, 189, 195, 198
routes for administration of, 1112
Anaphylaxis, 173, 177
in reaction to transfusion, 175
Angina, 23
228
229
Blood tests, reference ranges for, 203
Blood transfusion, 223
adverse reactions to, 174175
Blood urea nitrogen (BUN) values, 201
assessment of, 80
Braden scale, for pressure ulcer risk, 136
Bradycardia, 2021
sinus, 213f
Brain, functional areas of, 77f
vascular lesions of, and sudden neurological
deficit, 7577
Breathing, assessment of, 37
in emergency, 161, 169, 170
compromised, 16, 4044, 4546
rescue, in CPR, 169
Bretylium (Bretylol), 188
Brevibloc (esmolol), 191
Bronchodilators, 185
BUN (blood urea nitrogen) values, 201
assessment of, 80
C
Calan (Isoptin, verapamil), 199
Calcium, reference range for, 201
Calcium channel blockers, 188, 199
Calcium chloride, 188
Calcium gluconate, 188
Calcium imbalance, 82
Cannula delivery, of oxygen, 53, 53f
Capillary refill, normal vs. delayed, 16
Carbon dioxide, delivery and pickup of, 59f
reference range for, 201
Cardiac cycle. See also Heart and Cardioentries.
waveform of, 208f
studies of, 206, 206f219f, 210, 212
Cardiac markers, 202203
Cardiogenic shock, 178, 179f
Cardiopulmonary resuscitation (CPR), 167f, 168f,
169
Cardiovascular system, assessment of, 1516
Cardizem (diltiazem), 188189
CDAD (Clostridium difficileassociated diarrhea),
148149
Central lines, care of, 220221
Cervical spine, assessment of, in emergency, 163
Charcoal, activated, 184
Chemistries, reference ranges for, 201202
Chest, assessment of, in emergency, 163
compressions of, in CPR, 169
pain in, 2124
thrusts to, in Heimlich maneuver, 168f
Chest tube, dislodgement of, 3940
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D
Dantrolene (Dantrium), 189
Data sheets, 224f226f
Dbriding agents, for pressure ulcer, 140
Decadron (dexamethasone), 189
Defibrillators, automated external, 169, 171
Dehydration, 8485
Delegation, in nursing, 56
Delirium, 6768
Deltoid site, for IM injection, 204f
Demerol (meperidine), 189
Dexamethasone (Decadron), 189
Dextran solution, 222
Dextrose solutions, 189, 222
Diabetic ketoacidosis (DKA), 116117
Diagnostic studies, in emergency, 164
Diarrhea, 104105
Clostridium difficileassociated, 148149
in patient with feeding tube, 108
Digestive tract, 115f
assessment of, 99100
bleeding from, 109112
Digoxin (Lanoxin), 190
Digoxin immune fab (Digibind), 189190
Diltiazem (Cardizem), 188189
Diphenhydramine (Benadryl), 187
Diprivan (propofol), 197
Disability, assessment for, 162
Distention, abdominal, 100101
Diuretics, 194
Dizziness, 6869
DKA (diabetic ketoacidosis), 116117
Dobutamine (Dobutrex), 190
Documentation, in emergency situations, 45
in management of pressure ulcer, 137
Do Not Resuscitate orders, 164
Dopamine (Intropin), 190
Dorsogluteal site, for IM injection, 204f
Dressings, for pressure ulcers, 139140
Droplet precautions, in infection prevention,
147
Dyspnea, 16, 4042
Dysrhythmias, medications for, 185, 186, 188, 190,
191, 192, 194, 196
types of. See specific problems, e.g.,
Tachycardia.
E
ECG (electrocardiography), 206, 206f219f, 210,
212
Edema, assessment of, 16
Education, of patients, regarding medications,
182183
230
231
Gamma-GT, reference range for, 201
Gastric secretions, leakage of, in patient with
feeding tube, 107
Gastroesophageal reflux, in patient with feeding
tube, 107
Gastrointestinal tract, 115f
assessment of, 99100
bleeding from, 109112
Genitourinary system, 97f98f
assessment of, 8082
Glasgow coma scale, 61
Gloves, in infection prevention, 146
Glucagon, 191
Glucose, reference range for, 201
Glucose imbalance, 118121
Glycoprotein IIb/IIIa inhibitors, 191192
Gowns, in infection prevention, 147
H
Hand placement, in CPR, 167f, 168f
Hand washing, in infection prevention, 146
Head, assessment of, 15
in emergency, 162
support of, in Heimlich maneuver, 168f
tilting of, chin lift and, to open airway, 167f,
168f, 169, 170
trauma to, 6970
Heart. See also Cardiac and Cardio- entries.
anatomy of, 35f
conditions compromising, and chest pain, 23,
24
electrical conduction in, 206f
studies of, 206, 206f219f, 210, 212
Heart block, 217f218f
Heart failure, 2526
Heart sounds, 209f
sites for assessment of, 17f
Heimlich maneuver, 167f, 168f
Hematemesis, 109111
Hematological tests, reference ranges for, 203
Hematoma, arterial, 1718
Hemolytic reaction, to transfusion, 175
Hemorrhage/bleeding, 2627
gastrointestinal, 109112
wound, 2627
Heparin, 192
Hepatitis, 153154
Hetastarch solution, 222
HHNC (hyperosmolar hyperglycemic nonketotic
coma), 119120
High-alert medications, 181
High-pressure alarm, 49
High respiratory rate alarm, 49
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232
233
Necrotizing fasciitis (NF), 130131
Needles/sharps, prevention of injury from, 147
Neurogenic shock, 178, 180f
Neurological assessment, 6061
in emergency, 163
Neurological deficit, sudden, 7577
Neuromuscular blocking agents, 186, 198
Neurovascular status, assessment of, 125126
NF (necrotizing fasciitis), 130131
NGT (nasogastric tube), insertion of, 102103
Nitroglycerin (Nitrostat), 196
Nitroprusside (Nipride, Nitropress), 195
Nonhemolytic reaction, febrile, transfusion and,
175
Nonketotic coma, hyperosmolar hyperglycemic,
119120
Nonrebreather delivery, of oxygen, 53, 53f
Norcuron (vecuronium), 199
Numeric rating scale, in pain assessment, 9
Nursing, 114. See also Patient(s).
critical thinking in, 68
cultural sensitivity in, 1213
delegation in, 56
documentation in, 45
legal aspects of, 14
pain management in, 812. See also Pain.
spiritual care in, 14
O
Obtundation, 66
Oliguria, 92
Organ dysfunction syndrome, multiple, 151
Oropharyngeal airway, 55, 55f
Osmitrol (mannitol), 194195
Oxygen delivery systems, 5355, 53f55f
Oxygen transport, in respiratory system, 58f
Oxytocin (Pitocin), 196
P
Pacing, transcutaneous, 171
Packed red blood cells, 223
Pain, 812
abdominal, 100101
assessment of, 911
mnemonics aiding, 1011
rating scales in, 910
chest, 2124
management of, 812
Palpitations, 3031
Pathological fracture, 131132
Patient(s). See also Nursing.
code responses for, 165166
communication of status of, 12
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R
Rapid response teams, 164165
Recovery position, 167f
Reference ranges, for laboratory tests, 201203
Reflexes, assessment of, 6061
Reflux, in patient with feeding tube, 107
Renal assessment, 8082
Renal failure, acute, 92
Rescue breathing, in CPR, 169
Respiratory distress/failure, 4546
Respiratory system, 57f
assessment of, 3738
oxygen and carbon dioxide transport in,
58f59f
Responsiveness, assessment of, 65
management of choking victim based on, 170
Resuscitation, cardiopulmonary, 167f, 168f, 169
orders against, 164
Romazicon (flumazenil), 197
S
Safety, of patient, 23
medication administration and, 181182
Saline solutions, 221, 222
SC (subcutaneous) injection sites, 205f
Second-degree AV block, 217f218f
Seizure(s), 7273
Self-harm, protection of patient from, 23
Sensation, assessment of, 60
Sepsis, 151
Septic shock, 151, 178
Sharps/needles, prevention of injury from, 147
Shock, 176178, 179f180f
anaphylactic, 177
cardiogenic, 178, 179f
hypovolemic, 178, 179f
neurogenic, 178, 180f
septic, 151, 178
Shortness of breath (SOB), 16, 4042
SIMV (synchronized intermittent mandatory
ventilation), 47
Sinus bradycardia, 213f
Sinus rhythm, 211f
Sinus tachycardia, 213f
SIRS (systemic inflammatory response
syndrome), 151
Skeletal system, 144f
Skin, assessment of, 126127
structures of, 145f
SOB (shortness of breath), 16, 4042
Sodium, reference range for, 202
Sodium bicarbonate, 197198
234
235
U
Ulcer, pressure, 127, 135140
Unresponsiveness, assessment for, 169
management of choking in presence of,
170
Upper gastrointestinal tract, bleeding from,
109111
Urgent situations. See Emergency(ies).
Uric acid, reference range for, 202
Urinary tract, 97f98f
assessment of, 8082
catheterization of, 9495
infection of, 9596
Urine, low output of, 92
retention of, 9394
UTI (urinary tract infection), 9596
V
Vacuum-assisted closure (VAC) units, for
wounds, 142, 143f
Vancomycin-resistant staphylococcal infection,
157158
Vasopressin (Pitressin), 199
Vastus lateralis site, for IM injection, 204f
Vecuronium (Norcuron), 199
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236
Notes