NCLEX-PN® Review Made Incredibly Easy! (Incredibly Easy! Series)

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NCLEX-PN Review
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NCLEX-PN Review
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Staff The clinical treatments described and recommended in this publica-

tion are based on research and consultation with nursing, medical,
and legal authorities. To the best of our knowledge, these procedures
Executive Publisher reflect currently accepted practice. Nevertheless, they can't be con-
Judith A. Schilling McCann, RN, MSN sidered absolute and universal recommendations. For individual appli-
cations, all recommendations must be considered in light of the pa-
Editorial Director tient's clinical condition and, before administration of new or infre-
David Moreau quently used drugs, in light of the latest package-insert information.
The authors and publisher disclaim any responsibility for any adverse
Clinical Director effects resulting from the suggested procedures, from any undetected
Joan M. Robinson, RN, MSN errors, or from the reader's misunderstanding of the text.
Art Director © 2009 by Lippincott Williams & Wilkins. All rights reserved. This book
Mary Ludwicki is protected by copyright. No part of it may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means—
Electronic Project Manager electronic, mechanical, photocopy, recording, or otherwise—without
John Macalino prior written permission of the publisher, except for brief quotations
embodied in critical articles and reviews and testing and evaluation
Clinical Project Manager materials provided by publisher to instructors whose schools have
Kate Stout, RN, MSN, CCRN adopted its accompanying textbook. Printed in the United States of
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Editorial Assistants Library of Congress Cataloging-in-Publication Data

Karen J. Kirk, Jeri O'Shea, Linda K. Ruhf NCLEX-PN review made incredibly easy!. — 3rd ed.
p. ; cm.
Design Assistant Includes bibliographical references and index.
1. Practical nursing—Outlines, syllabi, etc. 2. National Council
Kate Zulak Licensure Examination for Practical/Vocational Nurses—Study
guides.
Indexer [DNLM: 1. Nursing, Practical—United States—Examination
Questions. WY 18.2 N3366 2009]
Barbara Hodgson RT62.N3366 2009
610.73076—dc22
ISBN-13: 978-0-7817-9920-1 (alk. paper)
ISBN-10: 0-7817-9920-1 (alk. paper)
2008030115
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Contents
Contributors and consultants vii
Advisory board viii
Not another boring foreword ix
Joy’s NCLEX adventure xi
Part I Getting ready

1 Preparing for the examination 3
2 Strategies for success 13
Part II Care of the adult

3 Cardiovascular system 21
4 Respiratory system 69
5 Hematologic & immune systems 113
6 Neurosensory system 169
7 Musculoskeletal system 215
8 Gastrointestinal system 237
9 Endocrine system 277
10 Genitourinary system 303
11 Integumentary system 339
Part III Psychiatric care

12 Essentials of psychiatric nursing 363
13 Somatoform & sleep disorders 373
14 Anxiety & mood disorders 387
15 Cognitive disorders 399
16 Personality disorders 409
17 Schizophrenic & delusional disorders 417
18 Substance-related disorders 429
19 Dissociative disorders 437
20 Sexual disorders 445
21 Eating disorders 453
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Contents
vi
Part IV Maternal-neonatal care

22 Antepartum care 471
23 Intrapartum care 495
24 Postpartum care 519
25 Neonatal care 531
Part V Care of the child

26 Growth & development 559
Part VI Coordinating care

36 Management concepts 707
37 Law and ethics 717
Appendices and index

Alternate-format questions review 747
Physiologic changes in aging 806
Positioning clients 811
State boards of nursing 813
NANDA nursing diagnoses 818
Selected references 822
Index 823
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Contributors and consultants

Carol A. Allred, RN-BC, MSN Nancy M. Glassgow, RN, BSN, BA Noel C. Piano, RN, MS
Director, Allied Health Instructor Instructor/Coordinator
Uintah Basin Applied Technology College Western Dakota Tech Lafayette School of Practical Nursing
Roosevelt, Utah Rapid City, S.Dak. Adjunct Faculty
Thomas Nelson Community College
Carol A. Buttz, RN, BS, CEN Carol Healey, APRN-BC, MS
Williamsburg, Va.
Nursing Instructor Associate Professor of Nursing
Dakota County Technical College Union County College Sahar Radi, RN, BSN, MSN, PhD
Rosemount, Minn. Plainfield, N.J. Nursing Instructor
South Seattle Community College
Patricia L. Clowers, MSN, APRN-BC Ruth Howell, BSN, MEd
Director of Practical Nursing Director of Practical Nursing Alice Raymond, RN, MSN, CRRN
East Mississippi Community College TriCounty Technology Center Division Chair, Allied Health Technology
Mayhew Bartlesville, Okla. J.F. Drake State Technical College
Huntsville, Ala.
Kathy Cochran, RN, MSN Lynn Jordan, RN, MSN
Director of Practical Nursing Full-time Faculty Kristi Robinia, RNC, MSN
Department Chair of Health Carolinas College of Health Sciences Program Coordinator, Practical Nursing
Coosa Valley Technical College Charlotte, N.C. Northern Michigan University
Rome, Ga. Marquette
Kimber Lea Landeck, RN
Kim Cooper, RN, MSN Adjunct Faculty Kendra S. Seiler, RN, MSN
Nursing Department Chair Cerro Coso Community College Nursing Instructor
Ivy Tech Community College Ridgecrest, Calif. Rio Hondo College
Terre Haute, Ind. Whittier, Calif.
C. Kay Lucas, RN, MSEd
Donna S. Davis, RN, BSN Director/Instructor Nursing Education Gina Sirach, RN, MSN
Nursing Instructor Giles County Technology Center Nursing Faculty
Giles County Technology Center Pearisburg, Va. Southeastern Illinois College
Pearisburg, Va. Shirley MacNeill, RN, MSN Harrisburg
Cheryl DeGraw, RN, MSN, CRNP, CNE Nursing Faculty Paula M. Smith, RN, ASN
Nursing Instructor Lamar State College Staff Nurse
Florence-Darlington Technical College Port Arthur, Tex. Ridgecrest (Calif.) Regional Hospital
Florence, S.C. Jane V. McCloskey, RN, MSN Tamara Thell, RN, BSN, PHN
Lula English, RN, MSN Faculty Nurse Educator
PN Instructor Carolinas College of Health Sciences Anoka (Minn.) Technical College
Reid State Technical College Charlotte, N.C. Laura Travis, RN, BSN
Atmore, Ala. Jennifer McWha, RN, MSN Health Careers Coordinator
Shirley Lyon Garcia, RN, BSN Assistant Professor Tennessee Technology Center at Dickson
Adjunct Nursing Faculty, PNE Del Mar College Dickson
Mcdowell Technical Community College Corpus Christi, Tex.
Frances M. Warrick, RN, MS
Marion, N.C. Program Coordinator, Vocational Nursing
El Centro College
Dallas
vii
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Advisory board
Susan Barnason, RN, PhD, CCRN, CEN, CS Kathy Henley Haugh, RN, PhD
Associate Professor Assistant Professor
University of Nebraska Medical Center University of Virginia
College of Nursing School of Nursing
Lincoln Charlottesville
Michael A. Carter, DNSC, FAAN, APRN-BC Janice J. Hoffman, RN, PhD
University Distinguished Professor Faculty/Course Coordinator
University of Tennessee Health Science Center Nursing in Adult Physical Health and Special Topics in Critical
College of Nursing Care Nursing
Memphis Johns Hopkins University
School of Nursing
Caroline Dorsen, MSN, APRN, BC, FNP
Baltimore
Clinical Instructor and Coordinator
Adult Nurse Practitioner Program Linda Honan Pellico, APRN, MSN, PhD
New York University Assistant Professor
College of Nursing Yale University
New York School of Nursing
New Haven, Conn.
Stephen Gilliam, PhD, FNP, APRN-BC
Assistant Professor Susan L. Woods, RN, PhD, FAAN, FAHA
Medical College of Georgia Professor and Associate Dean for Academic Programs
School of Nursing University of Washington
Athens Seattle
Margaret Mary Hansen, RN, MSN, EdD, NI Certificate
Associate Professor
University of San Francisco
viii
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Not another boring foreword

If you’re like most nursing students I know, you’re too busy attending classes,
going to clinicals, and preparing for NCLEX to have the time to wade through
a foreword that uses pretentious terms and umpteen dull paragraphs to get to
the point. So let’s cut right to the chase! Here’s why this book is so terrific:
1. It will teach you all the important things you need to know about preparing
for and passing the NCLEX. (And it will leave out all the fluff that wastes your
time.)
2. It will help you remember what you’ve learned.
3. It will make you smile as it enhances your knowledge and skills.
Don’t believe me? Try these features on for size:
• Reliable NCLEX preparation guidelines and hundreds of test-taking hints
and strategies
• Easy-to-follow outline review format covering all major topics tested on the
exam
• Dozens of cheat sheets and memory joggers to help you remember key
information
• Hundreds of NCLEX-style questions in the book and more than 1,000 others
available online
• All information based on the latest test blueprint.
See? I told you! And that’s not all. Look for me and my friends in the mar-
gins throughout this book. We’ll be there to explain key concepts, provide im-
portant hints, and offer reassurance. Oh, and if you don’t mind, we’ll be spicing
up the pages with a bit of humor along the way, to teach and entertain in a way
that no other resource can.
I hope you find this book helpful. Best of luck on the exam and throughout
your career!
Joy
ix
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I’VE EARNED ADVENTURE

AN OFFICIAL
DIPLOMA
FROM AN ONLY ONE THING
ACCREDITED STANDS BETWEEN
GUESS WHAT?! SCHOOL OF ME AND MY
NURSING. PROFESSIONAL
PRACTICE AS A
NURSE…
BY PASSING THE NCLEX,

I DEMONSTRATE TO MY
STATE BOARD OF NURSING
THAT I HAVE THE
KNOWLEDGE, SKILLS, AND
ABILITIES ESSENTIAL FOR
THE SAFE AND EFFECTIVE
PRACTICE OF NURSING AT
THE ENTRY LEVEL.
xi
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Joy’s NCLEX adventure

xii
LOOK. LET’S SO WHAT’S THE SECRET TO

BE HONEST. SURVIVING THE NCLEX? KEEP
STANDARDIZED FOCUSED ON MY GOALS.
TESTS ARE A
DRAG.
FIRST, I NEED TO
ALL RIGHT!
TIE UP LOOSE ENDS.
LET’S DO IT!
I BETTER MAKE
SURE I DON’T OWE
MY SCHOOL ANY
MONEY, OTHERWISE
THEY WON’T RELEASE
MY TRANSCRIPT. I
ALSO HAVE TO
RETURN ALL MY
OVERDUE LIBRARY
BOOKS.
NEXT, I NEED TO
APPLY TO MY STATE
BOARD OF NURSING.
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xiii
ALSO, I
I MUST BE SURE OF NEED TO
THE LICENSURE REGISTER TO
REQUIREMENTS OF THE TAKE THE
STATE WHERE NCLEX.
I PLAN TO
PRACTICE. MY
SCHOOL’S NURSING
DEPARTMENT OR THE
APPROPRIATE STATE
BOARD OF NURSING
CAN PROVIDE
THE INFORMATION
I NEED.
MOST NCLEX CANDIDATES

REGISTER
WITH PEARSON VUE.
I CAN COMPLETE MY
REGISTRATION ONLINE,
AT WWW.PEARSONVUE.COM/
NCLEX, OR I CAN CALL
PEARSON VUE AT
866-49-NCLEX
(866-496-2539).
I CAN’T FORGET
TO PAY THE
REQUIRED FEE.
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xiv
LET’S BE HONEST.
FILL OUT THE
APPLYING FOR
APPLICATION FOR
A LICENSE AND
LICENSURE AND
TAKING THE NCLEX
OTHER REQUIRED
CAN BE FRUSTRATING…
FORMS.
PAY THE
LICENSE FEE.
IF YOU START
TO WORK
BEFORE
YOU TAKE THE
NCLEX, FILL OUT
THE
APPLICATION
FOR A LIMITED
PERMIT.
SEND YOUR
APPLICATION
VIA CERTIFIED
MAIL SO
YOU HAVE
CONFIRMATION
OF ITS DELIVERY
AND RECEIPT.
FILL OUT THE

CERTIFICATION OF
NURSING EDUCATION
FORM AND SEND IT
TO YOUR SCHOOL.
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xv
OF COURSE, THE
…BUT I WON’T LET MOST IMPORTANT
THE SYSTEM GET PART OF PREPARING
ME DOWN. FOR THE NCLEX IS
STUDYING.
REVIEW BASIC BECOME LEARN HOW

DO AND
NURSING FAMILIAR TO APPLY
PRACTICE CONTROL
INFORMATION. WITH WHAT I
QUESTIONS. PRETEST
NCLEX-TYPE KNOW TO
ANXIETY.
QUESTIONS. CLINICAL
SITUATIONS.
I NEED TO OH, LOOK. MY

TAKE A SHORT AUTHORIZATION-TO-TEST
BREAK FROM FORM ARRIVED.
STUDYING TO
CHECK THE MAIL.
A FEW WEEKS LATER…

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xvi
I’LL NEED THIS MY

FORM TO GET AUTHORIZATION-
INTO THE TO-TEST FORM ALSO
EXAM. LETS ME KNOW MY
ASSIGNED
CANDIDATE NUMBER.
I’LL NEED THIS
NUMBER WHEN I
SCHEDULE
MY EXAM.
NOW I’M
READY TO
CONTACT THE THE GOOD THING IS
LOCAL TEST THAT I CAN SCHEDULE
CENTER TO THE EXAMINATION
SCHEDULE DATE, LOCATION,
MY EXAM. AND TIME AT MY
CONVENIENCE,
EITHER BY PHONE
OR ONLINE.
WELL, TOMORROW IS THE

BIG DAY. I BETTER GET A
GOOD NIGHT’S SLEEP.
IT’S
MORNING!
BETTER MAKE
SURE I EAT A
GOOD
BREAKFAST.
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xvii
WHOOPS. I BETTER
MAKE SURE I BRING …AND LEAVE FOR THE
TWO FORMS OF ID AND TEST WITH PLENTY
MY AUTHORIZATION- OF TIME TO SPARE.
TO-TEST FORM…
NOW IT’S WELCOME. PLEASE SIGN

TIME TO IN TO THE TEST CENTER
CHECK IN. LOG. I’LL NEED TO SEE
TWO FORMS OF ID AND
YOUR AUTHORIZATION-
TO-TEST FORM.
NEXT, YOUR PLEASE ALLOW

THUMBPRINT ME TO
AND PHOTOGRAPH ESCORT YOU
WILL BE TAKEN. TO YOUR
ASSIGNED
COMPUTER.
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xviii
YOU’LL HAVE UP TO FIVE EVEN AFTER THE

HOURS TO COMPLETE THE TWO EXAM BEGINS,
EXAM. THIS INCLUDES A PREPROGRAMMED YOU CAN
SHORT TUTORIAL TO OPTIONAL BREAKS REQUEST
FAMILIARIZE YOU WITH AND ANY OTHER ASSISTANCE
THE WAY THE NCLEX EXAM IS UNSCHEDULED REGARDING USE
GIVEN ON THE COMPUTER. BREAKS ARE OF THE COMPUTER.
INCLUDED IN THE
TIME LIMIT.
ELIMINATE
CHOICES THAT HEY, I KNOW
STAY BE LOGICAL.
THIS IS IT. ARE THIS ONE!
CALM AND…
OBVIOUSLY
INCORRECT.
…READ CHOICES
THOROUGHLY.
ABOUT THREE HOURS LATER… WHEW!

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xix
RESULTS ARE MAILED TO THE

APPROPRIATE BOARD OF NURSING
WITHIN 48 HOURS AFTER THE CANDIDATE
HAS COMPLETED THE EXAMINATION.
EACH BOARD OF NURSING FOLLOWS ITS
OWN POLICY FOR DISTRIBUTING
RESULTS. USUALLY, RESULTS ARE
RECEIVED IN 2 TO 4 WEEKS.
WHAT’S THE
BEST WAY
TO PREPARE
FOR THE NCLEX?
THE INCREDIBLY
EASY WAY…
GOOD LUCK!
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920101.qxd 8/7/08 2:52 PM Page 1
Part I Getting ready

1 Preparing for the examination 3
2 Strategies for success 13

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1 Preparing for
the examination
Mix ’em up
In this chapter,
you’ll learn:
NCLEX basics In nursing school, you probably took courses
organized according to the medical model.
✐ why you must take Passing the National Council Licensure Ex- Courses were separated into such subjects as
the NCLEX amination (NCLEX®) is an important land- medical-surgical, pediatric, maternal-neonatal,
✐ what you need to mark in your career as a nurse. The first step and psychiatric nursing. In contrast, the
on your way to passing the NCLEX is to un- NCLEX is integrated, which means that dif-
know about taking
derstand what it is and how it’s administered. ferent subjects are mixed together.
the NCLEX by com-
As you answer NCLEX questions, you may
puter encounter patients in any stage of life, from
✐ strategies to use Exam structure neonatal to geriatric. These patients—clients,
when answering in NCLEX lingo—may be of any background,
NCLEX questions The NCLEX is a test written by registered may be completely well or extremely ill, and
✐ how to recognize nurses with a master’s degree and clinical ex- may have any of a variety of disorders.
and answer new pertise in a particular area of nursing. Only
NCLEX alternate- one small difference distinguishes nurses Client needs, front and center
format questions who write NCLEX questions from those who The NCLEX draws questions from four cate-
✐ how to avoid com- are similarly qualified: They’re trained to gories of client needs that were developed by
write questions in a style particular to this ex- the National Council of State Boards of Nurs-
mon mistakes when
amination. ing (NCSBN), the organization that sponsors
taking the NCLEX.
If you’ve completed an accredited nursing and manages the NCLEX. Client needs cate-
program, you’ve already taken numerous gories ensure that a wide variety of topics ap-
tests written by nurses with backgrounds and pear on every NCLEX.
experiences similar to those of the nurses The NCSBN developed client needs cate-
who write for the NCLEX. Therefore, the gories after conducting a work-study analysis
test-taking experience you’ve already gained of new nurses. All aspects of nursing care
will help you pass the NCLEX and your observed in the study were broken down into
NCLEX review should be just that—a review four main categories, some of which were
of what you’ve already learned and should broken down further into subcategories. (See
know. Client needs categories, page 4.)
What’s the point? The whole kit and caboodle

The NCLEX is designed for one purpose: to The categories and subcategories are used to
determine whether it’s appropriate for you to develop the NCLEX test plan, the content
receive a license to practice as a nurse. By guidelines for the distribution of test ques-
passing this exam, you demonstrate that you tions. Question-writers and the people who
possess the minimum level of knowledge, un- put the NCLEX together use the test plan and
derstanding, and skills necessary to practice client needs categories to make sure that a
nursing safely. full spectrum of nursing activities is covered
in the examination. Client needs categories
appear in most NCLEX review and question-
and-answer books, including this one. As a
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4 Preparing for the examination
Client needs categories

Each question on the NCLEX is assigned a category based on client needs. This chart lists client
needs categories and subcategories and the percentages of each type of question that appear on
the NCLEX.
Category Subcategories Percentage of questions
Safe, effective care environment Coordinated care 12% to 18%
Safety and infection control 8% to 14%
Health promotion and maintenance — 7% to 13%
Psychosocial integrity — 8% to 14%
Physiological integrity Basic care and comfort 11% to 17%
Pharmacological therapies 9% to 15%
Reduction of risk potential 10% to 16%
Physiological adaptation 11% to 17%
test-taker you don’t have to concern yourself question and four or more possible answers, a
with client needs categories. You’ll see those blank space in which to enter your answer, a
categories for each question and answer in figure on which you’ll identify the correct
this book, but they’ll be invisible on the actual area by clicking the mouse on it, a series of
NCLEX. charts or exhibits you’ll use to select the cor-
rect response, or items you must rearrange in
priority order by dragging and dropping them
Testing by computer in place.
Like many standardized tests today, the Feeling smart? Think hard!
NCLEX is administered by computer. That The NCLEX is a computer-adaptive test. When
means you won’t be filling in empty circles, you respond to a question on the test, the
I react to you!
sharpening pencils, or erasing frantically. It computer supplies more difficult questions if
also means that you must become familiar you answer correctly and slightly easier ques-
with computer tests, if you aren’t already. For- tions if you answer incorrectly. This means
tunately, the skills required to take the each test is uniquely adapted to the individual
NCLEX on a computer are simple enough to test-taker.
allow you to focus on the questions, not the
keyboard. A matter of time
You have a maximum of 5 hours to complete
Q&A formats—mixing them up the test. That gives you the flexibility to spend
When you take the test, depending on the extra time on more challenging questions.
question format, you’ll be presented with a Just the same, it’s important to keep an appro-
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NCLEX questions 5
priate pace. Most students have plenty of time Multiple, multiple: It’s all or nothing
to finish the test. However, if you fail to cor- The first type of alternate-format question is
rectly answer a set number of questions with- the multiple-response question. Unlike a tradi-
in 5 hours, the computer will determine that tional multiple-choice question, each multiple-
The harder it gets,
you lack minimum competency. response question has one or more correct
the better I’m doing.
answers. It may also contain more than four
Difficult items = Good news possible answer options. You’ll recognize this
As you progress through the test, you may type of question because it will ask you to
notice that the questions seem to be increas- select all of the correct answers that apply—
ingly difficult. That’s a good sign. The more not just the best answer.
questions you answer correctly, the more dif- Keep in mind that for each multiple-
ficult the questions become. response question, you must select all of the
Some students, knowing that questions get correct answers for the item to be counted
progressively harder, focus on the degree of as correct. On the NCLEX, you don’t re-
difficulty of subsequent questions to figure ceive partial credit in the scoring of these
out if they’re answering questions correctly. items.
Avoid this temptation and stay focused on se-
lecting the best answer for each question. Don’t go blank!
The second type of alternate-format question
Free at last! is the fill-in-the-blank. In this type of question,
The computer test ends when one of the fol- you perform a calculation and type your an-
lowing events occurs: swer (a number, without any words, commas,
• You demonstrate minimum competency, ac- or spaces) in the blank space provided after
cording to the computer program. the question. No answer options are pre-
• You demonstrate a lack of minimum compe- sented.
tency, according to the computer program.
• You answer the maximum number of ques- Feeling hot, hot, hot
tions (205). The third type of alternate-format question is
• You use the maximum time allowed one that asks you to identify an area on an il-
(5 hours). lustration or graphic. For these so-called “hot-
spot” questions, the computerized exam will
ask you to place your cursor and click over
the correct area on an illustration. Try to be
NCLEX questions as precise as possible when marking the loca-
tion. As with the fill-in-the-blanks, these ques-
Most of the questions on the NCLEX are stan- tions require extremely precise answers.
dard four-option, multiple-choice questions
with only one correct answer. However, some Take a look at that!
questions are presented in other formats. Be- The fourth alternate-format type is the
ing able to identify the different types of ques- chart/exhibit format. For this question type,
tions you might find on the NCLEX can help you’ll be given a problem and then a series of
you understand them and answer them cor- small screens with additional information
rectly. you’ll need to answer the question. By click-
ing on the tabs on screen, you can access
each chart or exhibit item. After viewing the
Alternate formats chart or exhibit, you select your answer from
four multiple-choice options.
The types of alternate-format questions are
multiple-response, fill-in-the-blank; hot spot;
chart/exhibit, and drag-and-drop.
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Sample NCLEX questions

Sometimes, getting used to the format is as important as knowing the material. Try your hand at
these sample questions, and you’ll have a leg up when you take the real test!
Four-option, multiple-choice question

The nurse turns a client 4 days after his abdominal surgery. When she observes the in-
cision, she notes that part of the intestine is protruding. How should she intervene?
1. Cover the incision and protruding intestine with a sterile dressing.
2. Irrigate the incision with normal saline solution.
3. Cover the incision and protruding intestine with gauze soaked in normal saline
solution.
4. Attempt to reinsert the protruding intestine and cover it with an abdominal
binder.
Correct answer: 3
Multiple-response question
A client is admitted with chronic obstructive pulmonary disease (COPD). Which find-
ings are characteristic of COPD? Select all that apply.
1. Decreased respiratory rate
2. Dyspnea on exertion
3. Barrel chest
4. Shortened expiratory phase
5. Clubbed fingers
6. Fever
Correct answers: 2, 3, 5
Fill-in-the-blank calculation question

The physician prescribes 600 mg of ceftriaxone oral suspension to be given once daily
to a client with pneumonia. The nurse obtains the suspension from the pharmacy and
reads the label, which indicates that the dosage strength is 125 mg/5 ml. How many
milliliters of the medication should the nurse administer? Record your answer using a
whole number.
_______________________________________ milliliters
Correct answer: 24
Hot-spot question
Orders for a client with cirrhosis request a daily measurement of his abdominal girth.
Identify the anatomical landmark where the tape measure should be placed to obtain
this measurement.
Correct answer:
⫻
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NCLEX questions 7
Sample NCLEX questions (continued)
Chart/exhibit question
A preschooler is being admitted to the hospital and isolation precautions need to be
implemented. Based on the progress note below, which isolation precautions would be
used for this client?
Progress notes
11/8/08 5-year-old with varicella admitted with high fever, dehydration, and pruritic
1100 rash on face and trunk with lesions in all stages. See graphic record for
vital signs. I.V. started in Ø arm. Isolation precautions instituted.
J. Trump, RN
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions
Correct answer: 2
Drag-and-drop question
The nurse thinks that her client may be in cardiac arrest. Based on American Heart
Association guidelines, the nurse should perform the actions listed below in what or-
der?
Unordered options: Correct answer:
1. Activate the emergency response system. 2. Assess responsiveness.
2. Assess responsiveness. 1. Activate the emergency response system.
3. Call for a defibrillator. 3. Call for a defibrillator.
4. Provide two slow breaths. 6. Assess breathing. Focusing on

what the
5. Assess pulse. 4. Provide two slow breaths. question is really
asking can help
6. Assess breathing. 5. Assess pulse. you choose the
correct answer.
Drop it! Repeat this process until you’ve moved all the
Drag-and-drop, the final type of alternate- available options into the correct order.
format question, involves prioritizing actions
or placing a series of statements in correct or- The standard’s still the standard
der using a drag-and-drop technique. To move The number of alternate-format questions will
an answer option from a list of unordered op- vary for each candidate. In fact, your exam
tions into the correct sequence, click on it us- may contain only one. Keep in mind that stan-
ing the mouse. While still holding down the dard four-option, multiple-choice questions
mouse button, drag the option to the ordered constitute the bulk of the test. (See Sample
response part of the screen. Release the NCLEX questions.)
mouse button to “drop” the option into place.
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Understanding the question telemetry unit? Probably not; his reaction to

furosemide won’t be affected by his location
NCLEX questions are commonly long. As a in the hospital.
result, it’s easy to become overloaded with in- Determine what you do know about the
formation. To focus on the question and avoid client. In the example, you know that:
becoming overwhelmed, apply these proven • he just received a dose of the diuretic
strategies for answering NCLEX questions: furosemide, a crucial fact
• Determine what the question is asking. • he has heart failure, the most fundamental
• Determine relevant facts about the client. aspect of the client’s underlying condition
• Rephrase the question in your mind. • he’s receiving oxygen at 6 L/minute, which
• Choose the best option(s) before entering suggests that his heart failure is moderately
your answer. severe
• he’s 74 years old and has had an MI, a fact
DETERMINE WHAT THE QUESTION IS that may or may not be relevant.
ASKING
Read the question twice. If the answer isn’t REPHRASE THE QUESTION
apparent, rephrase the question in simpler, After you’ve determined relevant information
more personal terms. This strategy may help about the client and the question being asked,
you to focus more effectively to determine the consider rephrasing the question to make it
correct answer. more clear. Eliminate jargon and put the ques-
tion in simpler, more personal terms. Here’s
Give it a try how you might rephrase the question in the
For example, a question might be, “A 74-year- example: “My client has heart failure. He re-
old client with a history of a myocardial in- quires 6 L/minute of oxygen. He’s 74 years
farction (MI) is admitted to the telemetry unit old and has had an MI. He received a dose of
with heart failure. He’s placed on 6 L of oxy- furosemide. What parameter should I moni-
gen per minute and given furosemide (Lasix). tor?”
Which parameters should the nurse watch
closely to monitor the client’s response to CHOOSE THE BEST OPTION
furosemide?” Armed with all the information, it’s time for
The answer options for this question might you to select an option. You know that the
include: client received a dose of furosemide. You
1. Daily weight know that monitoring fluid intake and output
2. 24-hour intake and output is a key nursing intervention for a client tak-
3. Serum sodium levels ing a diuretic, a fact that eliminates options 1
4. Hourly urine output and 3 (daily weight and serum sodium levels)
and narrows the answer down to option 2 or 4
Hocus, focus on the question (24-hour intake and output or hourly urine
Read the question again, ignoring all details output).
except what’s being asked. Focus on the last
line of the question. It asks you to select the Choose
appropriate parameter for monitoring a client wisely.
who received furosemide.
DETERMINE WHAT FACTS ABOUT THE

CLIENT ARE RELEVANT
Next, sort out the relevant client information.
Identify any irrelevant information provided
about the client. For instance, do you need to
know that the client has been admitted to the
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Key strategies 9
Can I use a lifeline? First things first

Monitoring the client’s 24-hour intake and The nursing process may provide insights
output would be appropriate for monitoring that help you analyze a question. According to
the effects of repeated doses of furosemide. the nursing process, data collection comes be- Say it 1,000
Hourly urine output, however, is most appro- fore planning, which comes before implemen- times:
priate in this situation because it monitors the tation, which comes before evaluation. Studying for
more immediate effect of this drug. You’re halfway to the correct answer when the NCLEX is
you encounter a four-option, multiple-choice fun…studying for
the NCLEX is fun…
question that asks you to collect data and then
provides two data collection options and
Key strategies two implementation options. You can im-
mediately eliminate the implementation
Regardless of the type of question, four key options. This gives you, at worst, a 50-50
strategies will help you determine the correct chance of selecting the correct answer.
answer for each question. (See Strategies for Use the following sample question to ap-
success.) These strategies include: ply the nursing process:
• considering the nursing process
• referring to Maslow’s hierarchy of needs A client returns from an endoscopic pro-
• reviewing client safety cedure during which he was sedated. Be-
• reflecting on principles of therapeutic com- fore offering the client food, which action
munication. should the nurse take?
1. Monitor the client’s respiratory
status.
Nursing process 2. Check the client’s gag reflex.
3. Place the client in a side-lying
One of the ways to answer a question is to ap- position.
ply the nursing process. Steps in the nursing 4. Have the client drink a few sips of
process are implemented in this order: water.
• data collection
• planning Collect data before intervening
• implementation According to the nursing process, the nurse
• evaluation. must collect client data before performing an
Advice from the experts
Strategies for success

Keeping a few main strategies in mind as you answer each NCLEX question can help ensure greater
success. These four strategies are critical for answering NCLEX questions correctly:
• If the question asks what you should do in a situation, use the nursing process to determine which
step in the process would be next.
• If the question asks what the client needs, use Maslow’s hierarchy to determine which need to
address first.
• If the question indicates that the client doesn’t have an urgent physiologic need, focus on the
client’s safety.
• If the question involves communicating with a client, use the principles of therapeutic communica-
tion.
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intervention. Does the question indicate that A client complains of severe pain 2 days after
data has been properly collected? No, it surgery. Which action should the nurse per-
doesn’t. Therefore, you can eliminate options form first?
3 and 4 because they’re both interventions. 1. Offer reassurance to the client that he
That leaves options 1 and 2, both of which will feel less pain tomorrow.
demonstrate data collection. Your nursing 2. Allow the client time to verbalize his
knowledge should tell you the correct feelings.
answer—in this case, option 2. The sedation 3. Check the client’s vital signs.
required for an endoscopic procedure may 4. Administer an analgesic.
impair the client’s gag reflex, so you would
check the gag reflex before giving food to the Phys before psych
client to reduce the risk of aspiration and air- In this example, options 3 and 4 address phys-
way obstruction. iologic needs. Options 1 and 2 address psy-
chosocial concerns. According to Maslow,
Final elimination physiologic needs must be met before psy-
Why not select option 1, monitoring the chosocial needs, so you can eliminate options
client’s respiratory status? The question is 1 and 2.
specifically asking about offering the client
food, an action that wouldn’t be taken if the Final elimination
client’s respiratory status was at all compro- Now, use your nursing knowledge to choose
mised. In this case, you’re making a judgment the best answer from the two remaining op-
based on the phrase, “before offering the tions. In this case, option 3 is correct because
client food.” If the question was designed to the client’s vital signs should be checked be-
test your knowledge of respiratory depres- fore administering an analgesic (data collec-
sion following an endoscopic procedure, it tion before intervention). When prioritizing
probably wouldn’t mention a function such as according to Maslow’s hierarchy, remember
Client safety
takes a high priority
feeding a client. This option clearly occurs your ABCs—airway, breathing, circulation—
on the NCLEX. only after the client’s respiratory status has to help you further prioritize. Check for a
been stabilized. patent airway before addressing breathing.
Check breathing before checking the health
of the cardiovascular system.
Maslow’s hierarchy
One caveat…
Knowledge of Maslow’s hierarchy of needs Always examine your choice in light of your
can be a vital tool for answering questions on knowledge and experience. Ask yourself,
the NCLEX that require you to establish pri- “Does this choice make sense for this client?”
orities. Maslow’s theory states that physiolog- Allow yourself to eliminate choices—even
ic needs are the most basic human needs of ones that might normally take priority—if
all. Only after physiologic needs have been they don’t make sense for a particular client’s
met can safety concerns be addressed. Only situation.
after safety concerns are met can concerns in-
volving love and belonging be addressed.
Once concerns of love and belonging are met, Client safety
an individual may explore the needs of self-es-
teem, then, ultimately, the needs of self-actual- As you might expect, client safety takes high
ization. Apply the principles of Maslow’s hier- priority on the NCLEX. You’ll encounter many
archy of needs to the following sample ques- questions that can be answered by asking
tion: yourself, “Which answer will best ensure the
safety of this client?” Use client safety criteria
for situations involving laboratory values,
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Avoiding pitfalls 11
drug administration, or nursing care proce- • offers a response that focuses on the nurse,
dures. not the client.
Client first, equipment second Ah, that’s better!

You may encounter a question in which some When answering NCLEX questions, look for
options address the client and others address responses that:
the equipment. When in doubt, select an op- • allow the client time to think and reflect
tion relating to the client; never place equip- • encourage the client to talk
ment before a client. • encourage the client to describe a particular
For instance, suppose a question asks what experience
the nurse should do first when entering a • reflect that the nurse has listened to the
client’s room where an infusion pump alarm client through paraphrasing the client’s re-
is sounding. If two options deal with the infu- sponse or another communication technique.
sion pump, one with the infusion tubing, and
another with the client’s catheter insertion
site, select the one relating to the client’s
catheter insertion site. Always check the
client first; the equipment can wait.
Avoiding pitfalls
Even the most knowledgeable students can
be tripped up by certain NCLEX questions.
Therapeutic communication Students commonly cite three areas that can
be difficult for unwary test-takers:
Some NCLEX questions focus on the nurse’s
ability to communicate effectively with the knowing the difference between the
client. Therapeutic communication incorpo- NCLEX and the “real world”
rates verbal or nonverbal responses and in-
delegating care
volves:
• listening to the client knowing laboratory values.
• understanding the client’s needs Remember, this
• promoting clarification is an exam, not the
• gaining insight into the client’s condition. NCLEX examination versus real world.
Room for improvement the real world

Like other NCLEX questions, those dealing
with therapeutic communication commonly Some students who take the NCLEX have ex-
require choosing the best response. First, tensive practical experience in health care.
eliminate options that indicate the use of poor For example, many test-takers have worked
therapeutic communication techniques, such as nursing assistants. In that capacity, test-tak-
as those in which the nurse: ers might have been exposed to less than op-
• tells the client what to do without regard to timum clinical practice and may carry those
his feelings or desires (the “do this” re- experiences over to the NCLEX.
sponse) However, the NCLEX is a textbook exami-
• asks a question that can be answered with a nation—not a test of clinical skills. Take the
one-word response, such as “yes” or “no” NCLEX with the understanding that what
• seeks reasons for the client’s behavior happens in the real world may differ from
• implies disapproval of the client’s behavior what the NCLEX and your nursing school rec-
• offers false reassurances ommend.
• attempts to interpret the client’s behavior
rather than allow the client to verbalize his
own feelings
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Don’t take shortcuts activities that involve data collection, evalua-

Normal If you’ve had practical experience in health tion, or your own nursing judgment. On the
care, you may know a quicker way to perform NCLEX and in the real world, these duties fall
laboratory a procedure or tricks to help you get by when squarely on your shoulders. Make sure that
values you don’t have the right equipment. Situations you take primary responsibility for collecting
such as staff shortages may force you to im- client data, evaluating the client, and making
• Blood urea
nitrogen: provise. On the NCLEX, such scenarios can decisions about the client’s care. Never hand
8 to 25 mg/dl lead to trouble. Always check your practical off those responsibilities to someone with less
experiences against textbook nursing care, training.
• Creatinine:
and take care to select the response that fol-
0.6 to 1.5 mg/dl
lows the textbook. Calling in reinforcements
• Sodium: 135 to Notifying a registered nurse, a physician or
145 mmol/L practitioner, a social worker, or another hospi-
• Potassium: Delegating care tal staff member is an important element of
3.5 to 5 mEq/L nursing care. On the NCLEX, however, choic-
• Chloride: On the NCLEX, you may encounter questions es that involve notifying the physician are
97 to 110 mmol/L that assess your ability to delegate care. Dele- usually incorrect. Remember that the NCLEX
• Glucose (fasting gating care involves coordinating the efforts tests you, the nurse, at work.
plasma): 70 to of other health care workers to provide effec- When you’re sure the correct answer is to
100 mg/dl tive care for your client. On the NCLEX, you notify the physician, first make sure the
• Hemoglobin may be asked to assign duties to nursing as- client’s safety has been addressed. On the
sistants and other support staff. NCLEX, the client’s safety has a higher priori-
Male: In addition, you’ll be asked to decide when ty than notifying other health care providers.
13.8 to 17.2 g/dl
to notify a registered nurse, a physician or
Female: practitioner, a social worker, or another hospi-
12.1 to 15.1 g/dl tal staff member. In each case, you’ll have to Knowing laboratory values
• Hematocrit decide when, where, and how to delegate.
Male: Some NCLEX questions supply laboratory re-
40.7% to 50.3% Shoulds and shouldn’ts sults without indicating normal levels. As a re-
As a general rule, it’s okay to delegate actions sult, answering questions involving laboratory
Female:
36.1% to 44.3% that involve stable clients or standard proce- values requires you to have the normal range
dures. Bathing, feeding, dressing, and trans- of the most common laboratory values memo-
ferring clients are examples of procedures rized to make an informed decision (See Nor-
that can be delegated. mal laboratory values.)
Be careful not to delegate complicated or
complex activities. In addition, don’t delegate
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2 Strategies for
success
in every area. Separating content areas this
In this chapter,
you’ll review:
Study preparations way helps you allocate your study time.
✐ how to properly pre- If you’re like most people preparing to take

pare for the NCLEX the NCLEX, you’re probably feeling nervous, Schedule study time
✐ how to concentrate anxious, or concerned. Keep in mind that
most test-takers pass the first time. Study when you’re most alert. If you feel most
during difficult study
Passing the test won’t happen by accident, alert and energized in the morning, for exam-
times
though; you’ll need to prepare carefully and ple, set aside sections of time early in the day
✐ how to make more efficiently. You should start studying sooner for topics that need a lot of review. Then you
effective use of your rather than later. To help jump-start your can use the evening, a time of lesser alert-
time preparations: ness, to refresh your memory about more fa-
✐ how creative strate- • determine your strengths and weaknesses miliar topics. The opposite is true as well; if
gies can enhance • create a study schedule you’re more alert in the evening, study diffi-
study. • set realistic goals cult topics at that time.
• find an effective study space
• think positively. What you’ll do when
Set up a basic schedule for studying. Using a
calendar or an organizer, determine how
Determine strengths and much time remains before you’ll take the
NCLEX. (See 2 to 3 months before the NCLEX,
weaknesses page 14.) Fill in the remaining days with spe-
cific times and topics to study. For example,
Most students recognize that, even at the end you might schedule the respiratory system on
of their nursing studies, they know more a Tuesday morning and the GI system that af-
about some topics than others. Because the ternoon. Remember to schedule difficult top-
NCLEX covers a broad range of material, you ics during your most alert times.
should make some decisions about how inten- Keep in mind that you shouldn’t fill each
sively you’ll review each subject. day with studying. Be realistic and set aside
time for normal activities. Try to create ample
Make a review list study time before the NCLEX and then stick
Base those decisions on a comprehensive list to the schedule.
of topics you need to study. Start with the con-
tents page in the front of this book, which
summarizes the information you covered in Set realistic goals
school. Divide a sheet of paper in half vertical-
ly. Label one side “know well” and label the Part of creating a schedule means setting
other side “needs review.” List each topic goals you can accomplish. You no doubt stud-
from the contents page in the appropriate col- ied a great deal in nursing school, and by now
umn. Don’t worry if one list is longer than the you have a sense of your own capabilities. Ask
other. After you’ve studied, you’ll feel strong yourself, “How much can I cover in a day?”
Set aside that amount of time and then stay on
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14 Strategies for success
To-do list
2 to 3 months before the NCLEX

Take these steps 2 to 3 months before you plan to take the examination:
• Establish a study schedule. Set aside ample time to study but leave time for social activities, exer-
cise, family and personal responsibilities, and other matters.
• Become knowledgeable about the NCLEX: its content, the types of questions it asks, and the test-
ing format.
• Begin studying your notes, texts, and other appropriate materials.
• Take some NCLEX practice questions to help you diagnose your strengths and weaknesses as
well as to become familiar with NCLEX questions.
task. You’ll feel better about yourself—and

your chances of passing the NCLEX—when
you meet your goals regularly.
Maintaining
concentration
Find an effective study space When you’re faced with reviewing the amount
of information covered by the NCLEX, it’s
Find a space to study that is conducive to ef- easy to become distracted and lose your con-
fective learning. Whatever you do, don’t study centration. When you lose concentration, you
with a television on in the room. Instead, find make less effective use of valuable study time.
an inviting, quiet, convenient place, away from To stay focused, keep these tips in mind:
normal traffic patterns. Sit in a solid chair that • Alternate the order of the subjects you
encourages good posture. (Avoid studying in study to add variety to your day. Try alternat-
bed; you’ll be more likely to fall asleep and ing between topics you find more interesting
not accomplish your goals.) The room should and those you find less interesting.
have comfortable, soft lighting with which • Approach your study with enthusiasm, sin-
Approach your
studying with you can see clearly without straining, a tem- cerity, and determination.
enthusiasm, sincerity, perature between 65° and 70°F, flowers or • Begin studying on a schedule and don’t let
and determination. green plants, familiar photos or paintings, and anything interfere with your thought process-
easy access to soft, instrumental background es after you’ve begun.
music. • Concentrate on accomplishing one task at a
time, to the exclusion of everything else, such
as watching television and conversing with
Accentuate the positive friends.
• Work continuously without interruption for
Consider taping positive messages around a while, but don’t study for such a long period
your study space. Make signs with words of that the whole experience becomes grueling
encouragement, such as “You can do it!” and or boring.
“Remember the goal!” These upbeat mes- • Take breaks to give yourself a change of
sages can help keep you going when your at- pace. These breaks can ease your transition
tention begins to waver. into studying a new topic.
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Study schedule 15
• When studying in the evening, wind down view material out loud, you’re engaging your
from your studies slowly. Don’t go directly ears as well as your eyes—and making your
from studying to sleeping. study a more active process. Hearing the ma-
terial out loud fosters memory and subse-
quent recall.
You can also rewrite in your own words a
Taking care of yourself few of the more difficult concepts you’re re-
viewing. Explaining these concepts in writing
Never neglect your physical and mental well- forces you to think through the material and
being in favor of longer study hours. Main- can jump-start your memory.
taining physical and mental health is critical
for success in taking the NCLEX. (See 4 to 6
weeks before the NCLEX.)
A few simple rules

Study schedule
You can increase your likelihood of passing When you were creating your schedule, you
the test by following these simple health might have asked yourself, “How long should
rules: I study? One hour at a stretch? Two hours? Regular exercise
• Get plenty of rest. You can’t think deeply or Three?” To make the best use of your study helps you work
concentrate for long periods when you’re time, you’ll need to answer those questions. harder and think
tired. more clearly.
• Eat nutritious meals. Maintaining your ener-
gy level is impossible when you’re undernour- Optimum study time
ished.
• Exercise regularly. Regular exercise helps Experts are divided about the optimum dura-
you work harder and think more clearly. As a tion of study time. Some say you should study
result, you’ll study more efficiently and in- no more than 1 hour at a time several times
crease the likelihood of success on the all- per day. Their reasoning: You remember the
important NCLEX. material you study at the beginning and end
of a session best and are less likely to remem-
Memory powers, activate! ber material studied in the middle of the ses-
If you’re having trouble concentrating but sion.
would rather push through than take a break, Other experts say you should hold longer
try making your studying more active by study sessions because you lose time in the
reading out loud. Active studying can renew beginning, when you’re just warming up, and
your powers of concentration. By reading re- again at the end, when you’re cooling down.
To-do list
4 to 6 weeks before the NCLEX

Take these steps 4 to 6 weeks before you plan to take the examination:
• Focus on your areas of weakness. Keep in mind that you’ll have time to review these areas again
before the test date.
• Find a study partner or form a study group.
• Take a practice test to gauge your skill level early.
• Take time to eat, sleep, exercise, and socialize to avoid burnout.
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To-do list
1 week before the NCLEX

Studying One week before the NCLEX, take these steps:
getting dull?
• Take a review test to measure your progress.
Get creative
and liven it up. • Record key ideas and principles on note cards or audiotapes.
• Rest, eat well, and avoid thinking about the examination during nonstudy times.
• Treat yourself to one special event. You’ve been working hard, and you deserve it!
That means a long, concentrated study period • waiting for a train or bus
will allow you to cover more material. • standing in line at the bank, post office, or
bookstore.
To thine own self be true
So what’s the best plan? It doesn’t matter as
long as you determine what’s best for you. At
the beginning of your NCLEX study schedule,
try study periods of varying lengths. Pay
Creative studying
close attention to those that seem more suc- Even when you study in a perfect place and
cessful. concentrate better than ever, preparing for
Remember that you’re a trained nurse who the NCLEX can get a little, well, dull. Even
competently collects data. Think of yourself people with great study habits occasionally
as a client, and collect data about your own feel bored or sluggish. That’s why it’s impor-
progress. Then implement the strategy that tant to have some creative tricks in your study
works best for you. bag to liven up those down times.
Creative studying doesn’t have to be hard
work. It involves making efforts to alter your
Finding time to study study habits a bit. Some techniques that
might help include studying with a partner or
Regardless of the study plan you’ve chosen, group and creating flash cards or other audio-
remember that we all have periods in our day visual study tools.
that might otherwise be dead time. These are
perfect times to review for the NCLEX. How-
ever, you shouldn’t cover new material be- Study partners
cause, by the time you get deep into new ma-
terial, your time will be over. Always keep Studying with a partner or group of students
flash cards or a small notebook handy for situ- can be an excellent way to energize your
ations when you have a few extra minutes. studying. It allows you to test each other on
(See 1 week before the NCLEX.) the material you’ve reviewed and share ways
You’ll be amazed by how many short ses- of studying. You can also encourage and help
sions you can find in a day and how much re- each other to stay motivated. Perhaps most
view you can do in 5 minutes. For example, important, working with a partner can pro-
the following occasions offer short stretches vide a welcome break from solitary studying.
of time you can use for studying:
• eating breakfast
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Creative studying 17
What to look for in a partner Creating flash cards should be fun. Use
Exercise care when choosing a study partner magic markers, highlighters, and other color-
or assembling a study group. A partner who ful tools to make them visually stimulating.
doesn’t fit your needs won’t help you make The more effort you put into creating your
the most of your study time. Look for a part- flash cards, the better you’ll remember the
ner who: material contained on them.
• possesses goals similar to yours—for exam-
ple, someone taking the NCLEX at approxi- Other visual tools It isn’t easy to
mately the same date as you will likely feel Flowcharts, drawings, diagrams, and other find a partner who has
the same sense of urgency as you and might image-oriented study aids can also help you the same study
make an excellent partner. learn material more effectively. Substituting habits I do.
• possesses about the same level of knowl- images for text can be a great way to give
edge as you—tutoring someone can help you your eyes a break and recharge your brain.
learn, but each partner should add to the oth- Use vivid colors to make your creations visu-
er’s knowledge. ally engaging.
• studies without excess chatting or interrup-
tions—socializing is an important part of cre- Hear’s the thing
ative study but you have to pass the NCLEX, If you learn more effectively when you hear
so stay serious! information rather than see it, consider
recording key ideas using a handheld tape
recorder. Recording information helps pro-
Audiovisual tools mote memory because you say the informa-
tion aloud and then listen to it as it plays back.
Using flash cards and other audiovisual tools Like flash cards, tapes are portable and per-
fosters retention and makes learning and re- fect for those short study periods during the
viewing fun. day. Don’t forget to stock up on batteries.
(See The day before the NCLEX.)
Flash Gordon? No, it’s Flash Card!
Flash cards can be an excellent study tool.
The process of writing material on a flash
card will help you remember it. In addition,
flash cards are small and portable, perfect for
those 5-minute slivers of time during the day.
To-do list
The day before the NCLEX

One day before the NCLEX, take these steps:
• Drive to the test site to check traffic patterns and find out where to park. If your drive occurs dur-
ing heavy traffic or if you’re expecting bad weather, set aside extra time to ensure your prompt ar-
rival.
• Do something relaxing during the day.
• Avoid thinking too much about the test.
• Rest and eat well.
• Call a supportive friend or relative for some last-minute words of encouragement.
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To-do list
The day of the NCLEX

On the day of the NCLEX:
• Get up early.
• Wear comfortable clothes, preferably with layers you can add and remove to adjust to the room
temperature.
• Leave your house early so you can arrive at the test site early.
• Avoid looking at your notes as you wait for your test computer.
• Listen carefully to the instructions given before entering the test room.
ly, you’ll become accustomed to the question

Practice questions format and begin to focus more on the ques-
tions themselves.
You can take
practice tests on your Practice questions should be an important If you make practice questions a regular
computer using the part of your NCLEX study strategy. Practice part of your study regimen, you’ll be able to
CD-ROM in the back of questions can improve your studying by help- recognize areas in which you’re improving.
this book. ing you review material and familiarizing You can then adjust your study time accord-
yourself with the exact style of questions ingly.
you’ll encounter on the test.
Practice makes perfect
Practice at the beginning As you near the examination date, you should
Consider working through some practice increase the number of NCLEX practice ques-
questions as soon as you begin studying for tions you answer at one sitting. This will en-
the NCLEX. For example, you might try a few able you to approximate the experience of tak-
of the questions that appear at the end of each ing the actual NCLEX. Using the CD-ROM
chapter in this book. found at the back of this book, you can take
If you do well, you probably know that par- practice tests with varying numbers of ques-
ticular topic and can spend less time review- tions. Note that 85 questions is the minimum
ing it. If you have trouble with the questions, number of questions you’ll be asked on the
spend extra study time on that topic. actual NCLEX. By gradually tackling larger
practice tests, you’ll increase your confidence,
I’m getting there build test-taking endurance, and strengthen
Practice questions can also provide an excel- the concentration skills that will enable you to
lent means of marking your progress. Don’t succeed. (See The day of the NCLEX.)
worry if you have trouble answering the first
few practice questions; you’ll need time to
learn how the questions are asked. Eventual-
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Part II Care of the adult


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3 Cardiovascular
system
flow of blood into the atria when the ventri-
In this chapter,
you’ll review:
Brush up on key cles contract. The pulmonic semilunar
valve lies between the right ventricle and the
✐ the function of the concepts pulmonary artery. The aortic semilunar
valve lies between the left ventricle and the
heart, arteries, and
veins The heart, arteries, and veins make up the aorta. These valves prevent backflow of blood
cardiovascular system. These structures: into the ventricles during diastole.
✐ tests used to diag-
• transport life-supporting oxygen and nutri-
nose cardiovascular
ents to cells Pumping it in
disorders • help remove metabolic waste products The heart itself is nourished by blood from
✐ common cardiovas- • carry hormones from one part of the body two main arteries, the left coronar y arter y
cular disorders. to another. and the right coronar y arter y. As it branch-
At the center of the system, the heart pro- es off the aorta, the left coronary artery
pels blood through the body by continuous branches into the left anterior descending
rhythmic contractions. (LAD) artery and the circumflex artery. The
At any time, you can review the major points LAD artery then supplies blood to the anteri-
of this chapter by consulting the Cheat sheet or wall of the left ventricle, the anterior ven-
on pages 22 to 30. tricular septum, and the apex of the left ventri-
cle. The circumflex artery supplies blood to
2 atria & 2 ventricles the left atrium and the lateral and posterior
The heart is a muscular organ composed of portions of the left ventricle.
two atria and two ventricles. The right coronary artery (RCA) fills the
groove between the atria and ventricles. It
A sac gives rise to the acute marginal artery, which
The heart is surrounded by a pericardial becomes the posterior descending artery.
sac that consists of two layers: the visceral The RCA supplies blood to the sinoatrial (SA)
(inner) layer and the parietal (outer) layer. and AV nodes, the septum, the right atrium,
and the right ventricle. The posterior de-
3 layers scending artery supplies blood to the posteri-
The heart wall has three layers: or and inferior wall of the left ventricle and
• epicardium (visceral pericardium), the the posterior portion of the right ventricle.
outer layer
• myocardium, the thick, muscular middle Pumping it through (and out)
layer Blood circulates through the heart following
• endocardium, the inner layer. this pathway:
• from the inferior and superior venae cavae
4 valves to the right atrium
There are four heart valves. The tricuspid • through the tricuspid valve to the right ven-
valve (in the right side of the heart) and mi- tricle
tral valve (in the left side of the heart) lie be- • through the pulmonic valve to the pul-
tween the atria and ventricles; because of monary artery, to the lungs where blood is
their location, they’re also called atrioventric- oxygenated
ular (AV) valves. These valves prevent back- (Text continues on page 30.)
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22 Cardiovascular system
et
heat she
C
Cardiovascular refresher
ABDOMINAL AORTIC ANEURYSM ARRHYTHMIAS
Key signs and symptoms Key signs and symptoms
• Commonly produces no symptoms Atrial fibrillation
Key test results • Commonly produces no symptoms
• Chest X-ray shows an aneurysm. • Irregular pulse with no pattern to the
irregularity
Key treatments
Asystole
• Abdominal aortic aneurysm resection or repair
• Apnea
• Blood administration, as needed
• Cyanosis
Key interventions • No palpable blood pressure
• Monitor and record vital signs. • Pulselessness
• Monitor intake, output, and laboratory studies. Ventricular fibrillation
• Observe the patient for signs of hypovolemic • Apnea
shock from aneurysm rupture, such as: • No palpable blood pressure
– anxiety and restlessness • Pulselessness or pulselessness
– severe back pain Ventricular tachycardia
– decreased pulse pressure • Diaphoresis
– increased thready pulse • Hypotension
– pale, cool, moist, clammy skin. • Weak pulse or pulselessness
ANGINA • Dizziness
Key signs and symptoms Key test results
Want a quick
overview of this • Pain may be substernal, crushing, or compress- Atrial fibrillation
chapter? Check out ing; may radiate to the arms, jaw, or back; usually • ECG shows:
the Cheat sheet. lasts 3 to 5 minutes; usually occurs after exertion, – irregular atrial rhythm
emotional excitement, or exposure to cold but – atrial rate greater than 400 beats/minute
can also develop when the patient is at rest – irregular ventricular rhythm
– QRS complexes of uniform configuration and
Key test results
duration
• Electrocardiogram (ECG) shows ST-segment – no discernible PR interval
depression and T-wave inversion during anginal – no P waves or P waves that appear as erratic,
pain. irregular baseline fibrillation waves.
Key treatments Asystole
• Percutaneous transluminal coronary angioplas- • ECG shows no atrial or ventricular rate or
ty or coronary artery stent placement rhythm and no discernible P waves, QRS com-
Key interventions plexes, or T waves.
• Administer medications as prescribed. With- Ventricular fibrillation
hold nitrates and notify doctor if systolic blood • ECG shows ventricular activity that appears as
pressure is less than 90 mm Hg. Withhold beta- fibrillatory waves with no recognizable pattern.
adrenergic blockers and notify doctor if heart Atrial rate and rhythm and ventricular rhythm
rate is less than 60 beats/minute. can’t be determined because no pattern or regu-
• Monitor for chest pain; if present, evaluate its larity occurs. The P wave, PR interval, QRS com-
characteristics. plex, T wave, and QT interval can't be deter-
• Obtain 12-lead ECG during an acute attack. mined.
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Brush up on key concepts 23
Cardiovascular refresher (continued)

ARRHYTHMIAS (continued) ARTERIAL OCCLUSIVE DISEASE
Ventricular tachycardia Key signs and symptoms
• ECG shows ventricular rate of 100 to 250 beats/minute, wide Femoral, popliteal, or innominate arteries
and bizarre QRS complexes, and no discernible P waves. Ven- • Mottling of the affected extremity
tricular tachycardia may start or stop suddenly. • Pallor
Key treatments • Paralysis and paresthesia in the affected arm or leg
Atrial fibrillation • Pulselessness distal to the occlusion
• Antiarrhythmics: amiodarone (Cordarone), digoxin (Lanoxin), • Sudden and localized pain in the affected arm or leg (most
diltiazem (Cardizem), procainamide (Pronestyl), verapamil common symptom)
(Calan) • Temperature change distal to the occlusion
• Synchronized cardioversion (if patient is unstable) Internal and external carotid arteries
Asystole • Transient ischemic attacks (TIAs) that produce transient
• Cardiopulmonary resuscitation (CPR) monocular blindness, dysarthria, hemiparesis, possible aphasia,
• Advanced cardiac life support (ACLS) protocol for endotra- confusion, decreased mentation, headache
cheal (ET) intubation and possible transcutaneous pacing Subclavian artery
• Atropine, epinephrine (Adrenalin) per ACLS protocol • Subclavian steel syndrome (characterized by the backflow
Ventricular fibrillation of blood from the brain through the vertebral artery on the
• CPR same side as the occlusion into the subclavian artery distal to
• Defibrillation the occlusion; clinical effects of vertebrobasilar occlusion and
• ACLS protocol for endotracheal intubation exercise-induced arm claudication)
• Amiodarone (Cordarone), epinephrine (Adrenalin), lidocaine Vertebral and basilar arteries
(Xylocaine), magnesium sulfate, procainamide (Pronestyl), vaso- • TIAs that produce binocular vision disturbances, vertigo,
pressin per ACLS protocol dysarthria, and falling down without loss of consciousness
Ventricular tachycardia Key test results
• CPR, if pulseless • Arteriography demonstrates the type (thrombus or embolus),
• Defibrillation location, and degree of obstruction, and the status of collateral
• ACLS protocol for ET intubation circulation.
• Amiodarone (Cordarone), epinephrine (Adrenalin), lidocaine • Doppler ultrasonography shows decreased blood flow distal to
(Xylocaine), magnesium sulfate, procainamide (Pronestyl) the occlusion.
Key interventions Key treatments
• Monitor ECG to detect arrhythmias and ischemia. • Surgery (for acute arterial occlusive disease): atherectomy,
• If the patient’s pulse is abnormally rapid, slow, or irregular, balloon angioplasty, bypass graft, embolectomy, laser angioplas-
watch for signs of hypoperfusion, such as hypotension and al- ty, patch grafting, stent placement, thromboendarterectomy, am-
tered mental status. putation
• When life-threatening arrhythmias develop, rapidly assess the • Thrombolytic agents: alteplase (Activase), streptokinase
level of consciousness (LOC), respirations, and pulse. (Streptase)
• Initiate CPR, if indicated.
Key interventions
• Administer medications as needed, and prepare for medical
Preoperatively (during an acute episode)
procedures (for example, cardioversion) if indicated.
• Check the patient’s most distal pulses and inspect his skin col-
• Monitor pulse oximetry. Provide adequate oxygen to reduce
or and temperature.
the heart’s workload while carefully maintaining metabolic, neu-
• Provide pain relief as needed.
rologic, respiratory, and hemodynamic status.
• Maintain heparin infusion per protocol.
• Watch for signs of fluid and electrolyte imbalance, and monitor
intake and output for signs of renal failure (urine output less than
30 ml/hour).
(continued)
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ARTERIAL OCCLUSIVE DISEASE (continued) • Surgery: pericardiocentesis (needle aspiration of the pericar-
Postoperatively dial cavity) or surgical creation of an opening to drain fluid, tho-
• Monitor the patient’s vital signs. Continuously monitor his cir- racotomy
culatory function by inspecting skin color, taking temperature, • Inotropic agent: dopamine (Intropin)
and checking for distal pulses. While charting, compare earlier Key interventions
findings and observations. Watch closely for signs of hemor- For pericardiocentesis
rhage (tachycardia, hypotension), and check dressings for ex- • Keep a pericardial aspiration needle attached to a 50-ml
cessive bleeding. syringe by a three-way stopcock, an ECG machine, and an
• Check neurologic status frequently for changes in LOC, muscle emergency cart with a defibrillator at the bedside. Keep the
strength, or pupil size. equipment turned on to be prepared for immediate use.
• With mesenteric artery occlusion, connect a nasogastric tube • Position the patient at a 45- to 60-degree angle.
to low intermittent suction. Monitor intake and output. Check ab- • Monitor blood pressure during and after pericardiocentesis to
dominal status. watch for complications such as hypotension, which may indi-
• With saddle block occlusion, check distal pulses for adequate cate cardiac chamber puncture.
circulation. Watch for signs of renal failure and mesenteric • Be alert for complications of pericardiocentesis, such as ven-
artery occlusion (severe abdominal pain). tricular fibrillation, vasovagal response, or coronary artery or
• With iliac artery occlusion, monitor urine output for signs of re- cardiac chamber puncture.
nal failure from decreased perfusion to the kidneys as a result of For thoracotomy
surgery. Provide meticulous catheter care. • Explain the procedure to the patient. Tell him what to expect
• With femoral and popliteal artery occlusion, assist with early after the operation (chest tubes, drainage bottles, administration
ambulation and discourage prolonged sitting. of oxygen). Teach him how to turn, deep-breathe, and cough.
CARDIAC TAMPONADE • Maintain the chest drainage system, and observe the patient
for complications, such as hemorrhage and arrhythmias.
Key signs and symptoms
• Muffled heart sounds on auscultation CARDIOGENIC SHOCK
• Narrow pulse pressure Key signs and symptoms
• Jugular vein distention • Cold, clammy skin
• Pulsus paradoxus (an abnormal inspiratory drop in systemic • Hypotension (systolic pressure below 90 mm Hg)
blood pressure greater than 15 mm Hg) • Narrow pulse pressure
• Restlessness • Tachycardia or other arrhythmias
• Upright, leaning forward posture Key test results
Key test results • ECG shows myocardial infarction (MI), as indicated by an en-
• Chest X-ray shows slightly widened mediastinum and car- larged Q wave and elevated ST segment.
diomegaly. Key treatments
• Echocardiography identifies pericardial effusion with signs of
• Intra-aortic balloon pump
right ventricular and atrial compression.
• Adrenergic agent: epinephrine (Adrenalin)
• ECG may reveal:
• Cardiac glycoside: digoxin (Lanoxin)
– a low-amplitude QRS complex and electrical alternans
• Cardiac inotropic agents: dopamine (Intropin), dobutamine
– an alternating beat-to-beat change in the amplitude of the
(Dobutrex), inamrinone (Inocor), milrinone (Primacor)
P wave, QRS complex, and T wave
• Diuretics: furosemide (Lasix), bumetanide (Bumex), metola-
– a generalized ST-segment elevation is noted in all leads.
zone (Zaroxolyn)
Key treatments • Vasodilators: nitroprusside (Nitropress), nitroglycerin (Tridil)
• Supplemental oxygen • Vasopressor: norepinephrine (Levophed)
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CARDIOGENIC SHOCK (continued) Key treatments
Key interventions • Activity changes, including weight loss, if necessary
• Monitor vital signs, heart sounds, capillary refill, skin tempera- • Dietary changes, including establishing a low-sodium, low-
ture, and peripheral pulses. cholesterol, low-fat diet with increased dietary fiber (low-
• Monitor ECG. calorie only if appropriate)
• Monitor respiratory status, including breath sounds and arteri- • Oxygen therapy
al blood gas (ABG) levels. • Antilipemic agents: cholestyramine (Questran), lovastatin
• Administer oxygen and medications as prescribed. (Mevacor), simvastatin (Zocor), nicotinic acid (Niacor), gemfi-
• Maintain I.V. fluids. brozil (Lopid), colestipol (Colestid)
Key interventions
CARDIOMYOPATHY
• Obtain ECG during anginal episodes.
• Monitor vital signs.
• Murmur • Monitor ECG.
• S3 and S4 • Monitor intake and output.
Key test results • Administer nitroglycerin for anginal episodes.
• ECG shows left ventricular hypertrophy and nonspecific
changes. ENDOCARDITIS
Key treatments Key signs and symptoms
• Dual chamber pacing (for hypertrophic cardiomyopathy) • Chills
• Beta-adrenergic blockers: propranolol (Inderal), nadolol (Cor- • Fatigue
gard), metoprolol (Lopressor) for hypertrophic cardiomyopathy • Loud, regurgitant murmur
• Calcium channel blockers: verapamil (Calan), diltiazem Key test results
(Cardizem) for hypertrophic cardiomyopathy • Echocardiography may identify valvular damage.
• Diuretics: furosemide (Lasix), bumetanide (Bumex), metola- • ECG may show atrial fibrillation and other arrhythmias that ac-
zone (Zaroxolyn) for dilated cardiomyopathy company valvular disease.
• Inotropic agents: dobutamine (Dobutrex), milrinone (Primacor), • Three or more blood cultures in a 24- to 48-hour period identify
digoxin (Lanoxin) for dilated cardiomyopathy the causative organism in up to 90% of patients.
• Oral anticoagulant: warfarin (Coumadin) for dilated or hyper- Key treatments
trophic cardiomyopathy • Maintaining sufficient fluid intake
Key interventions • Antibiotics: based on causative organism
• Monitor ECG. • Antiplatelet agent: Aspirin
• Monitor vital signs. Key interventions
• Administer oxygen and medications, as prescribed. • Monitor ECG.
CORONARY ARTERY DISEASE • Monitor cardiovascular status.
• Watch for signs of embolization (hematuria, pleuritic chest
pain, left-upper-quadrant pain, and paresis), a common occur-
• Chest pain that may be substernal, crushing, or compressing; rence during the first 3 months of treatment.
may radiate to the arms, jaw, or back; usually lasts 3 to 5 min- • Monitor the patient’s renal status (blood urea nitrogen [BUN]
utes; usually occurs after exertion, emotional excitement, or ex- level, creatinine clearance, and urine output).
posure to cold but can also develop when the patient is at rest • Observe for signs of heart failure, such as dyspnea, tachypnea,
Key test results tachycardia, crackles, jugular vein distention, edema, and
• Blood chemistry tests show increased cholesterol (decreased weight gain.
high-density lipoproteins and increased low-density lipopro-
teins).
• ECG or Holter monitor shows ST-segment depression and
T-wave inversion during an anginal episode.
(continued)
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HEART FAILURE Key treatments
Key signs and symptoms • Weight reduction
Left-sided failure • Increased physical activity
• Crackles • Dietary changes
• Dyspnea • Reducing sodium intake
• Gallop rhythm: S3, S4 • Limiting alcohol intake
Right-sided failure • ACE inhibitors: captopril (Capoten), enalapril (Vasotec), lisino-
• Dependent edema pril (Prinivil)
• Jugular vein distention Key interventions
• Weight gain • Monitor vital signs. Take two or more blood pressure readings
Key test results rather than relying on a single, possibly abnormal reading.
Left-sided failure HYPOVOLEMIC SHOCK
• B-type natriuretic peptide (BNP) levels elevated
• Chest X-ray shows increased pulmonary congestion and left
ventricular hypertrophy. • Cold, pale, clammy skin
Right-sided failure • Decreased sensorium
• BNP levels elevated • Hypotension with narrow pulse pressure
• Chest X-ray reveals pulmonary congestion, cardiomegaly, and • Reduced urine output (less than 25 ml/hour)
pleural effusion. • Tachycardia
Key treatments Key test results
• Diuretics: furosemide (Lasix), bumetanide (Bumex), metola- • Blood tests show:
zone (Zaroxolyn) – elevated serum potassium, serum lactate, and BUN levels
• Human B-type natriuretic peptide: nesiritide (Natrecor) – increased urine specific gravity (greater than 1.020) and
• Angiotensin-converting enzyme (ACE) inhibitors: captopril urine osmolality
(Capoten), enalapril (Vasotec), lisinopril (Prinivil) – decreased hemoglobin and hematocrit
• Cardiac glycoside: digoxin (Lanoxin) – decreased blood pH
• Inotropic agents: dopamine (Intropin), dobutamine (Dobutrex), • ABG analysis reveals metabolic acidosis.
inamrinone (Inocor) Key treatments
• Nitrates: isosorbide dinitrate (Isordil), nitroglycerin (Nitro-Bid) • Supplemental oxygen
• Vasodilator: nitroprusside (Nitropress) • Blood and fluid replacement
Key interventions • Control of bleeding
• Administer oxygen. Key interventions
• Monitor ECG. • Record blood pressure, pulse rate, peripheral pulses, respira-
• Monitor vital signs. tory rate, and pulse oximetry readings every 15 minutes, and
• Monitor respiratory status. monitor the ECG continuously. A systolic blood pressure lower
• Keep the patient in semi-Fowler’s position. than 80 mm Hg usually results in inadequate coronary artery
• Weigh the patient daily. blood flow, cardiac ischemia, arrhythmias, and further complica-
tions of low cardiac output. When blood pressure drops below
HYPERTENSION 80 mm Hg, increase the oxygen flow rate and notify the charge
Key signs and symptoms nurse or doctor immediately.
• Produces no symptoms. • Maintain I.V. lines with normal saline or lactated Ringer’s.
Key test results • An indwelling urinary catheter may be inserted to measure
• Blood pressure measurements result in sustained readings urine output. If less than 30 ml/hour in adults, increase the fluid
greater than 140/90 mm Hg. infusion rate but watch for signs of fluid overload. Notify the
charge nurse or doctor if urine output doesn’t improve. An os-
motic diuretic such as mannitol (Osmitrol) may be ordered.
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HYPOVOLEMIC SHOCK (continued) • Cardiac glycoside: digoxin (Lanoxin) to increase myocardial
• During therapy, assess skin color and temperature and note contractility
any changes. • Diuretic: furosemide (Lasix)
Key interventions
MYOCARDIAL INFARCTION
• Observe breathing pattern and check lung status.
• Stress the importance of bed rest. Assist the patient with
• Crushing substernal chest pain that may: bathing as needed; provide a bedside commode. Reassure the
– radiate to the jaw, back, and arms patient that activity limitations are temporary.
– last longer than anginal pain
– not be relieved by rest or nitroglycerin PERICARDITIS
– not be present (in silent MI—present atypically in women) Key signs and symptoms
Key test results Acute pericarditis
• ECG shows an enlarged Q wave, an elevated or a depressed • Pericardial friction rub (grating sound heard as the heart
ST segment, and T-wave inversion. moves)
Key treatments • Sharp and commonly sudden pain that usually starts over the
• Antiplatelet aggregation: aspirin, abciximab (ReoPro), clopido- sternum and radiates to the neck, shoulders, back, and arms
grel (Plavix), eptifibatide (Integrilin) (Unlike the pain of MI, pericardial pain is commonly pleuritic, in-
• Thrombolytic agents: tissue plasminogen activator (Activase), creasing with deep inspiration and decreasing when the patient
streptokinase (Steptase), anistreplase (Eminase), reteplase (Re- sits up and leans forward, pulling the heart away from the di-
tavase); given within 6 hours of onset of symptoms but most ef- aphragmatic pleurae of the lungs.)
fective when started within 3 hours Chronic pericarditis
• Pericardial friction rub
Key interventions
• Symptoms similar to those of chronic right-sided heart failure
• Monitor respiratory status. (fluid retention, ascites, hepatomegaly)
• Obtain an ECG reading during acute pain.
Key test results
MYOCARDITIS • Echocardiography confirms the diagnosis when it shows an
Key signs and symptoms echo-free space between the ventricular wall and the pericardi-
• Arrhythmias (S3 and S4 gallops, faint S1) um (in cases of pleural effusion).
• Dyspnea • ECG shows the following changes in acute pericarditis: eleva-
• Fatigue tion of ST segments in the standard limb leads and most precor-
• Fever dial leads without significant changes in QRS morphology that
Key test results occur with MI, atrial ectopic rhythms such as atrial fibrillation,
and diminished QRS voltage in pericardial effusion.
• ECG typically shows diffuse ST-segment and T-wave abnor-
malities (as in pericarditis), conduction defects (prolonged PR Key treatments
interval), and other supraventricular arrhythmias. • Bed rest
• Endomyocardial biopsy confirms the diagnosis, but a negative • Surgery: pericardiocentesis (for cardiac tamponade), partial
biopsy doesn’t exclude the diagnosis. A repeat biopsy may be pericardectomy (for recurrent pericarditis), and total pericar-
needed. dectomy (for constrictive pericarditis)
Key treatments • Antibiotics according to sensitivity of causative organism
• Bed rest Key interventions
• Antiarrhythmics: amiodarone (Cordarone), procainamide • Provide complete bed rest.
(Pronestyl) • Monitor pain related to respiration and body position.
• Antibiotics according to sensitivity of causative organism • Place the patient in an upright position.
(continued)
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PERICARDITIS (continued) RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
• Provide analgesics and oxygen, and reassure the patient with Key signs and symptoms
acute pericarditis that his condition is temporary and treatable. • Temperature of 100.4° F (38° C) or higher
PULMONARY EDEMA • Migratory joint pain or polyarthritis
• Dyspnea, orthopnea, tachypnea • Blood tests show elevated white blood cell count and erythro-
cyte sedimentation rate and slight anemia during periods of in-
Key test results
flammation.
• Chest X-ray shows pulmonary congestion. • Cardiac enzyme levels may increase in severe carditis.
Key treatments • C-reactive protein test is positive (especially during the acute
• Diuretics: furosemide (Lasix), bumetanide (Bumex), metola- phase).
zone (Zaroxolyn) Key treatments
• Cardiac glycoside: digoxin (Lanoxin) • Bed rest (in severe cases)
• Inotropic agents: dobutamine (Dobutrex), inamrinone (Inocor), • Surgery: corrective valvular surgery (in cases of persistent
milrinone (Primacor), nesiritide (Natrecor) heart failure)
• Nitrates: isosorbide dinitrate (Isordil), nitroglycerin (Nitro-Bid) • Antibiotics: erythromycin (Erythrocin), penicillin (Pfizerpen)
• Vasodilator: nitroprusside (Nitropress) • Nonsteroidal anti-inflammatory drugs (NSAIDs): aspirin, in-
Key interventions domethacin (Indocin)
• Administer oxygen. Key interventions
• Monitor vital signs and breathing pattern. • Before giving penicillin, ask the patient if he has ever had a hy-
• Place the patient in high Fowler’s position if blood pressure re- persensitivity reaction to it. Even if the patient has never had a
mains stable; if hypotensive, maintain in semi-Fowler’s position if reaction to penicillin, warn him that such a reaction is possible.
tolerated. • Warn the patient to watch for and immediately report signs of
• Monitor ECG. recurrent streptococcal infection:
• Monitor pulse oximetry readings. – diffuse throat redness and oropharyngeal exudate
RAYNAUD’S DISEASE – swollen and tender cervical lymph glands
Key signs and symptoms – pain on swallowing
– temperature of 101° to 104° F (38.3° to 40° C).
• Numbness and tingling that are relieved by warmth
• Urge the patient to avoid people with respiratory tract infec-
• Typically, after exposure to cold or stress, blanching of the skin
tions.
on the fingers, which then become cyanotic before changing to
red THORACIC AORTIC ANEURYSM
Key test results Key signs and symptoms
• Arteriography reveals vasospasm. Ascending aneurysm
Key treatments • Pain (described as severe, penetrating, and ripping and ex-
• Activity changes: avoidance of cold tending to the neck, shoulders, lower back, or abdomen)
• Smoking cessation (if appropriate) • Unequal intensities of the right carotid and left radial pulses
• Surgery (used in less than 25% of patients): sympathectomy Descending aneurysm
• Calcium channel blockers: diltiazem (Cardizem), nifedipine • Pain (described as sharp and tearing, usually starting suddenly
(Procardia) between the shoulder blades and possibly radiating to the chest)
Key interventions
• Advise the patient to avoid exposure to the cold. Tell him to
wear mittens or gloves in cold weather and when handling cold
items.
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THORACIC AORTIC ANEURYSM (continued) Superficial vein thrombophlebitis
Transverse aneurysm • Redness along vein
• Dyspnea • Warmth and tenderness along vein
• Pain (described as sharp and tearing and radiating to the Key test results
shoulders) • Photoplethysmography shows venous-filling defects.
Key test results • Ultrasound reveals decreased blood flow.
• Aortography, the definitive test, shows the lumen of the Key treatments
aneurysm, its size and location, and the false lumen in a dissect- • Activity changes: maintaining bed rest and elevating the af-
ing aneurysm. fected extremity
• Chest X-ray shows widening of the aorta. • Anticoagulants: warfarin (Coumadin), heparin, dalteparin
• Computed tomography scan confirms and locates the (Fragmin), enoxaparin (Lovenox)
aneurysm and may be used to monitor its progression. • Antiplatelet aggregation agent: aspirin
Key treatments • Fibrinolytic agent: streptokinase (Streptase)
• Surgery: resection of aneurysm with a Dacron or Teflon graft Key interventions
replacement, possible replacement of aortic valve • Monitor breathing pattern and breath sounds.
• Blood product administration • Maintain bed rest, and elevate the affected extremity.
• Oxygen therapy and possibly ET intubation and mechanical • Apply warm, moist compresses to improve circulation.
ventilation • Perform neurovascular checks.
• Analgesic: morphine • Monitor laboratory values.
• Antihypertensives: nitroprusside (Nitropress), labetalol (Nor-
modyne) VALVULAR HEART DISEASE
• Negative inotropic agent: propranolol (Inderal) Key signs and symptoms
Key interventions Aortic insufficiency
• Monitor the patient’s blood pressure. Also evaluate pain, • Angina
breathing, and carotid, radial, and femoral pulses. • Cough
• Insert an indwelling urinary catheter. Maintain I.V. infusion of • Dyspnea
normal saline or lactated Ringer’s solution and antibiotics as • Fatigue
needed. • Palpitations
• When the doctor suspects that an aneurysm is leaking, give Mitral insufficiency
any ordered whole-blood transfusion. • Angina
After repair of thoracic aneurysm • Dyspnea
• Evaluate the patient’s LOC. Monitor vital signs, pulse rate, urine • Fatigue
output, and pain. • Orthopnea
• Check respiratory function. Carefully observe and record the • Peripheral edema
type and amount of chest tube drainage, and frequently assess Mitral stenosis
heart and breath sounds. • Dyspnea on exertion
• Monitor I.V. therapy to prevent fluid excess, which may occur • Fatigue
with rapid fluid replacement. • Orthopnea
• Give medications as appropriate. • Palpitations
• Peripheral edema
THROMBOPHLEBITIS • Weakness
Key signs and symptoms Mitral valve prolapse
Deep vein thrombophlebitis • May produce no symptoms
• Cramping calves • Palpitations
• Edema
• Tenderness to touch
(continued)
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VALVULAR HEART DISEASE (continued) Tricuspid insufficiency
Tricuspid insufficiency • Echocardiography shows systolic prolapse of the tricuspid
• Dyspnea valve.
• Fatigue • ECG shows right atrial or right ventricular hypertrophy.
Key test results • Chest X-ray shows right atrial dilation and right ventricular en-
Aortic insufficiency largement.
• Echocardiography shows left ventricular enlargement. Key treatments
• Chest X-ray shows left ventricular enlargement and pulmonary • Surgery: open-heart surgery using cardiopulmonary bypass for
vein congestion. valve replacement (in severe cases)
Mitral insufficiency • Anticoagulant: warfarin (Coumadin) to prevent thrombus for-
• Cardiac catheterization shows mitral regurgitation and elevat- mation around diseased or replaced valves
ed atrial and pulmonary artery wedge pressures. Key interventions
Mitral stenosis • Watch closely for signs of heart failure or pulmonary edema
• Cardiac catheterization shows diastolic pressure gradient and for adverse effects of drug therapy.
across valve and elevated left atrial and pulmonary artery • Place the patient in an upright position.
wedge pressures. • Maintain bed rest, and provide assistance with bathing, if nec-
• Echocardiography shows thickened mitral valve leaflets. essary.
• ECG shows left atrial hypertrophy. • If the patient undergoes surgery, watch for hypotension, ar-
• Chest X-ray shows left atrial and ventricular enlargement. rhythmias, and thrombus formation. Monitor vital signs, intake,
Mitral valve prolapse output, daily weight, and blood chemistry values.
• ECG shows prolapse of the mitral valve into the left atrium.
• through the pulmonary veins to the left atri- How’s it working?

um Cardiac function can be assessed by measur-
• through the mitral valve to the left ventricle ing three parameters:
• through the aortic valve to the aorta and • Cardiac output is the total amount of
Cardiac output is throughout the body. blood ejected from a ventricle per minute.
the total amount of Cardiac output equals stroke volume multi-
blood ejected from a
ventricle per minute.
The body electric plied by heart rate (CO ⫽ SV ⫻ HR).
The system that conducts electrical impulses • Stroke volume is the amount of blood
and coordinates the heart’s contractions con- ejected from a ventricle with each beat (nor-
sists of the SA node, internodal tracts, AV mally, 70 ml).
node, bundle of His, right and left bundle • Ejection fraction is the percentage of left
branches, and Purkinje fibers. ventricular end-diastolic volume ejected dur-
A normal electrical impulse is initiated at ing systole (normally, 60% to 70%).
the SA node, the heart’s intrinsic pacemaker,
which results in the following chain of events: A system of canals
• atrial depolarization Blood flows throughout the body via arteries
• atrial contraction and veins as well as smaller vessels, such as
• impulse transmission to the AV node arterioles, capillaries, and venules:
• impulse transmission to the bundle of His, • Arteries are three-layered vessels (intima,
bundle branches, and Purkinje fibers media, adventitia). The pulmonary artery car-
• ventricular depolarization ries deoxygenated blood to the lungs. The
• ventricular contraction other arteries carry oxygenated blood from
• ventricular repolarization. the heart to the tissues.
920103.qxd 8/7/08 3:51 PM Page 31
Keep abreast of diagnostic tests 31
• Arterioles are small-resistance vessels that Nursing actions

feed into capillaries. • Explain the purpose of Holter monitoring to
• Capillaries join arterioles to venules, the patient.
which are larger vessels that have lower pres- • Ask him to keep an activity diary. Memory
sure than arterioles. Nutrients and wastes are • Advise him not to bathe, shower, operate jogger
exchanged in the capillaries. machinery, use a microwave oven, or use an
• Venules join capillaries to veins. electric shaver while wearing the monitor.
To remem-
ber how
• Veins are large-capacity, low-pressure ves- blood flows from
sels. The pulmonary veins carry oxygenated View through a catheter the heart, think
blood to the left atrium. The other veins re- Cardiac catheterization and arteriography Arteries away.
turn unoxygenated blood to the heart. (also called angiography) involve injection of Arteries carry oxy-
Think of these vessels as a series of large radiopaque dye through a catheter. A fluoro- genated blood away
and small canals forming an interlocking sys- scope is then used to examine the coronary from the heart to
tem of blood flow. arteries and intracardiac structures. The pro- the tissues.
cedure is also used to monitor major intracar- Veins, by contrast,
diac pressures, oxygenation, and cardiac carry blood to the
output. heart. To remember
Keep abreast of Nursing actions
the flow of blood in
the veins, think
diagnostic tests Before the procedure
• Withhold food and fluids from the patient
veto, for veins to.
Here are some important tests used to diag- after midnight.

nose cardiovascular disorders, along with • Discuss any anxiety the patient may have
common nursing interventions associated about the procedure.
with each test. • Assess and record baseline vital signs and
peripheral pulses.
Graphing the heart’s electrical • Make sure that written, informed consent
activity has been obtained.
Electrocardiography is a noninvasive test • Inform the patient about possible nausea,
that gives a graphic representation—known chest pain, flushing of the face, or a sudden
as an electrocardiogram (ECG—of the heart’s urge to urinate after the injection of radi-
electrical activity. (See Obtaining an ECG, opaque dye.
Cardiac
page 32.) • Note any patient allergies to seafood, catheterization is an
iodine, or radiopaque dyes. invasive procedure.
Nursing actions After the procedure Be aware of the
• Determine the patient’s ability to lie still for • Monitor vital signs. Also monitor peripheral complications that
several minutes. pulses distal to the catheter insertion site. can occur.
• Reassure the patient that he won’t experi- Compare them to those on the opposite ex-
ence an electric shock. tremity.
• Maintain a pressure dressing or hemostatic
24-hour record of the heart device at the injection site and monitor for
An ambulatory ECG, also known as Holter bleeding. Enforce bed rest for 8 hours after
monitoring, is a noninvasive test that the procedure.
records the heart’s electrical activity and car- • Keep the patient’s left leg straight for 6 to 8
diac events over an extended period of time. hours if the femoral approach was used; keep
It’s usually conducted during the patient's the arm extended for 3 hours if the antecu-
normal daily activities. bital fossa was used.
• Encourage fluids unless contraindicated.
• Report any complaints of chest pain imme-
diately.
• If bleeding occurs at the site, apply manual
pressure until the bleeding stops.
920103.qxd 8/7/08 3:51 PM Page 32
Obtaining an ECG
WHY YOU DO IT – V1: fourth intercostal space at the right sternal border
One of the most valuable and frequently used diagnostic tools, – V2: fourth intercostal space at the left sternal border
electrocardiography measures the heart’s electrical activity as – V3: halfway between V2 and V4
waveforms. How? Impulses moving through the heart’s conduc- – V4: fifth intercostal space at midclavicular line
tion system create electric currents that can be monitored on – V5: fifth intercostal space at anterior axillary line, halfway
the body’s surface. Electrodes attached to the skin detect these between V4 and V6
electric currents and transmit them to an instrument that pro- – V6: fifth intercostal space at midaxillary line, level with V4.
duces a record (electrocardiogram) of cardiac activity. • Connect the leadwires to the electrodes as indicated by the
Electrocardiography can be used to identify myocardial is- coding on the tip of each leadwire.
chemia and infarction, rhythm and conduction disturbances, • Enter the appropriate information as prompted by the ECG
chamber enlargement, electrolyte imbalances, and drug toxici- machine.
ty. • Set the paper speed selector to the standard 25 mm/second
and select full voltage.
HOW YOU DO IT
• Ask the patient to breathe normally, lie still, and avoid talking.
• Place the electrocardiogram (ECG) machine close to the pa-
Press the AUTO button. Observe the tracing quality of all 12 leads.
tient’s bed, and plug the power cord into the wall outlet.
• When the machine has recorded the 12-lead ECG, remove the
• Explain the procedure to the patient.
electrodes and clean the patient’s skin. After disconnecting the
• Place the patient in the supine position in the center of the
leadwires from the electrodes, dispose of the electrodes or leave
bed with his arms at his sides. You may raise the head of the
them in place for subsequent ECGs, according to facility policy.
bed to make the patient more comfortable.
• If the machine doesn’t label the ECG recording for you, label the
• Place the electrodes on flat, fleshy areas; avoid muscular and
recording with the patient’s name and identification number as
bony areas. If an area is excessively hairy, clip it before apply-
well as the date and time. Note the test date and time as well as
ing the electrode. Also, clean excess oil and other substances
significant responses by the patient in the patient’s record, and
from the patient’s skin.
write any appropriate clinical information on the ECG.
• Apply the disposable electrodes to the patient’s wrists and the
medial aspects of his ankles. Position electrodes as follows:
Echoing heart structures • Withhold food and fluids for 2 to 4 hours be-
Echocardiography is a noninvasive examina- fore the test.
tion of the heart in which echoes from sound • Instruct the patient to wear loose-fitting
waves are used to visualize intracardiac struc- clothing and supportive shoes.
tures and monitor the direction of blood flow. • Perform a cardiopulmonary assessment.
• Tell the patient to report chest discomfort,
Nursing actions shortness of breath, fatigue, leg cramps, and
• Determine the patient’s ability to lie still for dizziness immediately if they occur during the
30 to 60 minutes. test.
No fallout here
Jog and monitor Nuclear cardiology examines the heart us-
An exercise ECG, also known as a stress test, ing radioisotopes. After I.V. injection of the
is a noninvasive test that records the heart’s isotopes, a monitor displays images of myo-
electrical activity by monitoring it for is- cardial perfusion and contractility.
chemic events during levels of increasing ex-
ercise. Nursing actions
Before the procedure
Nursing actions • Explain the procedure to the patient.
• Explain the procedure to the patient. • Determine the patient’s ability to lie still
during the procedure.
920103.qxd 8/7/08 3:51 PM Page 33
After the procedure Blood to the lab, part 1

• Examine the injection site for bleeding. Blood chemistr y tests use blood samples to
measure:
A complete picture of arterial blood • electrolytes (calcium, magnesium, phospho-
supply rus, potassium, sodium)
Digital subtraction angiography is an inva- • protein and protein metabolites (blood urea
sive procedure involving fluoroscopy with an nitrogen [BUN], creatinine)
image intensifier. This test allows complete vi- • lipids and lipoproteins (cholesterol, triglyc-
sualization of the arterial blood supply to a erides)
specific area. • cardiac enzymes and proteins (B-type natri-
uretic peptide assay, creatine kinase [CK], CK
Nursing actions isoenzymes, lactate dehydrogenase [LD], LD
Before the procedure isoenzymes, myoglobin, troponin)
• Determine the patient’s ability to lie still • bicarbonate
during the test. • glucose
• Make sure that written, informed consent • aspartate aminotransferase (AST).
has been obtained.
After the procedure Nursing actions
• Monitor the patient’s vital signs. Before the procedure
• Check the insertion site for bleeding. • Note any drugs the patient is taking that
• Instruct the patient to drink at least 1 L of might alter test results.
fluid after the procedure. • Restrict the patient’s exercise before the
blood sample is drawn.
Balloon and blood flow • Withhold I.M. injections, or note the time of
For hemodynamic monitoring, a balloon- the injection on the laboratory slip (with CK
tipped, flow-directed pulmonary artery levels).
catheter is used to measure intracardiac pres- • Withhold food and fluids as ordered.
sures and cardiac output. After the procedure
• Check the venipuncture site for bleeding.
Nursing actions
• Make sure that written, informed consent Blood to the lab, part 2
has been obtained. Hematologic and coagulation studies use
• Monitor the patient for such complications blood samples to analyze and measure red
as arrhythmias, hemorrhage, clot formation, blood cells (RBCs), white blood cells
and air embolus. (WBCs), erythrocyte sedimentation rate
• Check the insertion site for signs of (ESR), prothrombin time (PT), international
infection. normalized ratio (INR), partial thromboplas-
tin time (PTT), platelets, hemoglobin, and
One for the photo album hematocrit.
A chest X-ray supplies a radiographic picture
that can be used to determine the size and po- Nursing actions
sition of the heart. It can also detect the pres- • Before the procedure, note any drugs the
ence of fluid in the lungs and other abnormali- patient is taking that might alter test results.
ties such as pneumothorax. • After the procedure, check the venipunc-
ture site for bleeding.
Nursing actions
• Determine the patient’s ability to hold his ABCs of ABGs
breath during the test. An arterial blood gas (ABG) analysis as-
• Make sure that the patient removes all jew- sesses arterial blood for tissue oxygenation,
elry before the X-ray is taken. ventilation, and acid-base status.
920103.qxd 8/7/08 3:51 PM Page 34
Nursing actions To distinguish oxygen saturation obtained

Before the procedure by pulse oximetry from that obtained by ABG
• Document the patient’s temperature. analysis (abbreviated as SaO2), the pulse
• Note the amount of oxygen the patient is re- oximetry value is abbreviated as SpO2.
ceiving. If the patient is receiving mechanical
ventilation, note the ventilator settings. Nursing actions
After the procedure • Protect the sensor from bright light.
• Apply continuous pressure to the puncture • Don’t place the sensor on an extremity with
site for at least 5 minutes; then apply a pres- impeded blood flow.
sure dressing for at least 30 minutes. • Attach the monitoring sensor to a fingertip,
• Afterward, periodically check the site for an earlobe, the bridge of the nose, or a toe.
bleeding. • If a fingertip is used, remove artificial nails,
nail tips, and nail polish because they may in-
Hear that sound? It’s blood flow terfere with light transmission.
A Doppler ultrasound transforms echoes
from sound waves into audible sounds, allow-
ing examination of blood flow in peripheral
circulation. Polish up on patient
Nursing actions
• Determine the patient’s ability to lie still.
care
• Explain the procedure. Major cardiovascular disorders include ab-
dominal aortic aneurysm, angina, arrhyth-
Visualize the veins mias, arterial occlusive disease, cardiac tam-
For a venogram, a dye is injected to allow vi- ponade, cardiogenic shock, cardiomyopathy,
sualization of the veins. This picture is then coronary artery disease, endocarditis, heart
used to diagnose deep vein thrombosis or in- failure, hypertension, hypovolemic shock,
competent valves. myocardial infarction (MI), myocarditis, peri-
carditis, pulmonary edema, Raynaud’s dis-
Nursing actions ease, rheumatic fever and rheumatic heart
Before the procedure disease, thoracic aortic aneurysm, throm-
• Withhold food and fluids after midnight. bophlebitis, and valvular heart disease.
• Obtain and record the patient’s baseline vi- For most of these disorders, the goal of
tal signs and peripheral pulses. nursing management is to decrease cardiac
• Make sure that written, informed consent workload and increase myocardial blood sup-
has been obtained. ply. These steps increase oxygenation to the
For most cardiac
• Note any allergies the patient has to tissues and reduce overall damage to the
disorders, the goal of
nursing care is to seafood, iodine, or radiopaque dyes. heart.
decrease cardiac • Inform the patient about possible flushing
workload and increase of the face or throat irritation from the injec-
myocardial blood tion of the dye. Abdominal aortic aneurysm
supply. After the procedure
• Check the injection site for bleeding, infec- An abdominal aortic aneurysm results from
tion, and hematoma. damage to the medial layer of the abdominal
• Encourage fluids unless contraindicated. portion of the aorta. The underlying cause is
commonly atherosclerosis, which over time
Oxygen in arterial blood causes a weakening in the medial layer of the
Pulse oximetr y uses infrared light to mea- artery. Continued weakening from the force
sure arterial oxygen saturation in the blood. of blood flow may cause a bulge in the artery
This test helps assess a patient’s pulmonary known as an aneurysm. The aneurysm may
status. then cause a rupture, leading to hemorrhage,
hypovolemic shock, and possibly death.
920103.qxd 8/7/08 3:51 PM Page 35
Polish up on patient care 35
There are four types of abdominal aneu- • Abdominal aortic aneurysm resection or re-
rysms: pair
• Bed rest
dissecting (vessel wall layers become • Blood administration, as indicated.
separated by a column of blood, which pouch-
es out tissue) Drug therapy
• Analgesics: oxycodone (OxyContin), mor-
false (bilateral outpouching in which
phine Look for signs of
layers of the vessel wall separate, creating a
• Antihypertensives: hydralazine (Apreso- shock when caring for
cavity)
line), nitroprusside (Nitropress), enalaprilat patients with
fusiform (bilateral outpouching) (Vasotec) abdominal aortic
• Beta-adrenergic blockers: propranolol (In- aneurysms.
saccular (unilateral outpouching). deral), metoprolol (Lopressor)
CAUSES INTERVENTIONS AND RATIONALES

• Atherosclerosis • Monitor and record vital signs. Tachycardia,
• Congenital defect dyspnea, or hypotension may indicate fluid vol-
• Hypertension ume deficit caused by rupture of the aneurysm.
• Infection • Monitor ECG to detect arrhythmias.
• Marfan syndrome • Monitor intake and output and laboratory
• Syphilis studies. Low urine output and high specific
• Trauma gravity indicate hypovolemia.
• Observe the patient for signs of hypovo-
DATA COLLECTION FINDINGS lemic shock from aneurysm rupture, such as
• Abdominal mass to the left of the midline anxiety, restlessness, severe back pain, de-
• Abdominal pulsations creased pulse pressure, increased thready
• Bruits over the aneurysm pulse, and pale, cool, moist, clammy skin, to
• Commonly produces no symptoms detect early signs of compromise.
• Diminished femoral pulses • Gently palpate the abdomen for distention.
• Lower abdominal pain Increasing distention may signify impending
• Lower back pain rupture.
• Systolic blood pressure that’s lower in the • Check peripheral circulation—pulses, tem-
legs than in the arms perature, color, and complaints of abnormal
sensations—to detect poor arterial blood flow.
DIAGNOSTIC FINDINGS • Monitor pain to detect an enlarging
• Abdominal computed tomography (CT) aneurysm or rupture.
scan shows an aneurysm. • Administer medications, as prescribed, to
• Abdominal ultrasound shows an aneurysm. reduce hypertension and control pain.
• Arteriography shows an aneurysm. • Encourage the patient to express feelings,
• Chest X-ray shows an aneurysm. such as a fear of dying, to reduce anxiety.
• ECG differentiates an aneurysm from MI. • Maintain a quiet environment to control
• Magnetic resonance imaging of the ab- blood pressure and reduce risk of rupture.
domen shows an aneurysm.
Teaching topics
NURSING DIAGNOSES • Recognizing signs and symptoms of de-
• Acute pain creased peripheral circulation, such as
• Ineffective tissue perfusion: Peripheral change in skin color or temperature, com-
• Deficient fluid volume plaints of numbness or tingling, and absent
pulses
TREATMENT • Maintaining activity limitations, including
• Endovascular stenting for some patients alternating rest periods with activity, and ad-
920103.qxd 8/7/08 3:51 PM Page 36
hering to prescribed exercise and diet regi- • Cardiac enzymes are within normal limits.
men • Coronary arteriography shows plaque accu-
That makes sense! mulation.
If I don’t get enough • ECG shows ST-segment depression and
oxygen, it hurts. Angina T-wave inversion during anginal pain.
• Holter monitoring reveals ST-segment de-
Angina is chest pain caused by inadequate pression and T-wave inversion.
myocardial oxygen supply. It’s usually caused • Stress test results show abnormal heart ac-
by narrowing of the coronary arteries, which tivity on the ECG and chest pain.
results from plaque accumulation in the inti-
mal lining. NURSING DIAGNOSES
Angina is generally categorized into three • Acute pain
main forms: • Anxiety
• stable angina—symptoms are consistent • Decreased cardiac output
and pain is relieved by rest
• unstable angina (acute coronar y syn- TREATMENT
drome)—pain is marked by increasing sever- • Diet: low-fat, low-sodium, and low-choles-
ity, duration, and frequency and responds terol (low-calorie, if necessary)
slowly to nitroglycerin. • Coronary artery bypass grafting
• Prinzmetal’s angina—pain is unpre- • Oxygen therapy (typically 2 to 4 L)
dictable and may occur at rest. • Percutaneous transluminal coronary angio-
plasty (PTCA), stent placement
CAUSES
• Activity or disease that increases metabolic Drug therapy
demands • Anticoagulants: heparin, dalteparin (Frag-
• Aortic stenosis min), enoxaparin (Lovenox)
• Atherosclerosis • Beta-adrenergic blockers: propranolol (In-
• Pulmonary stenosis deral), nadolol (Corgard), atenolol (Tenor-
• Small-vessel disease (associated with rheu- min), metoprolol (Lopressor)
matoid arthritis, radiation injury, or lupus ery- • Calcium channel blockers: verapamil
Anginal pain can thematosus) (Calan), diltiazem (Cardizem), nifedipine
be difficult to identify. • Thromboembolism (Procardia), nicardipine (Cardene), amlodip-
However, it usually • Vasospasm ine (Norvase), bepridil (Vascor)
doesn’t last as long
• Nitrates: nitroglycerin (Nitrostat), isosor-
as MI pain.
DATA COLLECTION FINDINGS bide dinitrate (Isordil), topical nitroglycerin
• Anxiety (Nitrol), transdermal nitroglycerin (Trans-
• Diaphoresis derm-Nitro)
• Dyspnea • Platelet aggregation inhibitors: ticlopidine
• Epigastric distress (Ticlid), clopidogrel (Plavix), aspirin
• Palpitations • Thrombin inhibitor: bivalirudin (Angiomax)
• Pain that may be substernal, crushing, or
compressing; may radiate to the arms, jaw, or INTERVENTIONS AND RATIONALES
back; usually lasts 3 to 5 minutes; usually oc- • Monitor vital signs to detect evidence of car-
curs after exertion, emotional excitement, or diac compromise and patient’s response to
exposure to cold but can also develop when treatment.
the patient is at rest • Monitor ECG to detect arrhythmias and is-
• Tachycardia chemia.
• Observe pulse oximetry values to detect hy-
DIAGNOSTIC FINDINGS poxemia.
• Blood chemistry tests show increased cho- • Track and record intake and output to moni-
lesterol levels. tor fluid status.
920103.qxd 8/7/08 3:51 PM Page 37
• Administer medications, as prescribed, to Arrhythmias

increase oxygenation and to reduce cardiac
workload. Withhold nitrates and notify the In cardiac arrhythmias, abnormal electrical
charge nurse or doctor if the systolic blood conduction or automaticity changes heart rate
pressure is less than 90 mm Hg. Withhold and rhythm. Arrhythmias vary in severity.
beta-adrenergic blockers and notify doctor if Mild and asymptomatic ones (such as sinus
the heart rate is less than 60 beats/minute. arrhythmia, in which heart rate increases and
These steps may prevent complications that can decreases with respirations) require no treat-
occur as a result of therapy. ment. Catastrophic ventricular fibrillation
• Monitor for chest pain and evaluate its char- (VF) necessitates immediate resuscitation.
acteristics. Chest pain may indicate the need to Arrhythmias are generally classified accord- What a shock!
modify the care plan. ing to their origin (atrial or ventricular). Their A change in
• Tell the patient to call you immediately if he effect on cardiac output and blood pressure, electrical
experiences chest pain or discomfort to pre- partially influenced by the site of origin, deter- conduction breaks
vent treatment delay. mines their clinical significance. The most my rhythm.
• Advise patient in pain to rest to reduce car- common arrhythmias include atrial fibrillation
diac workload. (AF), asystole, VF, and ventricular tachy-
• Obtain a 12-lead ECG during an acute at- cardia (VT).
tack to assess for ischemic changes.
• Place the patient in semi-Fowler’s position CAUSES
to promote chest expansion and ventilation. • Congenital factors
• Maintain the patient’s prescribed diet • Degeneration of conductive tissue
(low-fat, low-sodium, and low-cholesterol; • Drug toxicity
low-calorie, if necessary) to reduce risk of • Electrolyte imbalance
coronary artery disease. • Excess caffeine intake
• Encourage weight reduction, if necessary, • Fluid imbalance
to reduce risk of coronary artery disease. • Heart disease
• Encourage the patient to express anxiety, • MI
fears, and concerns because anxiety can in- • Myocardial ischemia
crease oxygen demands.
• Administer oxygen to improve oxygenation. DATA COLLECTION FINDINGS
Atrial fibrillation
Teaching topics • Commonly produces no symptoms
• Taking sublingual nitroglycerin for acute at- • Palpitations
tacks and for prevention of anginal episodes • Complaints of feeling faint
• Keeping nitroglycerin in its original contain- • Irregular pulse with no pattern to the irreg-
er because exposure to light decreases the ularity
drug’s effectiveness
• Reducing risk factors through diet, exer- Asystole
cise, weight loss, smoking cessation, and • Apnea
stress reduction • Cyanosis
• Avoiding activities or situations that cause • No palpable blood pressure
angina, such as exertion, heavy meals, emo- • Pulselessness
tional upsets, and exposure to cold
• Seeking medical attention if pain lasts Ventricular fibrillation
longer than 20 minutes • Apnea
• Differentiating between symptoms of angi- • No palpable blood pressure
na and symptoms of MI • Pulselessness
• Contacting the American Heart Association
Ventricular tachycardia
• Chest pain
920103.qxd 8/7/08 3:51 PM Page 38
• Diaphoresis Asystole
Whatta ya know? • Hypotension • Cardiopulmonary resuscitation (CPR)
Fluid and electrolyte • Weak pulse or pulselessness • Advanced cardiac life support (ACLS) pro-
imbalances can • Dizziness tocol for endotracheal (ET) intubation and
predispose me to • Loss of consciousness possible transcutaneous pacing
arrhythmias. • Atropine, epinephrine (Adrenalin) per
DIAGNOSTIC FINDINGS ACLS protocol
Atrial fibrillation • Buffering agent: sodium bicarbonate
• ECG shows irregular atrial rhythm, atrial
rate greater than 400 beats/minute, irregular Ventricular fibrillation
ventricular rhythm, QRS complexes of uni- • CPR
form configuration and duration, no discern- • Defibrillation
ible PR interval, and no P waves (fibrillatory • ACLS protocol for ET intubation
waves). • Amiodarone (Cordarone), epinephrine
(Adrenalin), lidocaine (Xylocaine), magne-
Asystole sium sulfate, procainamide (Pronestyl), vaso-
• ECG shows no atrial or ventricular rate or pressin per ACLS protocol
rhythm and no discernible P waves, QRS • Implantable cardiac defibrillator
complexes, or T waves. • Buffering agent: sodium bicarbonate
Ventricular fibrillation Ventricular tachycardia

• ECG shows ventricular activity that appears • CPR (if patient is pulseless)
as fibrillatory waves with no recognizable pat- • Defibrillation
tern. Atrial rate and rhythm and ventricular • ACLS protocol for ET intubation
rhythm can't be determined because no pat- • Amiodarone (Cordarone), epinephrine
tern or regularity occurs. (Adrenalin), lidocaine (Xylocaine), magne-
• The P wave, PR interval, QRS complex, T sium sulfate, procainamide (Pronestyl)
wave, and QT interval can't be determined. • Implantable cardiac defibrillator
Ventricular tachycardia INTERVENTIONS AND RATIONALES

• ECG shows ventricular rate of 100 to 250 • Check pulse for rate and rhythm.
beats/minute, wide and bizarre QRS com- • Monitor ECG to detect arrhythmias and is-
plexes, and no P waves. VT may start or stop chemia.
suddenly. • If the patient’s pulse is abnormally rapid,
slow, or irregular, watch for signs of hypoper-
NURSING DIAGNOSES fusion, such as hypotension and altered men-
• Ineffective tissue perfusion: Cardiopul- tal status, to prevent such complications as re-
monary nal failure and cerebral anoxia.
• Decreased cardiac output • Document any arrhythmias in a monitored
• Impaired gas exchange patient to create a record of their occurrence.
• When life-threatening arrhythmias develop,
TREATMENT rapidly assess level of consciousness (LOC),
Atrial fibrillation respirations, and pulse to avoid crisis.
• Antiarrhythmics: amiodarone (Cordarone), • Initiate CPR, if indicated, to maintain cere-
digoxin (Lanoxin), diltiazem (Cardizem), pro- bral perfusion until other ACLS measures are
cainamide (Pronestyl), verapamil (Calan) successful.
• Anticoagulants: heparin, warfarin (Cou- • Evaluate the patient for altered cardiac out-
madin) put resulting from arrhythmias. Decreased
• Permanent pacemaker cardiac output may cause inadequate perfusion
• Radiofrequency catheter ablation of major organs, leading to irreversible dam-
• Synchronized cardioversion (if patient is un- age.
stable)
920103.qxd 8/7/08 3:51 PM Page 39
• Administer medications, as needed, and the time elapsed between the occlusion and
prepare for medical procedures (for example, its removal.
cardioversion), if indicated, to ensure prompt
treatment of life-threatening arrhythmias. CAUSES
• Monitor for predisposing factors—such as • Atherosclerosis
fluid and electrolyte imbalance—and signs of • Embolus formation
drug toxicity, especially with digoxin. Drug • Thrombosis
toxicity may require withholding the next • Trauma or fracture
dose. Alleviating predisposing factors decreases
the risk of arrhythmias. Risk factors
• Monitor pulse oximetry results and provide • Age
adequate oxygen to reduce the heart’s work- • Diabetes
load while carefully maintaining metabolic, • Family history of vascular disorders, MI, or
neurologic, respiratory, and hemodynamic stroke
status, to prevent arrhythmias in a cardiac pa- • Hyperlipidemia
tient. • Hypertension
• Restrict the patient’s activity after perma- • Smoking
nent pacemaker insertion. Monitor his car-
diac rhythm, and watch for signs of decreased DATA COLLECTION FINDINGS
cardiac output to detect pacemaker malfunc- Assessment findings depend on the site of the
tion. occlusion. Tickle my toes.
• If the patient has a permanent pacemaker, Everything depends on
warn him about environmental hazards as in- Femoral, popliteal, and innominate arteries me. If my aorta is
dicated by the pacemaker manufacturer to • Mottling of the affected extremity obstructed, even the
avoid pacemaker malfunction. • Pallor feet feel it.
• Paralysis and paresthesia in the affected
Teaching topics arm or leg
• Reporting light-headedness or syncope • Pulselessness distal to the occlusion
• Coming in for regular checkups • Sudden and localized pain in the affected
• Recognizing environmental hazards for pa- arm or leg (most common symptom)
tients with permanent pacemakers • Temperature change distal to the occlusion
•Returning for follow-up permanent pace-
maker function tests Internal and external carotid arteries
• Absent or decreased pulsation with an aus-
cultatory bruit over affected vessels
Arterial occlusive disease • Stroke
• Transient ischemic attacks (TIAs), which
With arterial occlusive disease, obstruction or can produce transient monocular blindness,
narrowing of the lumen of the aorta and its dysarthria, hemiparesis, possible aphasia,
major branches causes an interruption of confusion, decreased mentation, and
blood flow, usually to the legs and feet. Arteri- headache
al occlusive disease may affect the carotid,
basilar, vertebral, femoral, popliteal, innomi- Subclavian artery
nate, subclavian, mesenteric, and iliac arter- • Subclavian steel syndrome (characterized
ies. Occlusions may be acute or chronic and by the backflow of blood from the brain
commonly cause severe ischemia, skin ulcer- through the vertebral artery on the same side
ation, and gangrene. as the occlusion into the subclavian artery
Arterial occlusive disease is more common distal to the occlusion; clinical effects of verte-
in males than in females. The prognosis de- brobasilar occlusion and exercise-induced
pends on the location of the occlusion, the de- arm claudication)
velopment of collateral circulation to counter-
act reduced blood flow and, in acute disease,
920103.qxd 8/7/08 3:51 PM Page 40
Vertebral and basilar arteries perfusion causes mottling; skin also becomes
• TIAs, which produce binocular vision dis- cooler and skin texture changes.
turbances, vertigo, dysarthria, and falling • Provide pain relief, as needed, to help de-
down without LOC crease ischemic pain.
• Maintain heparin infusion per protocol to
DIAGNOSTIC FINDINGS prevent thrombi.
• Arteriography demonstrates the type • Move the affected foot frequently to prevent
(thrombus or embolus), location, and degree pressure on any one area. Strictly avoid elevat-
of obstruction and collateral circulation. ing or applying heat to the affected leg. Di-
• Doppler ultrasonography shows decreased rectly heating extremities causes increased tis-
blood flow distal to the occlusion. sue metabolism; if arteries don’t dilate normal-
• EEG and a CT scan may be necessary to ly, tissue perfusion decreases and ischemia may
rule out brain lesions. occur.
• Ophthalmodynamometry helps determine • Watch for signs of fluid and electrolyte im-
the degree of obstruction in the internal balance, and monitor intake and output for
carotid artery by comparing ophthalmic signs of renal failure (urine output less than
artery pressure to brachial artery pressure 30 ml/hour). Electrolyte imbalances and renal
on the affected side. A pressure more than failure may occur as a result of arterial occlu-
20% lower in the ophthalmic artery suggests sion and tissue damage.
insufficiency. • Monitor for signs of stroke, such as numb-
ness in an arm or leg and intermittent blind-
NURSING DIAGNOSES ness, to detect early signs of decreased cerebral
• Ineffective tissue perfusion (type depends perfusion.
on the location of the occlusion)
• Acute pain Postoperatively
• Risk for injury • Monitor the patient’s vital signs. Continu-
ously monitor his circulatory function by in-
TREATMENT specting skin color, noting temperature, and
• Light exercise such as walking checking for distal pulses. While charting,
• Surgery (for acute arterial occlusive dis- compare earlier findings and observations.
ease): atherectomy, balloon angioplasty, by- Watch closely for signs of hemorrhage (tachy-
pass graft, embolectomy, laser angioplasty, cardia, hypotension) and check dressings for
patch grafting, stent placement, thromboen- excessive bleeding to prevent or detect postop-
darterectomy, or amputation erative complications.
• Check neurologic status frequently for
Drug therapy changes in LOC, muscle strength, or pupil
• Anticoagulants: heparin, dalteparin (Frag- size to ensure prompt treatment of deteriorat-
min), enoxaparin (Lovenox), warfarin ing neurologic condition.
(Coumadin) • With mesenteric artery occlusion, connect
• Antiplatelet agents: aspirin, pentoxifylline a nasogastric tube to low intermittent suction.
(Trental) Monitor intake and output. (Low urine output
• Thrombolytic agents: alteplase (Activase), may indicate damage to renal arteries during
streptokinase (Streptase) surgery.) Check abdominal status. Increasing
abdominal distention and tenderness may indi-
INTERVENTIONS AND RATIONALES cate extension of bowel ischemia. Extended bow-
• Advise the patient to stop smoking and to el ischemia may cause peritonitis or gangrene,
follow the prescribed medical regimen to which could require further surgery.
modify risk factors and promote compliance. • With saddle block occlusion, check distal
pulses for adequate circulation. Watch for
Preoperatively (during an acute episode) signs of renal failure and mesenteric artery
• Check the most distal pulses by inspecting occlusion (severe abdominal pain) and car-
skin color and temperature. Decreased tissue diac arrhythmias, which may precipitate em-
920103.qxd 8/7/08 3:51 PM Page 41
bolus formation. These steps ensure prompt CAUSES

recognition and treatment of complications. • Dressler’s syndrome
• With iliac artery occlusion, monitor urine • Effusion (in cancer, bacterial infections, tu-
output for signs of renal failure from de- berculosis and, rarely, acute rheumatic fever)
creased perfusion to the kidneys as a result of • Hemorrhage from nontraumatic causes
surgery. Provide meticulous catheter care to (such as rupture of the heart or great vessels
prevent complications. or anticoagulant therapy in a patient with peri-
• With femoral or popliteal artery occlusion, carditis)
assist with early ambulation but tell the pa- • Hemorrhage from trauma (gunshot or stab
tient to avoid prolonged sitting to encourage wounds of the chest, perforation by a catheter
circulation in the extremities. during cardiac or central venous catheteriza-
• After amputation, check the patient’s stump tion, or cardiac surgery)
carefully for drainage and record its color, the • MI
amount, and the time to detect hemorrhage. El- • Uremia
evate the stump and administer adequate
analgesics to treat edema and pain. Because DATA COLLECTION FINDINGS
phantom limb pain is common, explain this • Anxiety
phenomenon to the patient to reduce his anxi- • Diaphoresis
ety. • Dyspnea
• When preparing the patient for discharge, • Hepatomegaly
instruct him to watch for signs of recurrence • Increased central venous pressure (CVP)
(pain, pallor, numbness, paralysis, absence of • Muffled heart sounds on auscultation
pulse) that can result from graft occlusion or • Narrow pulse pressure
occlusion at another site. Warn him against • Jugular vein distention
wearing constrictive clothing. These measures • Pallor or cyanosis
enable the patient to actively participate in his • Pulsus paradoxus (an abnormal inspiratory
care and make informed decisions about his drop in systemic blood pressure greater than
health status. 15 mm Hg)
• Reduced arterial blood pressure You think the
Teaching topics • Restlessness NCLEX creates
• Performing proper foot care • Tachycardia pressure? In cardiac
• Recognizing signs of arterial occlusion • Upright, leaning forward posture tamponade, excess
• Modifying risk factors fluid puts so much
DIAGNOSTIC FINDINGS pressure on me, I may
• Chest X-ray shows slightly widened medi- need emergency
Cardiac tamponade astinum and cardiomegaly. treatment.
• Echocardiography identifies pericardial ef-
With cardiac tamponade, a rapid rise in infusion with signs of right ventricular and atrial
trapericardial pressure impairs diastolic filling compression.
of the heart. The rise in pressure usually re- • ECG may reveal a low-amplitude QRS
sults from blood or fluid accumulation in the complex and electrical alternans, an alternat-
pericardial sac. ing beat-to-beat change in the amplitude of
Rapid fluid accumulation, a commonly fatal the P wave, QRS complex, and T wave. Gener-
condition, requires emergency lifesaving mea- alized ST-segment elevation is noted in all
sures. Slow accumulation and rise in pres- leads.
sure, as in pericardial effusion associated with • Pulmonary artery catheterization detects
cancer, may not produce immediate symp- increased right atrial pressure, right ventricu-
toms because the fibrous wall of the pericar- lar diastolic pressure, and CVP.
dial sac can gradually stretch to accommodate
as much as 1 to 2 L of fluid. NURSING DIAGNOSES
• Ineffective tissue perfusion: Cardiopul-
monary
920103.qxd 8/7/08 3:51 PM Page 42
• Anxiety For thoracotomy

• Decreased cardiac output • Make sure that informed consent has been
obtained.
TREATMENT • Explain the procedure to the patient. Tell
• Supplemental oxygen. him what to expect after the surgery (chest
• Surgery: pericardiocentesis (needle aspira- tubes attached to a chest drainage system, ad-
tion of the pericardial cavity), surgical cre- ministration of oxygen). Teach him how to
ation of an opening to drain fluid, or thoraco- turn, deep-breathe, and cough to prevent post-
tomy operative complications and relieve his anxiety.
• Give antibiotics to prevent or treat infection
Drug therapy and protamine sulfate or vitamin K (AquaME-
• Heparin antagonist: protamine sulfate in PHYTON) as needed to prevent hemorrhage.
heparin-induced cardiac tamponade • Postoperatively, monitor critical parameters,
• Inotropic agent: dopamine (Intropin) such as vital signs and pulse oximetry levels,
• Vitamin: vitamin K (AquaMEPHYTON) in and assess heart and breath sounds to detect
warfarin-induced cardiac tamponade early signs of complications such as reaccumu-
lation of fluid.
INTERVENTIONS AND RATIONALES • Give pain medication as needed to alleviate
• Monitor ECG to detect arrhythmias and is- pain and promote comfort.
chemia. • Maintain the chest drainage system and be
alert for complications, such as hemorrhage
For pericardiocentesis and arrhythmias, to prevent further decompen-
• Explain the procedure to the patient to alle- sation.
viate anxiety.
• Make sure that informed consent has been Teaching topics
obtained. • Alerting the nurse if condition worsens
• Keep a pericardial aspiration needle at-
tached to a 50-ml syringe by a three-way stop-
cock, an ECG machine, and an emergency Cardiogenic shock
cart with a defibrillator at the bedside. Make
sure the equipment is turned on and ready for Cardiogenic shock occurs when the heart
immediate use to avoid treatment delay. fails to pump adequately, thereby reducing
• Position the patient at a 45- to 60-degree cardiac output and compromising tissue per-
angle. fusion.
• Monitor pulse oximetry values to detect hy- Here’s how cardiogenic shock progresses:
poxia. • Decreased stroke volume results in in-
• Monitor blood pressure during and after creased left ventricular volume.
pericardiocentesis to monitor for complica- • Blood pooling in the left ventricle backs up
tions such as hypotension, which may indicate into the lungs, causing pulmonary edema.
cardiac chamber puncture. • To compensate for a falling cardiac output,
• Maintain I.V. solutions to support blood pres- heart rate and contractility increase.
sure. Watch for a rise in blood pressure, which • These compensating mechanisms increase
indicates relief of cardiac compression. the demand for myocardial oxygen.
• Watch for complications of pericardiocente- • An imbalance between oxygen supply and
sis (VF, vasovagal response, and coronary demand develops, which increases myocar-
artery or cardiac chamber puncture) to pre- dial ischemia and further compromises the
vent crisis. heart’s pumping action.
• Closely monitor pulse rate, LOC, and uri-
nary output to detect signs of decreased cardiac CAUSES
output. • Advanced heart block
• Cardiomyopathy
920103.qxd 8/7/08 3:51 PM Page 43
• Heart failure • Dietary changes, including withholding

• MI food and oral fluids
• Myocarditis • Heart transplantation if other measures fail.
• Papillary muscle rupture
Drug therapy
DATA COLLECTION FINDINGS • Adrenergic agent: epinephrine (Adrenalin)
• Anxiety, restlessness, disorientation, and • Cardiac glycoside: digoxin (Lanoxin)
confusion • Inotropic agents: dopamine (Intropin),
• Cold, clammy skin dobutamine (Dobutrex), inamrinone (Inocor),
• Crackles milrinone (Primacor)
• Hypotension (systolic pressure below • Diuretics: furosemide (Lasix), bumetanide
90 mm Hg) and narrow pulse pressure (Bumex), metolazone (Zaroxolyn)
• Jugular vein distention • Vasodilators: nitroprusside (Nitropress), ni-
• Oliguria (urine output of less than troglycerin (Tridil)
30 ml/hour) • Vasopressor: norepinephrine (Levophed)
• S3 and S4
• Tachycardia or other arrhythmias INTERVENTIONS AND RATIONALES
• Tachypnea • Monitor vital signs, heart sounds, capillary
• Hypoxia refill, skin temperature, and peripheral pulses
• Weak, thready pulse to monitor the effects of drug therapy and detect
cardiac decompensation.
DIAGNOSTIC FINDINGS • Monitor the ECG to detect arrhythmias and
• ABG levels show respiratory alkalosis ini- ischemia.
tially. As shock progresses, metabolic acidosis • Monitor respiratory status, including breath
develops. sounds and ABG values. Tachypnea, crackles,
• Blood chemistry test results show in- and hypoxemia may indicate pulmonary ede-
creased BUN, creatinine, and cardiac en- ma.
zymes and troponin levels. • Monitor fluid balance, including intake and
• ECG shows evidence of an MI (enlarged output, to keep track of renal function and de-
Q wave, elevated ST segment). tect fluid overload leading to pulmonary ede-
ma.
NURSING DIAGNOSES • Monitor LOC to detect cerebral hypoxia
• Decreased cardiac output caused by reduced cardiac output.
• Ineffective tissue perfusion: Cardiopul- • Review the results of laboratory studies to A post-MI patient
has cold, clammy skin;
monary, cerebral, peripheral, GI, and renal detect evidence of MI, evaluate renal function,
hypotension; oliguria;
• Excess fluid volume and assess the oxygen-carrying capacity of the and tachycardia.
blood. Hmmmm...it could be
TREATMENT • Withhold food and fluids, as directed, to re- cardiogenic shock.
• Intra-aortic balloon pump (IABP) duce the risk of aspiration that accompanies a
• Left ventricular assist device lower LOC.
• Surgery to repair papillary muscle rupture • Maintain I.V. fluids and administer oxygen
or ventricular septal defect and medications, as prescribed, to maximize
• Activity changes, including maintaining bed cardiac, pulmonary, and renal function.
rest and implementing passive range-of- • Provide suctioning to aid in the removal of
motion and isometric exercises secretions and reduce the risk of aspiration.
• Oxygen therapy: intubation and mechanical • Encourage the patient to express his feel-
ventilation, if necessary ings, such as a fear of dying, to reduce his anx-
• Continuous renal replacement therapy (a iety.
type of slow dialysis that can be done during
injury or trauma)
920103.qxd 8/7/08 3:51 PM Page 44
Teaching topics DATA COLLECTION FINDINGS

• Recognizing early signs and symptoms of • Cough
fluid overload • Crackles on lung auscultation
• Maintaining activity limitations, including • Dependent pitting edema
alternating rest periods with activity • Dyspnea, paroxysmal nocturnal dyspnea
• Maintaining a low-fat, low-sodium diet • Enlarged liver
• Monitoring daily weight and notifying the • Fatigue
doctor of a weight gain greater than 3 lb • Jugular vein distention
(1.4 kg) • Murmur, S3 and S4
DIAGNOSTIC FINDINGS
Cardiomyopathy • Cardiac catheterization excludes the diag-
nosis of coronary artery disease.
With cardiomyopathy, the myocardium (mid- • Chest X-ray shows cardiomegaly and pul-
dle muscular layer) around the left ventricle monary congestion.
becomes flabby, altering cardiac function and • ECG findings indicate left ventricular hyper-
resulting in decreased cardiac output. In- trophy and nonspecific changes.
creased heart rate and increased muscle • Echocardiogram shows decreased myocar-
mass compensate in early stages. In later dial function.
stages, heart failure develops.
The three types of cardiomyopathy are: NURSING DIAGNOSES
• Decreased cardiac output
dilated (congestive), the most common • Impaired gas exchange
form, in which dilated heart chambers con- • Activity intolerance
tract poorly, causing blood to pool and reduc-
ing cardiac output TREATMENT
• Dietary changes: establishing a low-sodium
hypertrophic (obstructive), in which a
diet with vitamin supplements
hypertrophied left ventricle is unable to relax
• Dual-chamber pacing (for hypertrophic car-
and fill properly
diomyopathy)
restrictive (obliterative), a rare form • Surgery (when medication fails): heart
In cardiomyopathy, characterized by stiff ventricles that are resis- transplantation or cardiomyoplasty (for dilat-
the muscles around tant to ventricular filling. ed cardiomyopathy); ventricular myotomy
my left ventricle (for hypertrophic cardiomyopathy)
become flabby. CAUSES
Dilated cardiomyopathy Drug therapy
• Chronic alcoholism • Beta-adrenergic blockers: propranolol (In-
• Infection deral), nadolol (Corgard), metoprolol (Lo-
• Metabolic and immunologic disorders pressor) for hypertrophic cardiomyopathy
• Pregnancy and postpartum disorders • Calcium channel blockers: particularly vera-
pamil (Calan) and diltiazem (Cardizem) for
Hypertrophic cardiomyopathy hypertrophic cardiomyopathy
• Congenital factors • Diuretics: furosemide (Lasix), bumetanide
• Hypertension (Bumex), metolazone (Zaroxolyn) for dilated
cardiomyopathy
Restrictive cardiomyopathy • Inotropic agents: dobutamine (Dobutrex),
• Amyloidosis milrinone (Primacor), digoxin (Lanoxin) for
• Cancer and other infiltrative diseases dilated cardiomyopathy
• Oral anticoagulant: warfarin (Coumadin) for
dilated and hypertrophic cardiomyopathy
920103.qxd 8/7/08 3:51 PM Page 45
INTERVENTIONS AND RATIONALES • Excessive alcohol intake

• Monitor ECG to detect arrhythmias and is- • Genetics
chemia. • High-fat, high-cholesterol diet
• Monitor laboratory results to detect abnor- • Hyperlipidemia
malities, such as hypokalemia, from the use of • Hypertension
diuretics. • Obesity
• Monitor respiratory status, including pulse • Sedentary lifestyle
oximetry values, to detect evidence of heart • Smoking
failure, such as dyspnea and crackles. • Stress
• Monitor vital signs to detect complications.
• Monitor and record intake and output to de- DATA COLLECTION FINDINGS
tect fluid volume overload. • Chest pain that may be substernal, crush-
• Keep the patient in semi-Fowler’s position to ing, or compressing; may radiate to the arms,
enhance gas exchange. jaw, or back; usually lasts 3 to 5 minutes if
• Maintain bed rest to reduce oxygen demands anginal pain (longer-lasting pain may signal
on the heart. an MI); usually occurs after exertion, emo-
• Administer oxygen and medications, as pre- tional excitement, or exposure to cold but can
scribed, to improve oxygenation and cardiac also develop when the patient is at rest
output.
• Maintain the patient’s prescribed diet. A DIAGNOSTIC FINDINGS
low-sodium diet reduces fluid retention. • Blood chemistry tests show increased cho-
lesterol levels (decreased high-density lipo-
Teaching topics protein [HDL] level, increased low-density
• Recognizing early signs and symptoms of lipoprotein [LDL] level).
heart failure • Coronary arteriography shows plaque for-
• Measuring weight daily and reporting in- mation.
creases over 3 lb (1.4 kg) • ECG or Holter monitoring shows ST-
• Doing exercises such as raising the arms to segment depression and T-wave inversion
increase cardiac output during anginal episode. Dietary changes
• Easing bowel movements to avoid straining • Stress test reveals ST-segment changes, are key for patients
• Avoiding the use of alcohol and tobacco multiple premature ventricular contractions, with CAD. Try
• Contacting the American Heart Association and chest pain. something from our
low-sodium, low-fat,
low-cholesterol menu.
NURSING DIAGNOSES
Coronary artery disease • Activity intolerance
• Impaired gas exchange
Coronary artery disease (CAD) results from • Acute pain
the buildup of atherosclerotic plaque in the ar-
teries of the heart. This causes a narrowing of TREATMENT
the arterial lumen, reducing blood flow to the • Activity changes, including weight loss, if
myocardium. The degree of occlusion that re- necessary
sults determines the type of acute coronary • Atherectomy
syndrome the patient may experience, such • Coronary artery bypass surgery
as unstable angina or an MI. • Coronary artery stent placement
• Dietary changes, including establishing a
CAUSES low-sodium, low-cholesterol, low-fat diet in-
• Aging volving increased dietary fiber (low-calorie
• Arteriosclerosis only if appropriate)
• Atherosclerosis • PTCA
• Depletion of estrogen after menopause • Oxygen therapy during an anginal episode
• Diabetes
920103.qxd 8/7/08 3:51 PM Page 46
Drug therapy Endocarditis

• Analgesic: morphine (I.V.)
• Anticoagulants: heparin, dalteparin (Frag- Endocarditis is an infection of the endocardi-
min), enoxaparin (Lovenox) um, heart valves, or a cardiac prosthesis
• Antilipemic agents: cholestyramine (Ques- caused by a bacterial or fungal invasion. This
tran), lovastatin (Mevacor), simvastatin (Zo- invasion produces vegetative growths on the
cor), nicotinic acid (Niacor), gemfibrozil heart valves, the endocardial lining of a heart
(Lopid), colestipol (Colestid) chamber, or the endothelium of a blood vessel
• Beta-adrenergic blockers: metoprolol (Lo- that may embolize to the spleen, kidneys, cen-
pressor), propranolol (Inderal), nadolol (Cor- tral nervous system, and lungs. This disorder
gard) may also be called infective endocarditis or
• Calcium channel blockers: amlodipine (Nor- bacterial endocarditis.
vase), bepridil (Vascor), nifedipine (Procar- With endocarditis, fibrin and platelets ag-
dia), verapamil (Calan), diltiazem (Cardizem) gregate on the valve tissue and engulf circu-
• Nitrates: nitroglycerin (Nitro-Bid), isosor- lating bacteria or fungi that flourish and pro-
bide dinitrate (Isordil) duce friable verrucous vegetations. Such veg-
• Platelet aggregation inhibitors: ticlopidine etations may cover the valve surfaces, causing
(Ticlid), clopidogrel (Plavix), abciximab (Reo- ulceration and necrosis; they may also extend
Pro), aspirin to the chordae tendineae, leading to their rup-
• Thrombin inhibitor: bivalirudin (Angiomax) ture and subsequent valvular insufficiency.
Untreated endocarditis is usually fatal, but
INTERVENTIONS AND RATIONALES with proper treatment, about 70% of patients
• Obtain an ECG during anginal episodes to recover. The prognosis is worst when endo-
detect evidence of ischemia. carditis causes severe valvular damage that
• Monitor vital signs to detect evidence of com- leads to insufficiency and heart failure or
promise. when it involves a prosthetic valve.
• Monitor the ECG to detect arrhythmias and
ischemia. CAUSES
• Monitor the patient’s intake and output to • Enterococci
detect changes in fluid status. • I.V. drug abuse
• Encourage the patient to express anxiety, • Mitral valve prolapse
fears, or concerns to help him cope with his ill- • Prosthetic heart valve
ness. • Rheumatic heart disease
• Administer nitroglycerin sublingually for • Streptococci (especially Streptococcus viri-
anginal episodes to relieve the pain. dans)
• Maintain bed rest during an anginal episode • Staphylococci (especially Staphylococcus au-
to decrease oxygen demand. reus)
• Monitor pulse oximetry values to detect hy-
poxia. Risk factors
• Coarctation of the aorta
Teaching topics • Degenerative heart disease
• Limiting alcohol intake and dietary fat • Marfan syndrome
• Beginning a smoking-cessation program, if • Pulmonary stenosis
appropriate • Subaortic and valvular aortic stenosis
• Properly storing and using nitroglycerin for • Tetralogy of Fallot
chest pain • Ventricular septal defects
DATA COLLECTION FINDINGS
• Anorexia
• Arthralgia
• Chills
• Fatigue
920103.qxd 8/7/08 3:51 PM Page 47
• Intermittent, recurring fever • Before giving antibiotics, obtain a patient

• Loud, regurgitant murmur history of allergies to prevent anaphylaxis.
• Malaise • Observe for signs of infiltration and inflam-
• Night sweats mation—possible complications of long-term
• Signs of cerebral, pulmonary, renal, or I.V. drug administration—at the venipuncture
splenic infarction site.
• Valvular insufficiency • Watch for signs of embolization (hematuria,
• Weakness pleuritic chest pain, left-upper-quadrant pain,
• Weight loss and paresis), a common occurrence during
the first 3 months of treatment. These signs
DIAGNOSTIC FINDINGS may indicate impending peripheral vascular
• Blood test results may include normal or occlusion or splenic, renal, cerebral, or pul-
elevated WBC count, abnormal histiocytes monary infarction.
(macrophages), elevated ESR, normocytic • Monitor the patient’s renal status (BUN lev-
normochromic anemia (in 70% to 90% of endo- els, creatinine clearance, and urine output) to Left-sided
carditis cases), and positive serum rheuma- check for signs of renal emboli or drug toxicity. heart failure
toid factor (in about one-half of all patients • Observe for signs of heart failure, such as causes pulmonary
with endocarditis after the disease is present dyspnea, tachypnea, tachycardia, crackles, symptoms.
for 3 to 6 weeks). jugular vein distention, edema, and weight
• Echocardiography may identify valvular gain. Detecting heart failure early ensures
damage. prompt intervention and treatment. It also de-
• ECG may show AF and other arrhythmias creases the risk that heart failure will progress
that accompany valvular disease. to pulmonary edema.
• Three or more blood cultures in a 24- to 48-
hour period identify the causative organism in Teaching topics
up to 90% of patients. • Importance of continuing antibiotic therapy
for as long as prescribed even if he’s feeling
NURSING DIAGNOSES better.
• Activity intolerance • Recognizing symptoms of endocarditis; no-
• Decreased cardiac output tifying the doctor immediately if symptoms
• Risk for injury occur
• Understanding the need for prophylactic an-
TREATMENT tibiotics before, during, and after dental work,
• Bed rest childbirth, and GU, GI, or gynecologic proce-
• Maintaining sufficient fluid intake dures Right-sided
heart failure
• Surgery (in cases of severe valvular dam-
causes systemic
age) to replace defective valve symptoms.
Heart failure
Drug therapy
• Antibiotics: most effective in treating Heart failure occurs when the heart can’t
causative organism pump enough blood to meet the body’s meta-
• Antiplatelet agent: aspirin bolic needs.
Heart failure can occur as left-sided failure
INTERVENTIONS AND RATIONALES or right-sided failure. Left-sided heart failure
• Monitor ECG to detect arrhythmias. causes mostly pulmonary symptoms, such as
• Monitor cardiovascular status to detect com- dyspnea, dyspnea on exertion, and a moist
plications. cough. Right-sided heart failure causes sys-
• Monitor pulse oximetry values to detect hy- temic symptoms, such as peripheral edema
poxia. and swelling, jugular vein distention, and
hepatomegaly.
920103.qxd 8/7/08 3:51 PM Page 48
CAUSES • Blood chemistry tests reveal decreased

• Atherosclerosis potassium and sodium levels and increased
• Cardiac conduction defects (left-sided fail- BUN and creatinine levels.
ure) • ECG shows left ventricular hypertrophy.
• Chronic obstructive pulmonary disease • Echocardiography shows enlarged cardiac
(COPD; right-sided failure) chambers and decreased wall motion.
• Fluid overload
• Hypertension (left-sided failure) Right-sided failure
• Left-sided heart failure (right-sided failure) • BNP levels are elevated.
• MI • Chest X-ray reveals pulmonary congestion,
• Pulmonary hypertension (right-sided fail- cardiomegaly, and pleural effusion.
ure) • ABG levels indicate hypoxemia.
In left-sided heart
failure, fluid in the • Valvular insufficiency • Blood chemistry tests show decreased sodi-
lungs interferes with • Valvular stenosis um and potassium levels and increased BUN
breathing and the and creatinine levels.
transfer of oxygen to DATA COLLECTION FINDINGS • ECG shows left and right ventricular hyper-
the blood… Left-sided failure trophy.
• Anxiety • Echocardiogram shows enlarged cardiac
• Arrhythmias chambers and decreased wall motion.
• Cough
• Crackles NURSING DIAGNOSES
• Diaphoresis • Decreased cardiac output
• Dyspnea • Excess fluid volume
• Fatigue • Impaired gas exchange
• Gallop rhythm: S3 and S4
• Orthopnea TREATMENT
• Paroxysmal nocturnal dyspnea • Establishing a low-sodium diet and limiting
• Tachycardia fluids
• Tachypnea • IABP
• Oxygen therapy, possibly requiring intuba-
Right-sided failure tion and mechanical ventilation
• Anorexia • Left ventricular assist device (for left-sided
• Ascites failure)
• Dependent edema • Paracentesis (for right-sided failure)
…which causes • Fatigue • Thoracentesis (for right-sided failure)
coughing, dyspnea, • Gallop rhythm: S3 and S4
and fatigue. • Hepatomegaly Drug therapy
• Jugular vein distention • Diuretics: furosemide (Lasix), bumetanide
• Nausea (Bumex), metolazone (Zaroxolyn)
• Signs of left-sided heart failure • Human B-type natriuretic peptide: nesiritide
• Tachycardia (Natrecor)
• Weight gain • Angiotensin-converting enzyme (ACE) in-
hibitors: captopril (Capoten), enalapril (Va-
DIAGNOSTIC FINDINGS sotec), lisinopril (Prinivil)
Left-sided failure • Analgesic: morphine (I.V.)
• BNP levels are elevated. • Cardiac glycoside: digoxin (Lanoxin)
• Chest X-ray shows increased pulmonary • Inotropic agents: dopamine (Intropin),
congestion and left ventricular hypertrophy. dobutamine (Dobutrex), inamrinone (Inocor),
• ABG levels indicate hypoxemia and hyper- milrinone (Primacor), nesiritide (Natrecor)
capnia. • Nitrates: isosorbide dinitrate (Isordil), nitro-
glycerin (Nitro-Bid)
• Vasodilator: nitroprusside (Nitropress)
920103.qxd 8/7/08 3:51 PM Page 49
INTERVENTIONS AND RATIONALES tance, necessitating increased force to circu-

• Administer oxygen to enhance arterial oxylate blood through the body.
genation. There are two major types of hypertension:
• Monitor pulse oximetry values to detect hy- • Essential hypertension, the most com-
poxia. mon, has no known cause, though many fac-
• Monitor ECG to detect arrhythmias and is- tors play a role in its development.
chemia. • Secondar y hypertension is caused by re-
• Monitor vital signs to detect signs of reduced nal disease or other systemic diseases.
cardiac output. The National Institutes of Health classifies
• Monitor respiratory status to detect increas- blood pressure as follows:
ing fluid in the lungs and respiratory failure.
Normal Systolic blood pressure
• Keep the patient in semi-Fowler’s position
(SBP) <120 mm Hg and
to increase chest expansion and improve venti-
diastolic blood pressure
lation.
(DBP) < 80 mm Hg
• Administer medications, as prescribed, to
enhance cardiac performance and reduce ex- Prehypertension SBP 120 to 139 mm Hg or
cess fluids. DBP 80 to 89 mm Hg
• Measure and record intake and output. In-
Stage 1 SBP 140 to 159 mm Hg or
take greater than output may indicate fluid re-
hypertension DBP 90 to 99 mm Hg
tention.
• Provide suctioning, if necessary, and assist Stage 2 SBP 160 mm Hg or
with turning, coughing, and deep breathing to hypertension DBP 100 mm Hg
prevent pulmonary complications.
• Restrict oral fluids because excess fluids can A blood pressure of 130/80 mm Hg or high-
worsen heart failure. er is considered high blood pressure for pa-
• Weigh the patient daily. A weight gain of 1.1 tients with diabetes or chronic kidney dis-
to 2.2 lb (0.5 to 1 kg) per day indicates fluid ease.
gain.
• Measure and record the patient’s abdominal CAUSES
girth. An increase in abdominal girth suggests • Coarctation of the aorta Understanding
worsening fluid retention and right-sided heart • Cushing’s disease risk factors for
failure. • Neurologic disorders hypertension is
• Maintain the patient’s prescribed diet (low • No known cause (essential hypertension) important. After all,
sodium) to reduce fluid accumulation. • Hormonal contraceptive use some of these risk
• Encourage the patient to express feelings, • Pheochromocytoma factors can be
modified, which may
such as a fear of dying, to reduce anxiety. • Pregnancy
eliminate the need for
• Primary hyperaldosteronism drug therapy.
Teaching topics • Renovascular disease
• Limiting sodium intake and supplementing • Thyroid, pituitary, or parathyroid disease
diet with foods high in potassium • Use of drugs, such as cocaine, epoetin alfa,
• Recognizing signs and symptoms of fluid and cyclosporine
overload
• Elevating legs when seated Risk factors for essential hypertension
• Contacting the American Heart Association • Aging (males over age 45, females over
age 55)
• Atherosclerosis
Hypertension • Diet (high sodium and caffeine intake)
• Family history
Persistent elevation of systolic or diastolic • Overweight
blood pressure indicates hypertension. Hy- • Race (more common in blacks)
pertension results from a narrowing of the ar- • Sex (more common in males over age 40)
terioles, which increases peripheral resis- • Smoking
920103.qxd 8/7/08 3:51 PM Page 50
• Stress • Chest X-ray reveals cardiomegaly.

• Lack of physical activity • ECG shows left ventricular hypertrophy.
• Excessive alcohol use • Ophthalmoscopic examination shows reti-
• Diabetes mellitus nal changes, such as severe arteriolar narrow-
ing, papilledema, and hemorrhage.
DATA COLLECTION FINDINGS • Urinalysis shows proteinuria, RBCs, and
• Ankle edema WBCs.
• Asymptomatic
• Chest pain NURSING DIAGNOSES
• Dizziness • Excess fluid volume
• Dyspnea • Deficient knowledge (hypertension)
• Elevated blood pressure • Imbalanced nutrition: More than body
• Headache requirements
• Papilledema
• Vision disturbances, including blindness TREATMENT
• Weight reduction
DIAGNOSTIC FINDINGS • Increasing physical activity to 30 minutes at
• Blood chemistry test results show elevated least 5 days per week
sodium, BUN, creatinine, and cholesterol lev- • Dietary changes:
els. – Consuming foods low in saturated fat, to-
• Blood pressure measurements show sus- tal fat, and cholesterol
tained readings higher than 140/90 mm Hg.
Dash into dietary changes

Studies indicate that using the National Institutes of Health DASH (Dietary Approaches to Stop Hypertension) combination diet
lowers blood pressure and may also help prevent hypertension. The diet is low in cholesterol; high in dietary fiber, potassium, cal-
cium, and magnesium; and moderately high in protein. If you educate your patient about this diet, he may be able to control his
blood pressure without the use of medication.
Here is a sample DASH plan based on a 2,000-calorie diet. Depending on caloric needs, the number of servings in a food group
may vary.
Food group Daily servings Serving sizes Food group Daily servings Serving sizes
Grains 7 to 8 • 1 slice bread Low-fat or 2 to 3 • 8 oz milk

• 1⁄2 cup celery nonfat dairy • 1 cup yogurt
• 1⁄2 cup cooked rice, pasta, products • 1⁄2 oz cheese
or cereal
Meat, 2 or less • 3 oz cooked meat, poultry,
Vegetables 4 to 5 • 1 cup raw leafy vegetable poultry, or fish
• 1⁄2 cup cooked vegetable and fish
• 6 oz vegetable juice
Nuts, 4 to 5 per week • 1⁄2 oz or 1⁄3 cup nuts
Fruits 4 to 5 • 6 oz fruit juice seeds, and • 1⁄2 oz or 2 tablespoons
• 1 medium fruit legumes seeds
• 1⁄4 cup dried fruit • 1⁄2 cup cooked legumes
• 1⁄4 cup fresh, frozen, or
canned fruit
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– Eating fruits, vegetables, and low-fat dairy • Encourage the patient to express feelings
foods, through programs such as the DASH about daily stress to reduce anxiety.
eating plan (see Dash into dietary changes) • Maintain a quiet environment to reduce
– Reducing sodium intake stress.
– Limiting alcohol intake
Teaching topics
Drug therapy • Taking blood pressure daily and recogniz-
• ACE inhibitors: captopril (Capoten), ing when to notify the doctor
enalapril (Vasotec), lisinopril (Prinivil) • Beginning a smoking-cessation program, if
• Aldosterone receptor blockers: spironolac- appropriate
tone (Aldactone), eplerenone (Inspra) • Reducing alcohol intake to moderate levels
• Antihypertensives: methyldopa (Aldomet), • Following the DASH diet
prazosin (Minipress), doxazosin (Cardura), • Following a program of regular exercise
clonidine (Catapres) • Losing weight, if appropriate
• Beta-adrenergic blockers: propranolol (In- • Contacting the American Heart Association
deral), metoprolol (Lopressor), carteolol
(Cartrol), penbutolol (Levatol), labetalol (Nor-
modyne), atenolol (Tenormin) Hypovolemic shock
• Angiotensin II antagonists: losartan
(Cozaar), valsartan (Diovan) In hypovolemic shock, reduced intravascular
• Calcium channel blockers: nifedipine (Pro- blood volume causes circulatory dysfunction
cardia), verapamil (Calan), diltiazem and inadequate tissue perfusion. Without suf-
(Cardizem), nicardipine (Cardene) ficient blood or fluid replacement, hypovole-
• Diuretics: furosemide (Lasix), spironolac- mic shock syndrome may lead to irreversible
tone (Aldactone), hydrochlorothiazide (Hy- cerebral and renal damage, cardiac arrest
droDIURIL), bumetanide (Bumex), metola- and, ultimately, death.
zone (Zaroxolyn) Hypovolemic shock requires early recogni-
• Vasodilators: nitroprusside (Nitropress), tion of signs and symptoms and prompt, ag-
hydralazine (Apresoline) gressive treatment to improve the prognosis.
INTERVENTIONS AND RATIONALES CAUSES

• Monitor vital signs. Take an average of two • Acute blood loss (approximately one-fifth of
or more blood pressure readings rather than total volume)
relying on a single abnormal one to establish • Acute pancreatitis
hypertension. • Dehydration from excessive perspiration
• Obtain blood pressure readings in the lying, • Diabetes insipidus
sitting, and standing positions to monitor for • Diuresis
orthostatic hypotension (observe for pallor, di- • Inadequate fluid intake
aphoresis, or vertigo). • Intestinal obstruction
• Note neurologic status and observe for • Peritonitis
changes that may indicate an alteration in • Severe diarrhea or protracted vomiting
cerebral perfusion (stroke or hemorrhage).
• Monitor and record intake and output and DATA COLLECTION FINDINGS
weigh the patient daily to detect fluid volume • Cold, pale, clammy skin
overload. • Decreased sensorium
• Administer medications, as prescribed, to • Hypotension with narrowing pulse pressure
lower blood pressure. • Rapid, shallow respirations
• Maintain the patient’s prescribed diet be- • Reduced urine output (less than
cause a high-sodium, high-cholesterol, high-fat 25 ml/hour)
diet may contribute to hypertension. • Tachycardia
920103.qxd 8/7/08 3:51 PM Page 52
DIAGNOSTIC FINDINGS a thready pulse generally signals inadequate

• Blood test results show elevated serum cardiac output from reduced intravascular vol-
potassium, serum lactate, and BUN levels, in- ume.
creased urine specific gravity (greater than • Maintain I.V. lines with normal saline or lac-
1.020) and urine osmolality; and decreased tated Ringer’s solution to correct fluid volume
hemoglobin and hematocrit (if blood loss oc- deficit.
curs). • Monitor pulse oximetry values to detect hy-
• Gastroscopy, aspiration of gastric contents poxia.
through a nasogastric tube, and X-rays identi- • An indwelling urinary catheter may be in-
fy internal bleeding sites. serted to measure hourly urine output. If out-
• ABG analysis reveals metabolic acidosis put is less than 30 ml/hour in adults, increase
(decreased blood pH, decreased bicarbonate the fluid infusion rate as indicated in the doc-
level). tor’s order, but watch for signs of fluid over-
load. Notify the doctor if urine output doesn’t
NURSING DIAGNOSES improve. An osmotic diuretic such as manni-
• Ineffective tissue perfusion: Cardiopul- tol (Osmitrol) may be ordered to increase re-
monary, cerebral, peripheral, renal nal blood flow and urine output.
• Decreased cardiac output • Administer oxygen to ensure adequate oxy-
• Deficient fluid volume genation of tissues. ET intubation and mechan-
ical ventilation may be necessary.
TREATMENT • Draw venous blood for complete blood
• Supplemental oxygen administration count, electrolyte levels, type and crossmatch,
I’d better back up
• Complete bed rest and coagulation studies to guide the treatment
and study data
collection findings • Blood and fluid replacement regimen.
again. Early • Control of bleeding (may require surgery) • During therapy, assess skin color and tem-
recognition of signs • Pneumatic antishock garment (sometimes perature and note any changes. Cold, clammy
and symptoms of used) skin may be a sign of continuing peripheral vas-
hypovolemic shock is cular constriction, indicating progressive shock.
necessary to prevent Drug therapy • Provide emotional support to the patient
irreversible damage. • Vitamin K if patient was receiving warfarin and his family to help them cope with this typi-
(Coumadin) cally overwhelming situation.
INTERVENTIONS AND RATIONALES Teaching topics

Management of hypovolemic shock necessi- • All procedures and their purpose
tates prompt, aggressive support measures, • Understanding the cause of hypovolemia
careful assessment, and monitoring of vital and treatment options
signs. Follow these priorities:
• Check for a patent airway and adequate cir-
culation. If blood pressure and heart rate are Myocardial infarction
absent, start CPR to prevent irreversible organ
damage and death. With MI, an acute coronary syndrome, re-
• Record blood pressure, pulse rate, peripher- duced blood flow in one of the coronary arter-
al pulses, respiratory rate, and other vital ies leads to myocardial ischemia, injury, and
signs every 15 minutes. Monitor the ECG necrosis.
continuously. A systolic blood pressure lower In Q-wave MI, tissue damage extends
than 80 mm Hg usually results in inadequate through all myocardial layers. In non–Q-wave
coronary artery blood flow, cardiac ischemia, MI, usually only the innermost layer is dam-
arrhythmias, and further complications of low aged.
cardiac output. When blood pressure drops
below 80 mm Hg, increase the oxygen flow CAUSES
rate and notify the doctor immediately. A pro- • Aging
gressive drop in blood pressure accompanied by • Decreased serum HDL levels
920103.qxd 8/7/08 3:51 PM Page 53
• Diabetes mellitus NURSING DIAGNOSES

• Elevated serum triglyceride, LDL, and cho- • Decreased cardiac output
lesterol levels • Ineffective denial
• Excessive intake of saturated fats, carbohy- • Ineffective tissue perfusion: Cardiopul- Memory
drates, or salt monary jogger
• Hypertension
• Obesity TREATMENT To remem-
ber the
• Family history of CAD • Bed rest with bedside commode for the first signs and symp-
• Sedentary lifestyle 12 hours toms of MI, think
• Smoking • Coronary artery bypass graft surgery DANCE PAD:
• Stress • IABP
• Use of amphetamines or cocaine • Left ventricular assist device
Dyspnea
• Postmenopause • Low-calorie, low-cholesterol, low-fat diet Anxiety
• Monitoring vital signs, urine output, ECG, Nausea and
DATA COLLECTION FINDINGS and hemodynamic status vomiting
• Anxiety • Ongoing laboratory studies: ABG, CK with
• Arrhythmias isoenzyme, electrolyte, and cardiac troponin
Crushing
substernal
• Crushing substernal chest pain that may ra- levels chest pain
diate to the jaw, back, and arms; lasts longer • Oxygen therapy
than anginal pain; isn’t relieved by rest or ni- • PTCA or coronary artery stent placement Elevated
troglycerin (may not be present in asympto- • Pulmonary artery catheterization (to detect temperature
matic or silent MI); in women, possibly atypi- left- or right-sided heart failure)
cal symptoms such as pain and fatigue • Pacemaker for symptomatic bradycardia Pallor
• Diaphoresis Arrhythmias
• Dyspnea Drug therapy
• Elevated temperature • Analgesic: morphine (I.V.) Diaphoresis
• Nausea and vomiting • ACE inhibitors: captopril (Capoten),
• Pallor enalapril (Vasotec)
• Antiarrhythmics: amiodarone (Cordarone),
DIAGNOSTIC FINDINGS lidocaine (Xylocaine), procainamide (Pron-
• ECG shows an enlarged Q wave, elevated estyl)
or depressed ST segment, and T-wave inver- • Anticoagulants: dalteparin (Fragmin),
sion. enoxaparin (Lovenox), heparin I.V. after
• Blood chemistry studies show increased thrombolytic therapy
CK, LD, AST, and lipid levels; positive CK-MB • Antiplatelet aggregation agents: aspirin, ab-
fraction; flipped LD1 (LD1 levels exceed LD2 ciximab (ReoPro), clopidogrel (Plavix), eptifi-
levels, the reverse of their normal patterns); batide (Integrilin)
and increased troponin (T and I). • Beta-adrenergic blockers: propranolol (In-
• Blood studies show increased WBC count. deral), nadolol (Corgard), metoprolol (Lo-
• Echocardiography may show ventricular pressor); beta-adrenergic blockers contraindi-
wall motion abnormalities and may reveal sep- cated if patient also has hypotension, asthma,
tal or papillary muscle rupture. or COPD
• The chest X-ray may show left-sided heart • Calcium channel blockers: nifedipine (Pro-
failure or cardiomegaly caused by ventricular cardia), verapamil (Calan), diltiazem (Cardi-
dilation. zem)
• Nuclear imaging scanning may show areas • I.V. atropine for symptomatic bradycardia or
of infarction and viable muscle cells. heart block
• Cardiac catheterization may be used to • Nitrate: nitroglycerin I.V. (Nitro-Bid)
identify the involved coronary artery as well • Thrombolytic agents: tissue plasminogen
as provide information on ventricular function activator (Activase), streptokinase (Strep-
and pressures and volumes within the heart. tase), anistreplase (Eminase), reteplase (Re-
tavase); should be given within 6 hours of on-
920103.qxd 8/7/08 3:51 PM Page 54
set of symptoms but are most effective when • Monitor breathing status to watch for signs
started within 3 hours of heart failure, such as an S3 or S4 gallop,
• Vasodilator: hydralazine (Apresoline) crackles, cough, tachypnea, and edema.
• Maintain bed rest for the first 12 hours to re-
INTERVENTIONS AND RATIONALES duce oxygen demands on the heart.
• Monitor the ECG to detect ischemia, injury, • Administer oxygen, as prescribed, to im-
new or extended infarction, arrhythmias, and prove oxygen supply to heart muscle.
conduction defects. (See Close monitoring for • Monitor pulse oximetry values to detect hy-
complications.) poxia.
• Monitor and record vital signs to track re- • Obtain an ECG reading during acute pain to
sponse to therapy and detect complications. detect myocardial ischemia, injury, or infarc-
• Monitor and record intake and output to as- tion.
sess renal perfusion and possible fluid reten- • Maintain the patient’s prescribed diet to re-
tion. duce fluid retention and cholesterol levels.
Close monitoring for complications

After a myocardial infarction (MI), closely monitor the patient for complications. Early recognition
and treatment of these complications can improve his outcome.
Complication What to look for
Arrhythmias • Ventricular tachycardia

• Ventricular fibrillation
• In inferior wall MI, bradycardia, junctional rhythms, or atrioventricular blocks
• In anterior wall MI, tachycardia or atrioventricular blocks
Heart failure • Dyspnea

• Dyspnea on exertion
• Crackles on auscultation of the lungs
• Jugular vein distention
Cardiogenic • Hypotension
shock • Tachycardia
• S3 and S4
• Decreased level of consciousness
• Decreased urine output
• Jugular vein distention
• Cool, pale skin
Papillary • Jugular vein distention

muscle • Dyspnea
rupture • Holosystolic murmur on auscultation
Pericarditis • Chest pain that’s relieved by sitting up

• Friction rub on auscultation
920103.qxd 8/7/08 3:51 PM Page 55
• Provide postoperative care, if necessary, to • Viral infections (most common cause in the
My oh my. In
avoid postoperative complications and help the United States and western Europe): coxsack- myocarditis, my
patient achieve a full recovery. ievirus A and B strains and, possibly, polio- middle muscle
• Allay the patient’s anxiety because anxiety myelitis, influenza, rubeola, rubella, and ade- layer becomes
increases oxygen demand. noviruses and echoviruses inflamed.
• Provide postprocedure care if PTCA is nec-
essary. DATA COLLECTION FINDINGS
• Arrhythmias (S3 and S4 gallops, faint S1)
Teaching topics • Dyspnea
• Undergoing cardiac rehabilitation • Fatigue
• Maintaining activity limitations • Fever
• Maintaining a low-cholesterol, low-fat, low- • Mild, continuous pressure or soreness in
sodium diet the chest (unlike the recurring, stress-related
• Differentiating between the pain of angina pain of angina pectoris)
and MI • Palpitations
• Importance of avoiding tobacco DIAGNOSTIC FINDINGS
• Reducing alcohol intake • Blood tests show elevated cardiac enzyme
• Losing weight levels (CK, the CK-MB isoenzyme, AST, and
• Obtaining regular follow-up care LD), increased WBC count and ESR, and ele-
vated antibody titers (such as antistreptolysin
O titer in rheumatic fever).
Myocarditis • ECG typically shows diffuse ST-segment
and T-wave abnormalities (as in pericarditis),
Myocarditis is focal or diffuse inflammation of conduction defects (prolonged PR interval),
the cardiac muscle (myocardium). It may be and other supraventricular arrhythmias.
acute or chronic and can occur at any age. In • Endomyocardial biopsy confirms the diag-
many cases, myocarditis fails to produce spe- nosis. A negative biopsy doesn’t exclude the
cific cardiovascular symptoms or ECG abnor- diagnosis and a repeat biopsy may be needed
malities, and recovery is usually spontaneous, to rule out the diagnosis.
without residual defects. Occasionally, myo- • Stool and throat cultures may identify the
carditis is complicated by heart failure; rarely, causative bacteria.
it may lead to cardiomyopathy.
NURSING DIAGNOSES
CAUSES • Activity intolerance
• Bacterial infections: diphtheria, tuberculo- • Decreased cardiac output
sis, typhoid fever, tetanus, and staphylococcal, • Hyperthermia
pneumococcal, and gonococcal infections
• Chemical poisons such as chronic alco- TREATMENT
holism • Bed rest
• Helminthic infections such as trichinosis • Diet: sodium restriction
• Hypersensitive immune reactions, such as
acute rheumatic fever and postcardiotomy Drug therapy
syndrome • Antiarrhythmics: amiodarone (Cordarone),
• Parasitic infections, especially South Ameri- procainamide (Pronestyl)
can trypanosomiasis (Chagas’ disease) in • Antibiotics: based on sensitivity of infecting
neonates and immunosuppressed adults; also, organism
toxoplasmosis • Anticoagulants: warfarin (Coumadin), hep-
• Radiation therapy: large doses of radiation arin, dalteparin (Fragmin), enoxaparin
to the chest for treatment of lung or breast (Lovenox)
cancer
920103.qxd 8/7/08 3:51 PM Page 56
• Cardiac glycoside: digoxin (Lanoxin) to in- CAUSES

crease myocardial contractility • Bacterial, fungal, or viral infection (infec-
• Diuretic: furosemide (Lasix) tious pericarditis)
• High-dose radiation to the chest
INTERVENTIONS AND RATIONALES • Hypersensitivity or autoimmune disease,
•Observe breathing pattern and check lung such as acute rheumatic fever (most common
status to detect signs of heart failure. cause of pericarditis in children), systemic lu-
• Monitor the ECG to detect arrhythmias. pus erythematosus, and rheumatoid arthritis
• Watch for signs of digoxin toxicity (anorex- • Idiopathic factors (most common in acute
ia, nausea, vomiting, blurred vision, cardiac pericarditis)
arrhythmias) and for complicating factors • Neoplasms (primary or metastases from
that may increase the potential for toxicity, lungs, breasts, or other organs)
such as electrolyte imbalances or hypoxia. • Postcardiac injury, such as MI (which later
Early identification of these signs may help pre- causes an autoimmune reaction [Dressler’s
vent further complications. syndrome] in the pericardium), trauma, or
• Stress the importance of bed rest to de- surgery that leaves the pericardium intact but
crease oxygen demands on the heart. Assist causes blood to leak into the pericardial cavity
with bathing as necessary; have the patient • Uremia
use a bedside commode, which is less stressful
on the heart than using a bedpan. Reassure DATA COLLECTION FINDINGS
the patient that activity limitations are tempo- Acute pericarditis
rary. • Pericardial friction rub (grating sound
• Offer diversional activities that aren’t physi- heard as the heart moves)
cally demanding to decrease his anxiety. • Sharp and commonly sudden pain that usu-
ally starts over the sternum and radiates to
Teaching topics the neck, shoulders, back, and arms; unlike
• Restricting activities for as long as the doc- the pain of MI, pericardial pain is commonly
tor prescribes pleuritic, increasing with deep inspiration and
• If taking digoxin at home, checking pulse decreasing when the patient sits up and leans
for 1 full minute before taking the dose and forward, pulling the heart away from the di-
withholding the dose and notifying the doctor aphragmatic pleurae of the lungs
Oh, the perils of if pulse rate falls below the predetermined • Symptoms of cardiac tamponade (pallor,
the pericardium. It rate (usually 60 beats/minute) clammy skin, hypotension, pulsus paradoxus,
becomes inflamed and, • Resuming normal activities slowly, when ap- jugular vein distention)
presto, pericarditis! propriate, and avoiding competitive sports • Symptoms of heart failure (dyspnea, or-
thopnea, tachycardia, ill-defined substernal
chest pain, feeling of fullness in the chest)
Pericarditis
Chronic pericarditis
Pericarditis is an inflammation of the peri- • Gradual increase in systemic venous pres-
cardium, the fibroserous sac that envelops, sure
supports, and protects the heart. It occurs in • Pericardial friction rub
both acute and chronic forms. Acute peri- • Symptoms similar to those of chronic right-
carditis can be fibrinous or effusive, with sided heart failure (fluid retention, ascites,
purulent, serous, or hemorrhagic exudate; hepatomegaly)
chronic constrictive pericarditis is charac-
terized by dense, fibrous pericardial thicken- DIAGNOSTIC FINDINGS
ing. The prognosis depends on the underly- • Blood tests reflect inflammation and may
ing cause but is generally good in acute peri- show normal or elevated WBC count, espe-
carditis, unless constriction occurs. cially in infectious pericarditis; elevated ESR;
and slightly elevated cardiac enzyme levels if
associated with myocarditis.
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• Culture of pericardial fluid obtained by open • Explain tests and treatments to the patient.
surgical drainage or cardiocentesis some- If surgery is necessary, teach him deep-
times identifies a causative organism in bacte- breathing and coughing exercises to alleviate
rial or fungal pericarditis. fear and anxiety and to promote compliance
• Echocardiography confirms the diagnosis with the postoperative treatment regimen. Post-
when it shows an echo-free space between the operative care is similar to that given after
ventricular wall and the pericardium (in cases cardiothoracic surgery.
of pleural effusion).
• ECG shows the following changes in acute Teaching topics
pericarditis: elevation of ST segments in the • Understanding all tests and treatments
standard limb leads and most precordial leads • Performing coughing and deep-breathing
without significant changes in QRS morpholo- exercises
gy that occur with MI, atrial ectopic rhythms • Slowly resuming daily activities and sched-
such as AF, and diminished QRS voltage in uling rest periods in daily routine
pericardial effusion.
NURSING DIAGNOSES Pulmonary edema

• Deficient diversional activity Pulmonary edema is a complication of left-
• Acute pain sided heart failure. It occurs when pulmonary
capillary pressure exceeds intravascular os-
TREATMENT motic pressure and results in increased pres-
• Bed rest sure in the capillaries of the lungs and acute
• Surgery: pericardiocentesis (for cases of transudation of fluid. This leads to impaired Face it.
cardiac tamponade), partial pericardectomy oxygenation and hypoxia. Cardiovascular
care is a huge
(for recurrent pericarditis), total pericardecto-
topic. Feeling
my (for constrictive pericarditis) CAUSES weighed down by
• Supplemental oxygen • Acute respiratory distress syndrome information? Take
• Atherosclerosis a break to clear
Drug therapy • Drug overdose: heroin, barbiturates, mor- your head.
• Antibiotics: according to sensitivity of phine
causative organism • Heart failure
• Corticosteroid: methylprednisolone (Solu- • Hypertension
Medrol) • MI
• Nonsteroidal anti-inflammatory drugs • Myocarditis
(NSAIDs): aspirin, indomethacin (Indocin) • Overload of I.V. fluids
• Smoke inhalation
INTERVENTIONS AND RATIONALES • Valvular disease
• Monitor vital signs to detect deterioration in
condition. DATA COLLECTION FINDINGS
• Monitor ECG to detect arrhythmias. • Agitation, restlessness, and intense fear
• Provide complete bed rest to decrease oxy- • Blood-tinged, frothy sputum
gen demands on the heart. • Paroxysmal cough
• Monitor pain in relation to respiration and • Cold, clammy skin
body position to distinguish pericardial pain • Crackles over lung fields
from myocardial ischemic pain. • Dyspnea, orthopnea, or tachypnea
• Place the patient in an upright position to re- • Jugular vein distention
lieve dyspnea and chest pain. • Syncope
• Provide analgesics and oxygen, and reas- • Tachycardia, S3 and S4, and chest pain
sure the patient with acute pericarditis that
his condition is temporary and treatable to
promote patient comfort and allay anxiety.
920103.qxd 8/7/08 3:51 PM Page 58
DIAGNOSTIC FINDINGS • Weigh the patient daily to detect fluid reten-

• ABG levels show respiratory alkalosis or tion. Weight gain of 1.1 to 2.2 lb (0.5 to 1 kg)
acidosis and hypoxemia. per day suggests fluid retention.
• Chest X-ray shows pulmonary congestion. • Keep the patient in high Fowler’s position if
• ECG reveals tachycardia and ventricular en- his blood pressure remains stable. If the pa-
largement. tient is hypotensive, have him maintain the
• Pulse oximetry reveals hypoxia. semi-Fowler’s position. Elevating the head of
the bed reduces venous return to the heart and
NURSING DIAGNOSES promotes chest expansion.
• Anxiety • Administer medications to improve gas ex-
• Excess fluid volume change, improve myocardial function, and re-
• Impaired gas exchange duce anxiety.
• Note the color, amount, and consistency of
TREATMENT sputum. The amount and consistency may indi-
• Oxygen therapy: possibly intubation and cate hydration status. A change in color or foul-
mechanical ventilation smelling sputum may indicate a respiratory in-
• Activity changes: maintaining bed rest and fection.
implementing range-of-motion and isometric • Withhold food and fluids, as directed, to pre-
exercises vent aspiration.
• Dietary changes: establishing a low-sodium • Encourage the patient to express his feel-
diet and limiting oral fluids ings, such as a fear of suffocation, to reduce
• Hemodialysis and ultrafiltration, if available anxiety and lessen oxygen demand.
Drug therapy Teaching topics

• Diuretics: furosemide (Lasix), bumetanide • Elevating the head of the bed while sleeping
(Bumex), metolazone (Zaroxolyn) • Eating foods high in potassium and low in
• Analgesic: morphine I.V. sodium
Hmmm… • Cardiac glycoside: digoxin (Lanoxin) • Recognizing early signs of fluid overload
Vasodilators are • Inotropic agents: dobutamine (Dobutrex), • Recognizing signs and symptoms of respira-
typically used only in inamrinone (Inocor), milrinone (Primacor), tory distress
severe cases of nesiritide (Natrecor) • Taking medications exactly as prescribed
Raynaud’s disease. • Nitrates: isosorbide dinitrate (Isordil), nitro- • Recording weight daily
That’s because the glycerin (Nitro-Bid)
adverse effects of
• Vasodilator: nitroprusside (Nitropress)
these drugs may be
more bothersome Raynaud’s disease
than the disease INTERVENTIONS AND RATIONALES
itself. • Administer oxygen, as prescribed, to in- Raynaud’s disease, characterized by episodic
crease alveolar oxygen concentration and en- vasospasm in the small peripheral arteries
hance arterial blood oxygenation. and arterioles, is precipitated by exposure to
• Monitor vital signs and breathing pattern to cold or stress. This condition occurs bilateral-
detect changes in fluid balance. Tachycardia, ly and usually affects the hands or, less often,
S3, hypotension, increased respiratory rate, and the feet. It’s most prevalent in women, partic-
crackles indicate increased fluid volume. ularly between puberty and age 40. A benign
• Monitor ECG to detect arrhythmias and is- condition, it requires no specific treatment
chemia. and has no serious residual effects.
• Monitor pulse oximetry values to detect Raynaud’s phenomenon, however, a con-
hypoxia. dition often associated with several connec-
• Monitor and record intake and output. In- tive tissue disorders—such as scleroderma,
take greater than output and elevated specific systemic lupus erythematosus, and
gravity suggest fluid retention. polymyositis—has a progressive course, lead-
ing to ischemia, gangrene, and amputation.
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Differentiating the two disorders is difficult • Advise the patient to avoid stressful situa-
because some patients who experience mild tions and to stop smoking. These lifestyle
symptoms of Raynaud’s disease for several changes can prevent exacerbation of symptoms.
years may later develop overt connective tis- • Instruct the patient to inspect his skin fre-
sue disease—most commonly scleroderma. quently and to seek immediate care for signs
of skin breakdown or infection to prevent com-
CAUSES plications.
• Unknown (most probable theory involves • Teach the patient about typically prescribed
an antigen-antibody immune response) drugs, their uses, and their adverse effects to
prevent further complications.
DATA COLLECTION FINDINGS • Provide psychological support and reassur-
• Numbness and tingling relieved by warmth ance to allay the patient’s fear of amputation
• Typically, blanching of skin on the fingers, and other disfigurement.
which then becomes cyanotic before chang-
ing to red (after exposure to cold or stress) Teaching topics
• Sclerodactyly (thickening of the skin of the • Eliminating risk factors such as smoking
digits), ulcerations, or chronic paronychia (in- • Maintaining preventive measures such as
flammation involving tissue folds around the avoiding cold and stress
nails) in longstanding disease
DIAGNOSTIC FINDINGS Rheumatic fever and

• Arteriography reveals vasospasm.
• Plethysmography reveals intermittent ves- rheumatic heart disease
sel occlusion.
Commonly recurrent, acute rheumatic fever
NURSING DIAGNOSES is a systemic inflammatory disease of child-
• Ineffective tissue perfusion: Peripheral hood that follows a group A beta-hemolytic
• Risk for injury streptococcal infection. Rheumatic heart dis-
• Risk for peripheral neurovascular dysfunc- ease refers to the cardiac manifestations of
tion rheumatic fever and includes pancarditis Fever vs. disease.
(myocarditis, pericarditis, and endocarditis) Rheumatic fever
TREATMENT during the early acute phase and chronic follows a group A
• Activity changes: avoidance of cold valvular disease later. beta-hemolytic
• Smoking cessation (if appropriate) Long-term antibiotic therapy can minimize streptococcal
• Surgery (used in less than 25% of patients): recurrence of rheumatic fever, reducing the infection. Rheumatic
sympathectomy risk of permanent cardiac damage and even- heart disease refers
to the cardiac
tual valvular deformity. However, severe pan-
manifestations of
Drug therapy carditis occasionally produces fatal heart fail- rheumatic fever.
• Calcium channel blockers: diltiazem ure during the acute phase. Of the patients
(Cardizem), nifedipine (Procardia) who survive this complication, about 20% die
• Vasodilators: phenoxybenzamine (Dibenzy- within 10 years.
line), reserpine (Diupres) This disease strikes most often during cool,
damp weather in the winter and early spring.
INTERVENTIONS AND RATIONALES In the United States, it’s most common in the
• Warn the patient against exposure to cold. northern states.
Tell him to wear mittens or gloves during cold
weather and when handling cold items or de- CAUSES
frosting the freezer. This prevents vasospasm, • Hypersensitivity reaction to a group A
which triggers symptoms. beta-hemolytic streptococcal infection
920103.qxd 8/7/08 3:51 PM Page 60
DATA COLLECTION FINDINGS • Stress the need for bed rest during the
• Temperature of at least 100.4° F (38° C) acute phase, and suggest appropriate diver-
• Migratory joint pain or polyarthritis sions that aren’t physically demanding. These
• Skin lesions such as erythema marginatum measures decrease oxygen demands on the
(in only 5% of patients) heart.
• Transient chorea (can develop up to 6 • After the acute phase, encourage family and
months after the original streptococcal infec- friends to spend as much time as possible
tion) with the patient to minimize boredom.
• If the patient has severe carditis, help him
DIAGNOSTIC FINDINGS prepare for permanent changes in his lifestyle
• Blood test results show elevated WBC to promote positive coping strategies.
count and ESR as well as slight anemia during • Warn the patient to watch for and immedi-
inflammation. ately report signs of recurrent streptococcal
• Cardiac catheterization findings help evalu- infection (oropharyngeal redness and exu-
ate valvular damage and left ventricular func- date, swollen and tender cervical lymph
tion in severe cardiac dysfunction. glands, pain on swallowing, a temperature of
• Cardiac enzyme levels may be increased in 101° to 104° F [38.3° to 40° C]). Early aware-
severe carditis. ness of these symptoms can help to prevent com-
• Chest X-rays show normal heart size (ex- plications associated with delayed treatment
cept in myocarditis, heart failure, or pericar- such as heart valve damage.
dial effusion). • Urge the patient to avoid people with respi-
• C-reactive protein test is positive (especially ratory tract infections to prevent reinfection.
during the acute phase). • Remind him of the need for additional anti-
• Echocardiography helps evaluate valvular biotics when undergoing dental surgery to
damage, chamber size, and ventricular func- prevent reinfection.
tion. • Arrange for a visiting nurse to oversee
• ECG shows prolonged PR interval in 20% of home care, if necessary, to promote compli-
patients. ance.
NURSING DIAGNOSES Teaching topics

• Activity intolerance • Watching for and reporting signs of heart
• Decreased cardiac output failure
For patients with • Risk for infection • Starting normal activities slowly
rheumatic fever, good • Taking prophylactic antibiotics before un-
dental hygiene is TREATMENT dergoing dental surgery
necessary to prevent • Bed rest (in severe cases) • Understanding the importance of good den-
gingival infection. • Surgery: corrective valvular surgery (in tal hygiene to prevent gingival infection
persistent heart failure)
Drug therapy Thoracic aortic aneurysm

• Antibiotics: erythromycin (Erythrocin),
penicillin (Pfizerpen) Thoracic aortic aneurysm is characterized by
• NSAIDs: aspirin, indomethacin (Indocin) an abnormal widening of the ascending, trans-
verse, or descending part of the aorta. Aneu-
INTERVENTIONS AND RATIONALES rysm of the ascending aorta is the most com-
• Monitor vital signs to detect changes. mon type and is commonly fatal.
• Administer antibiotic as ordered. Be sure to The aneurysm may be:
check for drug hypersensitivity, especially be- • dissecting, a hemorrhagic separation in
fore giving penicillin, to prevent anaphylaxis the aortic wall, usually within the medial layer
and other complications • saccular, an outpouching of the arterial
wall, with a narrow neck
920103.qxd 8/7/08 3:51 PM Page 61
• fusiform, a spindle-shaped enlargement DIAGNOSTIC FINDINGS

encompassing the entire aortic circumfer- • Aortography, the definitive test, shows the
ence. lumen of the aneurysm, its size and location,
Some aneurysms progress to life-threaten- and the false lumen in a dissecting aneurysm.
ing complications such as rupture into the • Blood tests may show low hemoglobin lev-
pericardium, with resulting tamponade. els caused by blood loss from a leaking aneu-
rysm.
CAUSES • Chest X-ray shows widening of the aorta.
• Atherosclerosis • A CT scan confirms that the patient has an
• Congenital disorders such as coarctation of aneurysm and shows its location.
the aorta • ECG helps distinguish a thoracic aneurysm
• Fungal infection of the aortic arch and de- from MI.
scending segments (in an infected aneurysm) • Echocardiography may help identify a dis-
• Hypertension secting aneurysm of the aortic root.
• Syphilis, usually of the ascending aorta (un- • Transesophageal echocardiography is used
common because of antibiotics) to measure an aneurysm in the ascending and
• Trauma, usually of the descending thoracic descending aorta.
aorta, from an accident that shears the aorta
transversely (acceleration-deceleration in- NURSING DIAGNOSES
juries) • Decreased cardiac output
• Ineffective breathing pattern
DATA COLLECTION FINDINGS • Acute pain
Ascending aneurysm
• Bradycardia TREATMENT
• Pain (described as severe, penetrating, and • Surgery: resection of aneurysm with a
ripping; extends to the neck, shoulders, lower Dacron or Teflon graft replacement, possible
back, or abdomen) replacement of aortic valve
• Pericardial friction rub caused by a hemo- • Blood product administration if the aneu-
pericardium rysm is leaking or ruptures
• Unequal intensities of the right carotid and • I.V. fluid administration
left radial pulses • Oxygen therapy and possibly ET intubation
• Hypertension followed by hypotension (if and mechanical ventilation
rupture occurs) • Sequential compression device after
surgery
Descending aneurysm
• Pain (described as sharp and tearing, usual- Drug therapy
ly starting suddenly between the shoulder • Analgesic: morphine
blades and possibly radiating to the chest) • Antihypertensives: nitroprusside (Nitro-
• Hypertension followed by hypotension (if press), labetalol (Normodyne)
rupture occurs) • Negative inotropic agent: propranolol (In-
deral)
Transverse aneurysm
• Dry cough INTERVENTIONS AND RATIONALES
• Dyspnea • Monitor the patient’s blood pressure to de-
• Dysphagia tect deficient fluid volume.
• Hoarseness • Evaluate pain, breathing, and carotid, radial,
• Pain (described as sharp and tearing; radi- and femoral pulses to detect early signs of
ates to the shoulders) aneurysm rupture.
• Hypertension followed by hypotension (if • Monitor cardiovascular status to detect com-
rupture occurs) plications.
• Monitor ECG to detect arrhythmias and is-
chemia.
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• Insert an indwelling urinary catheter to tions associated with ineffective blood pressure
monitor fluid status. management.
• Maintain I.V. lines with normal saline or • Throughout hospitalization, offer the pa-
lactated Ringer’s solution to help prevent hypo- tient and his family psychological support to
tension and correct fluid volume deficit. relieve anxiety and feelings of helplessness.
• When bleeding from an aneurysm is sus-
pected, give a whole-blood transfusion to ade- Teaching topics
quately replace lost fluid. • Monitoring blood pressure to prevent or
• Explain diagnostic tests. If surgery is sched- control hypertension
uled, explain the procedure and expected • Modifying risk factors by beginning a
postoperative care (I.V. lines, ET and drain- smoking-cessation program, if appropriate
age tubes, cardiac monitoring, and ventila-
tion) to alleviate the patient’s anxiety.
• Monitor pulse oximetry values to detect hy- Thrombophlebitis
poxia.
Thrombophlebitis is marked by inflammation
After repair of thoracic aneurysm of the venous wall and thrombus formation. It
• Monitor cardiovascular status to detect may affect deep veins or superficial veins.
changes. The thrombus may occlude a vein or detach
• Monitor ECG to detect arrhythmias. and embolize to the lungs.
• Evaluate the patient’s LOC. Monitor vital
signs, pulse rate, urine output, and pain to CAUSES
guide treatment regimen and evaluate its effec- • Hypercoagulability (from cancer, blood
tiveness. dyscrasias, or hormonal contraceptives)
• Check respiratory function. Carefully ob- • Injury to the venous wall (from I.V. injec-
serve and record the type and amount of tions, fractures, or antibiotics)
chest tube drainage, and frequently assess • Venous stasis (from varicose veins, preg-
heart and breath sounds to detect early signs of nancy, heart failure, or prolonged bed rest)
compromise.
• Monitor I.V. therapy to prevent fluid excess, DATA COLLECTION FINDINGS
Thrombus which may occur with rapid fluid replace- Deep vein thrombophlebitis
formation is typically ment. • Cramping calves
caused by • Give medications, as appropriate, to help im- • Edema
hypercoagulability,
prove the patient’s condition. • Tenderness to touch
endothelial damage,
and venous stasis. • Watch for signs of infection, especially
This is called fever, and excessive wound drainage to initi- Superficial vein thrombophlebitis
Virchow’s triad. ate treatment promptly and prevent complica- • Redness along the vein
tions such as sepsis. • Warmth and tenderness along the vein
• Assist with range-of-motion exercises of the
legs to prevent thromboembolism caused by DIAGNOSTIC FINDINGS
venostasis during prolonged bed rest. • Hematology results reveal increased WBC
• Encourage the patient to turn, cough, and count.
breathe deeply to promote lung expansion. • Photoplethysmography shows venous-filling
• Help the patient walk to prevent pneumonia, defects.
thromboembolism, and other complications of • Ultrasound reveals decreased blood flow.
immobility. • Venography shows venous-filling defects.
• Before the patient is discharged, educate
him on the importance of antihypertensive NURSING DIAGNOSES
drugs and potential adverse reactions. • Acute pain
• Teach the patient how to monitor his blood • Impaired skin integrity
pressure to prevent stroke and other complica- • Ineffective tissue perfusion: Peripheral
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TREATMENT Teaching topics

• Activity changes: maintaining bed rest and • Recognizing signs and symptoms of bleed-
elevating the affected extremity ing and clot formation
• Embolectomy and insertion of a vena cava • Avoiding prolonged sitting or standing, con-
umbrella or filter strictive clothing, and crossing the legs when
• Antiembolism stockings seated
• Warm, moist compresses • Avoiding hormonal contraceptives
Drug therapy
• Anticoagulants: warfarin (Coumadin), hep- Valvular heart disease
arin, dalteparin (Fragmin), enoxaparin
(Lovenox) In valvular heart disease, three types of me-
• Antiplatelet aggregation agent: aspirin chanical disruption can occur: stenosis, or
• Fibrinolytic agent: streptokinase (Streptase) narrowing, of the valve opening; incomplete
closure of the valve; or prolapse of the valve.
INTERVENTIONS AND RATIONALES These conditions can result from such disor- Three types of
• Monitor breathing pattern and breath ders as endocarditis (most common), congen- mechanical disruption
sounds. Crackles, dyspnea, tachypnea, hemopt- ital defects, and inflammation. They can also can affect heart
ysis, and chest pain suggest pulmonary em- lead to heart failure. valves: stenosis of the
bolism. Valvular heart disease occurs in several valve opening;
incomplete closure of
• Evaluate cardiovascular status. Tachycardia forms. The most common include:
the valve; and valve
and chest pain may indicate pulmonary em- • aortic insufficiency, in which blood flows prolapse.
bolism. back into the left ventricle during diastole,
• Observe for bleeding due to anticoagulant causing fluid overload in the ventricle, which
therapy. dilates and hypertrophies (the excess volume
• Monitor and record vital signs. Watch for causes fluid overload in the left atrium and, fi-
such complications as hypotension, tachycar- nally, the pulmonary system; eventually, it
dia, tachypnea, and restlessness. Observe for causes left ventricular failure and pulmonary
bruising, epistaxis, blood in stool, bleeding edema)
gums, and painful joints. Tachypnea and tachy- • mitral insufficiency, in which blood from
cardia may suggest pulmonary embolism or he- the left ventricle flows back into the left atri-
morrhage. um during systole, causing the atrium to en-
• Perform neurovascular checks to detect large to accommodate the backflow (as a re-
nerve or vascular damage. sult, the left ventricle also dilates to accommo-
• Monitor laboratory values. PTT in a patient date the increased volume of blood from the
taking heparin and PT in a patient receiving atrium and to compensate for diminishing car-
warfarin should be 11⁄2 to 2 times the control. diac output)
INR should be 2 to 3 for the patient receiving • mitral stenosis, in which narrowing of the
warfarin. A falling hemoglobin level and hema- valve caused by valvular abnormalities, fibro-
tocrit indicate blood loss. sis, or calcification obstructs blood flow from
• Keep the patient in bed and elevate the af- the left atrium to the left ventricle (conse-
fected extremity to promote venous return and quently, left atrial volume and pressure rise
reduce swelling. and the chamber dilates)
• Administer medications, as prescribed, to • mitral valve prolapse (MVP), in which
control or dissolve blood clots. one or both valve leaflets protrude into the
• Apply warm, moist compresses to improve left atrium (MVP syndrome is the term used
circulation to the affected area and relieve pain when the anatomic prolapse assessment find-
and inflammation. ings aren’t related to the valvular abnormal-
• Measure and record the circumference of ity)
thighs and calves. Compare the measure- • tricuspid insufficiency, in which blood
ments to determine worsening inflammation in flows back into the right atrium during sys-
the affected leg. tole, decreasing blood flow to the lungs and
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left side of the heart (cardiac output also • Palpitations

lessens; fluid overload in the right side of the • Peripheral edema
heart can eventually lead to right-sided heart • Weakness
failure)
MVP
CAUSES • Chest pain
Aortic insufficiency • Fatigue
• Endocarditis • Headache
• Hypertension • May produce no symptoms
• Idiopathic origin • Palpitations
• Rheumatic fever
• Syphilis Tricuspid insufficiency
• Dyspnea
Mitral insufficiency • Fatigue
• Hypertrophic cardiomyopathy • Peripheral edema
• Left ventricular failure
• MVP DIAGNOSTIC FINDINGS
• Rheumatic fever Aortic insufficiency
• Cardiac catheterization results show reduc-
Mitral stenosis tion in arterial diastolic pressures.
• Rheumatic fever • Echocardiography shows left ventricular en-
largement.
MVP • ECG shows sinus tachycardia and left ven-
• Unknown tricular hypertrophy.
• MI involving papillary muscles • Chest X-ray shows left ventricular enlarge-
ment and pulmonary vein congestion.
Tricuspid insufficiency
• Endocarditis Mitral insufficiency
• Rheumatic fever • Cardiac catheterization shows mitral regur-
• Right-sided heart failure gitation and elevated atrial and pulmonary
• Trauma artery wedge pressures.
• Echocardiography shows abnormal valve
Don’t lose your DATA COLLECTION FINDINGS leaflet motion.
motivation in the Aortic insufficiency • ECG may show left atrial and ventricular hy-
middle of your exam • Angina pertrophy.
preparation. It’s • Cough • Chest X-ray shows left atrial and ventricular
important to keep a
• Dyspnea enlargement.
positive attitude for
the long haul. • Fatigue
• Palpitations Mitral stenosis
• Rapidly rising and collapsing pulses • Cardiac catheterization shows diastolic
pressure gradient across the valve and elevat-
Mitral insufficiency ed left atrial and pulmonary artery wedge
• Angina pressures.
• Dyspnea • Echocardiography shows thickened mitral
• Fatigue valve leaflets.
• Orthopnea • ECG shows left atrial hypertrophy.
• Peripheral edema • Chest X-ray shows left atrial and ventricular
enlargement.
Mitral stenosis
• Dyspnea on exertion MVP
• Fatigue • Color-flow Doppler studies show mitral in-
• Orthopnea sufficiency.
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Pump up on practice questions 65
• ECG shows prolapse of the mitral valve into Teaching topics

the left atrium. • Following diet restrictions and medication
schedule
Tricuspid insufficiency • Understanding the need for consistent
• Echocardiography shows systolic prolapse follow-up care
of the tricuspid valve. • Incorporating rest into the daily routine
• ECG shows right atrial or right ventricular
hypertrophy.
• Chest X-ray shows right atrial dilation and
right ventricular enlargement.
NURSING DIAGNOSES
• Activity intolerance
• Anxiety
TREATMENT
• Diet: sodium restriction (in heart failure)
• Surgery: open-heart surgery using car-
diopulmonary bypass for valve replacement
(in severe cases) Pump up on practice
Drug therapy
• Anticoagulant: warfarin (Coumadin) to pre-
questions
vent thrombus formation around diseased or 1. After undergoing cardiac catheterization, a
replaced valves client has a 10-lb sandbag resting over the left
femoral insertion site. When the nurse re-
INTERVENTIONS AND RATIONALES moves the sandbag, she observes a swelling
• Watch closely for signs of heart failure or at the site, about 2⬙ (5 cm) in diameter. The
pulmonary edema and for adverse effects of nurse should initially:
drug therapy to prevent cardiac decompensa- 1. replace the 10-lb bag with a 15-lb sand-
tion. bag for additional pressure.
• Observe breathing patterns to detect respi- 2. place a pressure dressing over the site
ratory distress or signs of heart failure. and elevate the left leg at least 45 degrees.
• Place the patient in an upright position to re- 3. draw a stat partial thromboplastin time
lieve dyspnea. and stop any heparin infusions.
• Maintain bed rest and provide assistance 4. apply firm pressure to the site and in-
with bathing, if necessary, to decrease oxygen struct another staff member to notify the
demands on the heart. physician.
• If the patient undergoes surgery, watch for Answer: 4. The client has likely developed a
hypotension, arrhythmias, and thrombus for- hematoma from bleeding at the femoral punc-
mation. Monitor vital signs, intake and output, ture site. The bleeding must be stopped, so
daily weight, blood chemistry test results, and the nurse should apply pressure to the site
chest X-rays to detect early signs of postopera- and notify the physician. At some point, a
tive complications and ensure early interven- heavier sandbag may be indicated but not in
tion and treatment. lieu of direct pressure. The leg should be neu-
• Allow the patient to verbalize his concerns tral, not elevated. Monitoring coagulation is a
about being unable to meet demands of daily concern to be considered later.
life because of activity restrictions. This helps
to reduce anxiety.
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Client needs category: Physiological genation and reducing cardiac workload. Con-
integrity firming the diagnosis of MI, preventing com-
Client needs subcategory: Reduction of plications, reducing anxiety, relieving pain,
risk potential and providing a nondemanding environment
Cognitive level: Application are secondary interventions. Stressors can be
reduced but not eliminated.
2. A client is prescribed diltiazem (Cardizem) Client needs category: Physiological
to manage his hypertension. The nurse integrity
should tell the client the diltiazem will: Client needs subcategory: Reduction of
1. lower his blood pressure only. risk potential
2. lower his heart rate and blood pres- Cognitive level: Analysis
sure.
3. lower his blood pressure and increase 4. A 42-year-old man with a history of two MI
his urine output. incidents is diagnosed with acute pulmonary
4. lower his heart rate and blood pressure edema. He has severe dyspnea with noisy,
and increase his urine output. wet respirations. The nurse’s initial action
Answer: 2. Diltiazem (Cardizem), a calcium should be to:
channel blocker, will reduce both the heart 1. place the client in high Fowler’s posi-
rate and blood pressure. It doesn’t directly af- tion.
fect urine output. 2. perform nasotracheal suctioning to re-
Client needs category: Physiological lieve congestion.
integrity 3. determine the cause of the attack.
Client needs subcategory: Pharmaco- 4. monitor cardiac rhythm.
logical therapies Answer: 1. High Fowler’s position reduces ve-
Cognitive level: Comprehension nous congestion and eases dyspnea. Suction-
ing isn’t a priority. After the client is stabi-
lized, further assessments can be made to de-
termine the cause of the attack. Although
appropriate, cardiac monitoring isn’t the
nurse’s priority in this situation.
Client needs category: Safe, effective
care environment
Client needs subcategory: Coordinated
care
Cognitive level: Application
5. A client with unstable angina receives rou-

3. A client reports substernal chest pain. Test tine applications of nitroglycerin ointment.
results show electrocardiographic changes The nurse should delay the next dose if the
and an elevated cardiac troponin level. What client has:
should be the focus of nursing care? 1. atrial fibrillation.
1. Improving myocardial oxygenation and 2. a systolic blood pressure below
reducing cardiac workload 90 mm Hg.
2. Confirming a suspected diagnosis and 3. a headache.
preventing complications 4. skin redness at the current site.
3. Reducing anxiety and relieving pain Answer: 2. Nitroglycerin is a vasodilator and
4. Eliminating stressors and providing a can lower arterial blood pressure. As a rule,
nondemanding environment when the client’s systolic blood pressure is
Answer: 1. The client is exhibiting clinical below 90 mm Hg, the nurse should delay the
signs and symptoms of an MI. Nursing care dose and notify the physician. Nitroglycerin
should focus on improving myocardial oxy- isn’t contraindicated in a client with atrial fib-
920103.qxd 8/7/08 3:51 PM Page 67
rillation. Headache, a common occurrence tion should the nurse perform every day be-
with nitroglycerin, can be treated with an fore administering the medication?
analgesic and isn’t a cause for withholding a 1. Check the client’s weight.
dose. Sites should be changed with each 2. Check the client’s apical heart rate.
dose, especially if skin irritation occurs. 3. Ask the client whether he’s experienc-
Client needs category: Physiological ing any numbness.
integrity 4. Provide the client with extra fluids.
Client needs subcategory: Pharmaco- Answer: 1. Heart failure develops because the
logical therapies heart can’t move blood as quickly as it should.
Cognitive level: Application This decreases urine output and increases
weight. Therefore, the client should be
weighed daily. Checking the client’s apical
heart rate isn’t indicated before administering
furosemide. Clients may have numbness in
the extremities because of increased periph-
eral edema, but numbness doesn’t inhibit the
administration of the medication. The nurse
shouldn’t provide the client with extra fluids
because clients with heart failure are com-
monly on fluid restrictions.
Client needs category: Physiological
integrity
Client needs subcategory: Reduction of
risk potential
6. A male client has been admitted to the Cognitive level: Application
coronary care unit to rule out MI. Which
symptoms during the health interview would 8. A client who is 70 lb (31.8 kg) overweight
indicate that he may be developing an MI? has started taking medication for essential hy-
1. Epigastric pain and heartburn pertension. Desired goals for this client
2. Fatigue and headache should include:
3. Diaphoresis and substernal pain 1. checking his blood pressure every 3
4. Dizziness and nausea months.
Answer: 3. Diaphoresis and substernal or radi- 2. maintaining a weight-reduction diet and
ating chest pain are classic signs of an MI. losing 2 lb (0.9 kg) each week.
Epigastric pain and heartburn are more in- 3. following a strict weight-reduction diet
dicative of indigestion or esophagitis. Fatigue until he has lost at least 30 lb
and headache typically aren’t reported in (13.6 kg).
clients with MI. Although dizziness and nau- 4. maintaining a high-fiber diet.
sea may accompany MI, they aren’t common Answer: 2. The most effective weight-loss
symptoms. campaign is one that is gradual and changes
Client needs category: Physiological eating habits. A moderate weight-reduction
integrity diet that aims for a weight loss of 2 lb per
Client needs subcategory: Physio- week is best for an overweight client with
logical adaptation essential hypertension. The client’s blood
Cognitive level: Comprehension pressure should be checked more than once
every 3 months. A strict weight-reduction diet
7. A 65-year-old client is admitted for heart isn’t as effective as a slow, gradual decrease in
failure. The physician orders daily administra- weight. Maintaining a high-fiber diet won’t
tion of furosemide (Lasix). Which interven- control blood pressure.
920103.qxd 8/7/08 3:51 PM Page 68
Client needs category: Health pro- Client needs subcategory: Pharmaco-

motion and maintenance logical therapies
Client needs subcategory: None Cognitive level: Application
10. A client comes into the emergency de-
9. A nurse administers warfarin (Coumadin) partment with a dissecting aortic aneurysm.
to a client with deep vein thrombophlebitis. The client is at greatest risk for:
Which of the following laboratory values indi- 1. septic shock.
cates that the client has a therapeutic level of 2. anaphylactic shock.
warfarin? 3. cardiogenic shock.
1. PTT 11⁄2 to 2 times the control 4. hypovolemic shock.
2. PT 2 to 3 times the control Answer: 4. A dissecting aortic aneurysm is a
3. INR of 2 to 3 precursor to aortic rupture, which leads to
4. Hematocrit of 32% hemorrhage and hypovolemic shock. Septic
Answer: 3. Warfarin is at a therapeutic level shock results from an uncontrolled infection.
when the INR is 2 to 3. Values greater than Anaphylactic shock results from exposure to
this increase the risk of bleeding and hemor- an allergen. Cardiogenic shock results from
rhage; lower values increase the risk of blood cardiac damage.
clot formation. Heparin, not warfarin, pro- Client needs category: Physiological
longs PTT. PT may also be used to determine integrity
whether warfarin is at a therapeutic level; PT Client needs subcategory: Reduction of
at 11⁄2 to 2 times the control is considered risk potential
therapeutic. Hematocrit doesn’t provide infor- Cognitive level: Comprehension
mation on the effectiveness of warfarin. On
the other hand, a falling hematocrit in a client
taking warfarin may be a sign of hemorrhage.
integrity
Congrats! You
finished the chapter.
My advice: Take a
break to exercise your
body and give your
mind a rest.
920104.qxd 8/7/08 3:52 PM Page 69
4 Respiratory
system
If you can read this aloud, thank
In this chapter,
you’ll review:
Brush up on key your larynx
The lar ynx, also known as the voice box, con-
✐ components of the concepts nects the upper and lower airways. It contains
vocal cords, which produce sounds. The lar-
respiratory system
and their function The major function of the respiratory system ynx also initiates the cough reflex, which is
is gas exchange. During gas exchange, air is one part of the respiratory system’s defense
taken into the body through inhalation and mechanisms.
nose respiratory dis-
travels through respiratory passages to the
orders lungs. In the lungs, oxygen (O2) takes the C-shaped connector
✐ common respiratory place of carbon dioxide (CO2) in the blood. The trachea contains C-shaped cartilaginous
disorders. The carbon dioxide is then expelled from the rings composed of smooth muscle. It con-
body through exhalation. nects the larynx to the bronchi.
At any time, you can review the major points
of this chapter by consulting the Cheat sheet Branching into bronchi
on pages 70 to 77. The trachea branches into the right and left
bronchi, which are the large air passages
Enter here that lead to the right and left lungs. The right
The nose and mouth allow air to flow in and main bronchus is slightly larger and more
out of the body. They also humidify inhaled vertical than the left.
air, which reduces irritation of the mucous As they pass into the lungs, the bronchi
Because the major membranes. The nares (nostrils) contain ol- form smaller branches called bronchioles,
function of the factory receptor sites and provide the body’s which themselves branch into terminal bron-
respiratory system is sense of smell. chioles and alveoli.
gas exchange, focus
on keeping airways Keep out! Gas exchange center
clear and facilitating The paranasal sinuses are air-filled, cilia- Alveoli are clustered microscopic sacs en-
breathing. lined cavities within the nose. Their function veloped by capillaries. Exchange and diffu-
is to trap particles of foreign matter that sion of gases in the lungs takes place over
might interfere with the respiratory system the approximately 3 million alveoli and the
or cause infection. alveolar capillary membranes. The alveoli
also contain a coating of surfactant, which re-
Going down duces surface tension and keeps them from
The phar ynx serves as a passageway to the collapsing.
digestive and respiratory tracts. It maintains
air pressure in the middle ear. It also contains Lobes: 3 and 2
a mucosal lining that continues the process of As a unit, the lungs are composed of three
humidifying and warming inhaled air in addi- lobes on the right side and two lobes on the
tion to trapping foreign particles. left side. The lungs regulate air exchange by a
concentration gradient. In the alveoli, gases
(Text continues on page 77.)
920104.qxd 8/7/08 3:52 PM Page 70
70 Respiratory system
et
heat she
C
Respiratory refresher
ACUTE RESPIRATORY DISTRESS SYNDROME Key test results
Key signs and symptoms • ABG levels show hypoxemia, acidosis, alkalo-
• Anxiety, restlessness sis, and hypercapnia.
• Crackles, rhonchi, decreased breath sounds Key treatments
• Dyspnea, tachypnea • Supplemental oxygen (O2) therapy, intubation,
Key test results and mechanical ventilation (possibly with PEEP)
• Arterial blood gas (ABG) levels show respirato- • Analgesic: morphine
ry acidosis, metabolic acidosis, and hypoxemia • Antianxiety agent: lorazepam (Ativan)
that doesn’t respond to increased fraction of in- • Bronchodilators: terbutaline (Brethine), amino-
spired oxygen. phylline (Phyllocontin); via nebulizer: albuterol
• Chest X-ray shows bilateral infiltrates (in early (Proventil), ipratropium (Atrovent), metapro-
stages), lung fields with a “ground-glass” ap- terenol (Alupent)
pearance and, with irreversible hypoxemia, mas- • Neuromuscular blocking agents: pancuronium
sive consolidation of both lung fields (in later (Pavulon), vecuronium (Norcuron), atracurium
stages). (Tracrium)
Key treatments • Steroids: hydrocortisone (Solu-Cortef), methyl-
prednisolone (Solu-Medrol)
• Intubation and mechanical ventilation using
positive end-expiratory pressure (PEEP) or Key interventions
pressure-controlled inverse ratio ventilation • Monitor respiratory status.
• Antibiotics most effective in treating causative • Administer O2.
organism • Provide suctioning; assist with turning, cough-
• Analgesic: morphine ing, and deep breathing; and perform chest phys-
• Neuromuscular blocking agents: pancuronium iotherapy and postural drainage.
(Pavulon), vecuronium (Norcuron) • Maintain bed rest.
• Steroids: hydrocortisone (Solu-Cortef), methyl- ASBESTOSIS
prednisolone (Solu-Medrol)
Key interventions
• Dry crackles at lung bases
• Monitor respiratory, cardiovascular, and neuro- • Dry cough
logic status. • Dyspnea on exertion (usually first symptom)
• Monitor electrocardiogram (ECG). • Pleuritic chest pain
• Maintain bed rest, with alternating supine and
Key test results
prone positioning if possible.
• Perform turning, chest physiotherapy, and pos- • Chest X-rays show fine, irregular, and linear dif-
tural drainage. fuse infiltrates; extensive fibrosis results in a
“honeycomb” or “ground-glass” appearance.
ACUTE RESPIRATORY FAILURE X-rays may also show pleural thickening and cal-
Key signs and symptoms cification, with bilateral obliteration of costo-
• Decreased respiratory excursion, accessory phrenic angles and, in later stages, an enlarged
muscle use, retractions heart with a classic “shaggy” heart border.
• Difficulty breathing, dyspnea (shortness of Key treatments
breath), tachypnea, orthopnea • Chest physiotherapy
• Fatigue • Fluid intake up to 3,000 ml/day
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Respiratory refresher (continued)

ASBESTOSIS (continued) Key test results
• O2 therapy or mechanical ventilation (with advanced cases) • Pulmonary function tests (PFTs) during attacks show de-
• Antibiotics most effective in treating causative organism (for creased forced expiratory volumes that improve with therapy,
treatment of respiratory tract infections) increased residual volume, and increased total lung capacity.
• Mucolytic inhalation therapy: acetylcysteine (Mucomyst) Key treatments
Key interventions • Fluid intake up to 3,000 ml/day as tolerated
• Perform chest physiotherapy techniques, such as controlled • Beta-adrenergic drugs: epinephrine (Adrenalin), salmeterol
coughing and segmental bronchial drainage, with chest percus- (Serevent), formoterol (Foradil)
sion and vibration. • Bronchodilators: terbutaline (Brethine), aminophylline (Phyllo-
• Administer O2 by cannula or mask (1 to 2 L/minute). Use me- contin), theophylline (Theo-Dur); via nebulizer: albuterol (Proven-
chanical ventilation if arterial oxygen saturation can’t be main- til), ipratropium (Atrovent), metaproterenol (Alupent)
tained above 40 mm Hg. • Mast cell stabilizer: cromolyn (Intal), nedocromil (Tilade)
• Anti-immunoglobulin E agent: omalizumab (Xolair)
ASPHYXIA
Key interventions
• Administer low-flow humidified O2.
• Agitation
• Monitor respiratory status and pulse oximetry values.
• Altered respiratory rate (apnea, bradypnea, occasionally
• Keep the patient in high Fowler’s position.
tachypnea)
• Anxiety ATELECTASIS
• Central and peripheral cyanosis (cherry-red mucous mem- Key signs and symptoms
branes in late-stage carbon monoxide poisoning) • Diminished or bronchial breath sounds
• Altered mental status • Dyspnea
• Decreased breath sounds • Low-grade fever
• Dyspnea In severe cases
Key test results • Anxiety
• Pulse oximetry reveals decreased oxygen saturation. • Cyanosis
• ABG measurement indicates decreased partial pressure of ar- • Diaphoresis
terial oxygen (PaO2) < 60 mm Hg and increased partial pressure • Severe dyspnea
of arterial carbon dioxide (PaCO2) > 50 mm Hg. • Substernal or intercostal retractions
Key treatments • Tachycardia
• O2 therapy, which may include endotracheal (ET) intubation Key test results
and mechanical ventilation • Chest X-ray shows characteristic horizontal lines in the lower
• Bronchoscopy (for extraction of a foreign body) lung zones and, with segmental or lobar collapse, characteristic
• Opioid antagonist: naloxone (Narcan) (for opioid overdose) dense shadows often associated with hyperinflation of neigh-
Key interventions boring lung zones (in widespread atelectasis).
• Monitor cardiac and respiratory status. Key treatments
• Position the patient upright, if he can tolerate it. • Bronchoscopy
• Suction carefully, as needed, and encourage deep breathing. • Chest physiotherapy
• Bronchodilators: albuterol (Proventil)
ASTHMA
• Mucolytic inhalation therapy: acetylcysteine (Mucomyst)
Key signs and symptoms • Pain control
• Usually produces no symptoms between attacks Key interventions
• Wheezing, primarily on expiration but sometimes on inspiration
• Encourage postoperative and other high-risk patients to cough
and deep breathe every hour during their waking hours.
(continued)
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ATELECTASIS (continued) • Increased sputum production
• Postoperatively, teach the patient to hold a pillow tightly over • Productive cough
the incision while deep breathing or moving. Gently reposition Key test results
these patients often, and help them walk as soon as possible. • Chest X-ray shows hyperinflation and increased bronchovas-
• Administer adequate analgesics. cular markings.
• Teach the patient how to use an incentive spirometer, and en- • PFTs may reveal increased residual volume, decreased vital
courage him to use it hourly during his waking hours. capacity and forced expiratory volumes, and normal static com-
• Humidify inspired air, and encourage adequate fluid intake. pliance and diffusion capacity.
Perform postural drainage and chest percussion.
Key treatments
• Monitor breath sounds and ventilatory status frequently, and
• Fluid intake up to 3,000 ml/day, if not contraindicated by other
be alert for any changes.
conditions
BRONCHIECTASIS • Intubation and mechanical ventilation, if respiratory status de-
Key signs and symptoms teriorates
• Chronic cough that produces copious, foul-smelling, mucopu- • Antibiotics most effective in treating causative organism
rulent secretions, possibly totaling several cupfuls daily • Bronchodilators: terbutaline (Brethine), aminophylline (Phyllo-
• Coarse crackles during inspiration over involved lobes or seg- contin), theophylline (Theo-Dur); via nebulizer: albuterol (Proven-
ments til), ipratropium (Atrovent), metaproterenol (Alupent)
• Dyspnea • Influenza and Pneumovax vaccines
• Hemoptysis • Steroids: hydrocortisone (Solu-Cortef), methylprednisolone
• Weight loss (Solu-Medrol)
• Steroids (via nebulizer): beclomethasone (Vanceril), triamci-
Key test results
nolone (Azmacort)
• Chest X-rays show peribronchial thickening, areas of atelecta-
sis, and scattered cystic changes. Key interventions
• Sputum culture and Gram stain identify predominant organ- • Administer low-flow O2.
isms. • Monitor respiratory status and pulse oximetry values.
• Assist with diaphragmatic and pursed-lip breathing.
Key treatments
• Monitor and record the color, amount, and consistency of
• Bronchoscopy (to mobilize secretions)
sputum.
• Chest physiotherapy
• Provide chest physiotherapy, postural drainage, incentive
• O2 therapy
spirometry, and suction.
• Antibiotics most effective in treating the causative organism
• Bronchodilator: albuterol (Proventil) COR PULMONALE
Key interventions Key signs and symptoms
• Monitor respiratory status and pulse oximetry values. • Dyspnea on exertion
• Provide supportive care and help the patient adjust to the per- • Edema
manent changes in lifestyle that irreversible lung damage makes • Fatigue
necessary. • Orthopnea
• Perform chest physiotherapy, including postural drainage and • Tachypnea
chest percussion designed for involved lobes, several times a • Weakness
day. The best times to do this are early morning and just before Key test results
bedtime. Instruct the patient to maintain each position for • ABG analysis shows decreased PaO2 (< 70 mm Hg).
10 minutes. Then perform percussion and tell him to cough. • Chest X-ray shows large central pulmonary arteries and sug-
CHRONIC BRONCHITIS gests right ventricular enlargement by rightward enlargement of
cardiac silhouette on an anterior chest film.
• Cyanosis
• Dyspnea
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COR PULMONALE (continued) • O2 therapy at 2 to 3 L/minute, transtracheal therapy for home
• Pulmonary artery pressure measurements show increased O2 therapy
right ventricular and pulmonary artery pressures because of in- • Antibiotics most effective in treating causative organism
creased pulmonary vascular resistance. • Bronchodilators: terbutaline (Brethine), aminophylline (Phyllo-
Key treatments contin), theophylline (Theo-Dur); via nebulizer: albuterol (Proven-
• O2 therapy as necessary by mask or cannula in concentrations til), ipratropium (Atrovent), metaproterenol (Alupent)
of 24% to 40%, depending on PaO2 and, in acute cases, mechani- • Influenza and Pneumovax vaccines
cal ventilation • Steroids: hydrocortisone (Solu-Cortef), methylprednisolone
• Cardiac glycoside: digoxin (Lanoxin) (Solu-Medrol)
• Diuretic (to reduce edema): furosemide (Lasix) • Steroids (via nebulizer): beclomethasone (Vanceril), triamci-
• Vasodilators: diazoxide (Proglycem), hydralazine (Apresoline), nolone (Azmacort)
nitroprusside (Nipride), prostaglandins (in primary pulmonary Key interventions
hypertension) • Monitor respiratory status and pulse oximetry values.
• Calcium channel blocker: diltiazem (Cardizem) • Assist with diaphragmatic and pursed-lip breathing.
• Angiotensin-converting enzyme inhibitor: captopril (Capoten) • Monitor and record the color, amount, and consistency of
Key interventions sputum.
• Monitor respiratory status and pulse oximetry values. • Perform chest physiotherapy, postural drainage, incentive
• Monitor cardiovascular status. spirometry, and suction.
• Limit the patient’s fluid intake to 1,000 to 2,000 ml/day, and pro- LEGIONNAIRES’ DISEASE
vide a low-sodium diet. Key signs and symptoms
• Reposition bedridden patients often.
• Cough, initially nonproductive, that eventually produces gray-
• Provide meticulous respiratory care, including O2 therapy and,
ish, nonpurulent, blood-streaked sputum
for patients with chronic obstructive pulmonary disease, teach
• Fever
pursed-lip breathing exercises.
• Generalized weakness
• Watch for signs of respiratory failure, such as a change in
• Malaise
pulse rate, increased fatigue from exertion, and deep, labored
• Recurrent chills
respirations.
Key test results
EMPHYSEMA • Chest X-ray shows patchy, localized infiltration, which pro-
Key signs and symptoms gresses to multilobar consolidation (usually involving the lower
• Barrel chest lobes), pleural effusion and, in fulminant disease, opacification
• Dyspnea of the entire lung.
• Pursed-lip breathing • Direct immunofluorescence of Legionella pneumophila and
Key test results indirect fluorescent serum antibody testing compare findings
• Chest X-ray of patients in an advanced disease stage reveals a from initial blood studies with findings from those done at least
flattened diaphragm, reduced vascular markings in the lung pe- 3 weeks later. A convalescent serum sample showing a fourfold
riphery, enlarged anteroposterior chest diameter, and a vertical or greater rise in antibody titer for L. pneumophila confirms the
heart. diagnosis.
• PFTs show increased residual volume, total lung capacity, and Key treatments
compliance as well as decreased vital capacity, diffusing ca- • Antibiotics: erythromycin (Erythrocin), rifampin (Rifadin), tetra-
pacity, and expiratory volumes. cycline (Achromycin V)
Key treatments • Antipyretics: acetaminophen (Tylenol), aspirin
• Chest physiotherapy, postural drainage, and incentive spirom- Key interventions
etry • Closely monitor the patient’s respiratory status. Evaluate chest
• Fluid intake up to 3,000 ml/day, if not contraindicated by heart wall expansion, depth and pattern of respirations, cough, and
failure chest pain.
(continued)
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LEGIONNAIRES’ DISEASE (continued) – ratio of LD in pleural fluid to LD in serum greater than 0.6 (in
• Monitor the patient’s vital signs, pulse oximetry values, level of exudative effusions)
consciousness, and dryness and color of the lips and mucous – acute inflammatory white blood cells and microorganisms (in
membranes. Watch for signs of shock (decreased blood pres- empyema).
sure, thready pulse, diaphoresis, clammy skin). Key treatments
• Administer I.V. fluids. • Supplemental O2 therapy
• Provide respiratory therapy as needed. • Thoracentesis to remove fluid
• Give antibiotics as necessary, and observe carefully for ad- • Thoracotomy if thoracentesis isn’t effective
verse effects. • Antibiotics most effective in treating the organism that causes
LUNG CANCER empyema
Key signs and symptoms Key interventions
• Cough, hemoptysis • Explain thoracentesis to the patient. Before the procedure, tell
• Weight loss, anorexia the patient to expect a stinging sensation from the local anes-
thetic and a feeling of pressure when the needle is inserted.
Key test results
• Instruct the patient to tell you immediately if he feels uncom-
• Chest X-ray shows lesion or mass.
fortable or has trouble breathing during the procedure.
Key treatments • Administer O2.
• Resection of the affected lobe (lobectomy) or lung (pneu- • Administer antibiotics.
monectomy) • Provide chest tube care carefully to prevent dislodging the
• Antineoplastics: cyclophosphamide (Cytoxan), doxorubicin chest tube.
(Adriamycin), cisplatin (Platinol), vincristine (Oncovin), vinorel- • Ensure chest tube patency by watching for bubbles in the un-
bine (Navelbine), gemcitabine (Gemzar), paclitaxel (Taxol), doc- derwater seal chamber.
etaxel (Taxotere), irinotecan (Camptosar) • Record the amount, color, and consistency of any tube
Key interventions drainage.
• Monitor the patient’s pain level, and administer analgesics as
PLEURISY
prescribed.
• Perform suctioning, and assist with turning, coughing, and Key signs and symptoms
deep breathing. • Pleural friction rub (a coarse, creaky sound heard during late
• Monitor for bleeding, infection, and electrolyte imbalance inspiration and early expiration)
caused by effects of chemotherapy. • Sharp, stabbing pain that increases with respiration
Key test results
PLEURAL EFFUSION AND EMPYEMA
• Although diagnosis generally rests on the patient’s history and
Key signs and symptoms respiratory assessment, diagnostic tests help rule out other
• Decreased breath sounds causes and pinpoint the underlying disorder.
• Dyspnea Key treatments
• Fever
• Bed rest
• Pleuritic chest pain
• Analgesic: acetaminophen with oxycodone (Percocet)
Key test results • Anti-inflammatory: indomethacin (Indocin)
• Chest X-ray shows radiopaque fluid in dependent regions. Key interventions
• Thoracentesis results include:
• Stress the importance of bed rest, and allow the patient as
– lactate dehydrogenase (LD) levels less than 200 IU
much uninterrupted rest as possible.
– protein levels less than 3 g/dl (in transudative effusions)
• Administer antitussives and pain medication as needed.
– ratio of protein in pleural fluid to protein in serum greater
• Encourage the patient to cough. During coughing exercises,
than or equal to 0.5
apply firm pressure at the pain site.
– LD in pleural fluid greater than or equal to 200 IU
920104.qxd 8/7/08 3:52 PM Page 75

PNEUMOCYSTIS CARINII PNEUMONIA PNEUMONIA
• Generalized fatigue • Chills, fever
• Low-grade, intermittent fever • Crackles, rhonchi, and pleural friction rub on auscultation
• Nonproductive cough • Dyspnea, tachypnea, and accessory muscle use
• Dyspnea • Sputum that’s rusty, green, or bloody with pneumococcal
• Weight loss pneumonia and yellow-green with bronchopneumonia
Key test results Key test results
• Chest X-ray may show slowly progressing, fluffy infiltrates and • Chest X-ray shows pulmonary infiltrates.
occasionally nodular lesions or a spontaneous pneumothorax. • Sputum study identifies the causative organism.
These findings must be differentiated from findings in other Key treatments
types of pneumonia or acute respiratory distress syndrome. • Antibiotics most effective in treating causative organism
• Histologic study results confirm P. carinii. In patients with hu- • Supplemental O2 therapy; intubation and mechanical ventila-
man immunodeficiency virus (HIV) infection, initial examination tion if condition deteriorates
of a first morning sputum specimen (induced by inhaling an ul-
Key interventions
trasonically dispersed saline mist) may be sufficient; however,
• Monitor and record intake and output.
this technique is usually ineffective in patients without HIV infec-
• Monitor pulse oximetry values.
tion.
• Monitor respiratory status.
Key treatments • Force fluids to 3 to 4 L/day and maintain I.V. fluids.
• O2 therapy, which may include ET intubation and mechanical
ventilation PNEUMOTHORAX AND HEMOTHORAX
• Antibiotics most effective in treating causative organism Key signs and symptoms
Key interventions • Diminished or absent breath sounds unilaterally
• Monitor the patient’s respiratory status and pulse oximetry • Dyspnea, tachypnea, subcutaneous emphysema, and cough
values. • Sharp chest pain that increases with exertion
• Administer O2 therapy as needed. Encourage the patient to Key test results
ambulate and to perform deep-breathing exercises and incen- • Chest X-rays confirm the diagnosis.
tive spirometry. Key treatments
• Administer antipyretics as needed. • Chest tube to water-seal drainage
• Monitor intake and output and weigh the patient daily. Replace
Key interventions
fluids as needed.
• Administer antimicrobial drugs as ordered. Never give pen- • Monitor and record vital signs.
tamidine (NebuPent) I.M. Administer the I.V. form slowly over 60 • Monitor respiratory status and pulse oximetry values.
minutes. • Monitor chest tube site for subcutaneous emphysema.
• Monitor the patient for adverse reactions to antimicrobial • Monitor chest tube drainage.
drugs. If he’s receiving co-trimoxazole (Bactrim), watch for nau- • Evaluate cardiovascular status.
sea, vomiting, rash, bone marrow suppression, thrush, fever, he- • Maintain chest tube to water-seal drainage. The water-seal
patotoxicity, and anaphylaxis. If he’s receiving pentamidine, chamber prevents air from entering the chest tube when the pa-
watch for cardiac arrhythmias, hypotension, dizziness, azotemia, tient inhales.
hypocalcemia, and hepatic disturbances. PULMONARY EMBOLISM
• Supply nutritional supplements as needed. Encourage the pa- Key signs and symptoms
tient to eat a high-calorie, protein-rich diet. Offer small, frequent
• Sudden onset of dyspnea, tachypnea, and crackles
meals if the patient can’t tolerate large amounts of food.
Key test results
• ABG levels typically show decreased PaO2 and PaCO2.
• Lung scan shows ventilation-perfusion mismatch.
(continued)
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PULMONARY EMBOLISM (continued) • Light-headedness or dizziness (from decreased cerebral blood
Key treatments flow)
• Vena cava filter insertion Key test results
• Anticoagulants: heparin (Heparin Sodium Injection), warfarin • ABG analysis confirms respiratory alkalosis and rules out re-
(Coumadin) spiratory compensation for metabolic acidosis. PaCO2 is below
• Fibrinolytics: streptokinase (Streptase), tissue plasminogen ac- 35 mm Hg, and pH is elevated in proportion to the fall in PaCO2 in
tivator (Activase) the acute stage but drops toward normal in the chronic stage.
Key interventions Bicarbonate level is normal in the acute stage but below normal
• Monitor respiratory status and pulse oximetry values. in the chronic stage.
• Evaluate cardiovascular status and monitor ECG. Key treatments
• Administer O2. • Having the patient breathe into a paper bag, which helps re-
lieve acute anxiety and increases CO2 levels (for severe respira-
RESPIRATORY ACIDOSIS
tory alkalosis)
Key interventions
• Cardiovascular abnormalities, such as tachycardia, hyperten-
• Watch for and report any changes in neurologic, neuromuscu-
sion, atrial and ventricular arrhythmias and, in severe acidosis,
lar, or cardiovascular function.
hypotension with vasodilation
Key test results
• ABG measurements confirm that the patient has respiratory SARCOIDOSIS
acidosis. PaCO2 exceeds the normal level of 45 mm Hg, and pH is Key signs and symptoms
usually below the normal range of 7.35 to 7.45. The patient’s bi- Initial signs
carbonate level is normal in the acute stage and elevated in the • Arthralgia in the wrists, ankles, and elbows
chronic stage. • Fatigue
Key treatments • Malaise
• Correction of the underlying cause • Weight loss
• Sodium bicarbonate in severe cases Respiratory
• Breathlessness
Key interventions
• Substernal pain
• Closely monitor the patient’s blood pH level.
Cutaneous
• Be alert for critical changes in the patient’s respiratory, central
• Erythema nodosum
nervous system (CNS), and cardiovascular functions. Maintain
• Subcutaneous skin nodules with maculopapular eruptions
adequate hydration.
Ophthalmic
• If acidosis requires mechanical ventilation, maintain a patent
• Anterior uveitis (common)
airway and provide adequate humidification. Perform tracheal
Musculoskeletal
suctioning regularly and vigorous chest physiotherapy if needed.
• Muscle weakness
RESPIRATORY ALKALOSIS • Pain
Key signs and symptoms Hepatic
• Agitation • Granulomatous hepatitis (usually produces no symptoms)
• Cardiac arrhythmias that fail to respond to conventional treat- Genitourinary
ment (severe respiratory alkalosis) • Hypercalciuria (excessive calcium in the urine)
• Circumoral or peripheral paresthesia (a prickling sensation Cardiovascular
around the mouth or extremities) • Arrhythmias (premature beats, bundle-branch block, or com-
• Deep, rapid breathing, possibly exceeding 40 breaths/minute plete heart block)
(cardinal sign) Central nervous system
• Cranial or peripheral nerve palsies
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SARCOIDOSIS (continued) • Reverse transcription polymerase chain reaction test detects
• Basilar meningitis (inflammation of the meninges at the base of ribonucleic acid of the SARS virus.
the brain) Key treatments
Key test results • Supplemental O2; may require ET intubation and mechanical
• Positive Kveim-Siltzbach skin test supports the diagnosis. In ventilation
this test, the patient receives an intradermal injection of an anti- • Droplet precautions
gen prepared from human sarcoidal spleen or lymph nodes from • Antiviral agents: oseltamivir (Tamiflu), ribavirin (Vibrazole), in-
patients with sarcoidosis. If the patient has active sarcoidosis, terferon beta-1a (Avonex)
granuloma develops at the injection site in 2 to 6 weeks. This re- Key interventions
action is considered positive when a biopsy of the skin at the in- • Monitor respiratory status.
jection site shows discrete epithelioid cell granuloma. • Administer supplemental O2 as prescribed.
Key treatments • Maintain droplet precautions.
• A low-calcium diet
TUBERCULOSIS
• Avoidance of direct exposure to sunlight (in patients with hy-
percalcemia) Key signs and symptoms
• O2 therapy • Fever
• Corticosteroid: prednisone (Deltasone) • Night sweats
• Cytotoxic agents: methotrexate (Rheumatrex), azathioprine Key test results
(Imuran) • Mantoux skin test is positive.
Key interventions • Sputum study results are positive for acid-fast bacillus and
• Provide a nutritious, high-calorie diet and plenty of fluids. If the Mycobacterium tuberculosis.
patient has hypercalcemia, suggest a low-calcium diet. Key treatments
• Weigh the patient regularly. • Standard and airborne precautions (While the patient is conta-
gious, everyone entering the patient’s room must wear a respira-
SEVERE ACUTE RESPIRATORY SYNDROME
tor with a high-efficiency particulate air filter.)
Key signs and symptoms • Antitubercular agents: isoniazid (INH), ethambutol (Myambu-
• High fever (usually >100.4° F [38° C]) tol), rifampin (Rifadin), pyrazinamide (Pyrazinamide)
• Dry cough Key interventions
• Dyspnea
• Monitor respiratory status and pulse oximetry values.
Key test results • Maintain infection-control precautions.
• History reveals recent travel to an area with documented • Instruct the patient to cover his nose and mouth when
severe acute respiratory syndrome (SARS) cases or close con- sneezing.
tact with a person suspected of having SARS. • Provide a room with negative pressure ventilation.
• Chest X-ray shows atypical pneumonia.
move from an area of high concentration to an A pleura-lity of coverings

area of low concentration. Because the con- The pleura is the membrane covering the
centration of carbon dioxide is greater in the lungs and lining the thoracic cavity. The vis-
alveoli, it diffuses out into the lungs and is ex- ceral pleura covers the lungs, while the pari-
haled. Because the lungs contain a greater etal pleura lines the thoracic cavity. Pleural
concentration of oxygen, oxygen diffuses out fluid lubricates the pleura to reduce friction
of the lungs and into the alveoli, to be carried during respiration.
to the rest of the body.
920104.qxd 8/7/08 3:52 PM Page 78
Nursing actions
Keep abreast of Before the procedure
• Note any patient allergies to iodine,
After any invasive
test involving the
airway—such as a
diagnostic tests seafood, or radiopaque dyes.
• Withhold food and fluids for 8 hours.
bronchoscopy— Here are some important tests used to diag- • Make sure that written, informed consent
assess respiratory nose respiratory disorders, along with com- has been obtained.
status to ensure the mon nursing interventions associated with • Inform the patient about the possibility of
patient’s safety.
each test. flushing of the face or burning in the throat
after the dye is injected.
Deep, direct visualization After the procedure
A bronchoscopy involves the use of a bron- • Monitor peripheral neurovascular status.
choscope to directly visualize the trachea and • Check the insertion site for bleeding.
bronchial tree. During a bronchoscopy, the • Avoid taking blood pressure measurements
physician may take biopsies, perform deep in the extremity used for dye injection for
tracheal suctioning, and remove foreign ob- 24 hours after the procedure.
jects.
Sensitive about sputum
Nursing actions A sputum study is a laboratory test that pro-
Before the procedure vides a microscopic evaluation of sputum,
• Withhold food and fluids for 6 to 12 hours, if evaluating it for culture and sensitivity, Gram
possible. stain, and acid-fast bacillus.
• Make sure that written, informed consent
has been obtained. Nursing actions
After the procedure • Obtain an early-morning sterile specimen
• Check the patient’s cough and gag reflexes from suctioning or expectoration.
to minimize the risk of aspiration. • Make sure that the specimen is truly spu-
• Monitor sputum and respiratory status. tum—not saliva—before sending it to the lab-
• Withhold food and fluids until the gag re- oratory.
Patients who flex returns.
are allergic to • Monitor heart rate during and after the pro- Focusing on intrapleural fluid
iodine or seafood cedure for bradycardia, which may be caused With thoracentesis, a needle is used to re-
are at risk for by a vasovagal response. move fluid from the pleural space or to obtain
reactions in any
a sample of intrapleural fluid to determine the
test involving
radiopaque dyes. Looking in from the outside cause of an infection or empyema. It’s per-
A chest X-ray produces a radiographic pic- formed using local anesthesia.
ture of lung tissue. It can detect tumors, in-
flammation, air, and fluid in and around the Nursing actions
lungs. It can also be used to monitor equip- Before the procedure
ment, such as catheters and chest tubes. • Make sure that written, informed consent
has been obtained.
Nursing actions • Reassure the patient.
• Determine the patient’s ability to inhale and • Place the patient in the proper position (ei-
hold his breath. ther sitting on the edge of the bed or, if the
• Make sure that the patient removes jewelry patient is unable to sit up, on his unaffected
before the X-ray is taken. side with the arm of his affected side raised
above his head; elevate the head of the bed 30
Dye-ing to see the lungs to 45 degrees, if possible).
With pulmonar y angiography, the patient After the procedure
receives an injection of a radiopaque dye • Monitor the patient’s respiratory status.
through a catheter. This provides a radi- • Monitor vital signs frequently.
ographic picture of pulmonary circulation.
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• Position the patient on the affected side, as Nursing actions

ordered, for at least 1 hour to seal the punc- • Note any patient allergies to iodine, sea-
ture site. food, or radiopaque dyes.
• Check the puncture site for fluid leakage. • Make sure that written, informed consent
has been obtained.
Finding out about lung function • Instruct the patient to remove all metal ob-
Pulmonar y function tests (PFTs) are non- jects before the procedure.
invasive tests that measure lung volume, • Confirm that the patient is able to lie still for
ventilation, and diffusing capacity using a about 1 hour during the procedure.
spirometer. The patient breathes through a • Check the catheter insertion site for bleed-
mouthpiece following specific directions. A ing after the procedure.
computer then calculates the volumes.
TB or not TB?
Nursing actions With a Mantoux intradermal skin test, the
• Tell the patient to refrain from smoking or patient receives an injection of tuberculin to
eating a heavy meal for 4 to 6 hours before detect tuberculosis (TB) antibodies.
testing.
• Document bronchodilators or opioids used Nursing actions
before testing. • Document any dermatitis or rashes.
• Document exposure to bacille Calmette-
From the artery to the lab Guérin immunization.
Arterial blood gas (ABG) analysis is a labo- • Circle the test site and note it in the
ratory test that assesses the arterial blood for patient’s record.
tissue oxygenation, ventilation, and acid-base • Note the date and time for a follow-up read-
status. ing (48 to 72 hours after the injection).
Nursing actions Let’s look at the larynx

Before the procedure Lar yngoscopy uses a laryngoscope to direct-
• Note the patient’s temperature. ly visualize the larynx.
• Document oxygen and assisted mechanical
ventilation used. Nursing actions
After the procedure Before the procedure
• Apply pressure to the site for at least 5 min- • Make sure that written, informed consent
utes (for an extended period if coagulopathy has been obtained.
is present). • Withhold food and fluids for 6 to 8 hours.
• Assess the puncture site for bleeding or • Explain that the patient will receive a seda-
hematoma formation. tive to promote relaxation.
• Maintain a pressure dressing for at least After the procedure
30 minutes. • Monitor respiratory status and check for
• Monitor circulation distal to the puncture presence of the gag reflex.
site. • Allay the patient’s anxiety.
• Withhold food and fluid until the gag reflex
Image through inhalation or returns.
injection · ·
A lung scan, or ventilation/perfusion (V/Q) Little bit of lung tissue
scan, uses inhalation or I.V. injection of ra- A lung biopsy involves the removal of a small
dioisotopes to create an image of blood flow amount of lung tissue for histologic evalua-
in the lungs. tion. A lung biopsy may be done by surgical
exposure of the lung (open biopsy) or by en-
doscopy using a needle designed to remove a
core of lung tissue.
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Nursing actions naires’ disease, lung cancer, pleural effusion

Before the procedure and empyema, pleurisy, Pneumocystis carinii
• Withhold food and fluid for 8 hours. pneumonia, pneumonia, pneumothorax and
• Make sure that written, informed consent hemothorax, pulmonary embolism, respirato-
has been obtained. ry acidosis, respiratory alkalosis, sarcoidosis,
After the procedure severe acute respiratory syndrome (SARS),
• Monitor and record vital signs. and TB.
• Monitor respiratory status for signs of
pneumothorax, air embolism, hemoptysis,
and hemorrhage. Acute respiratory distress
• Check the incision site for bleeding.
syndrome
Time to switch Analyzing blood, part A
gears. Now that you’re
A blood chemistr y test assesses a blood With ARDS, fluid builds up in the lungs and
familiar with
diagnostic tests, get sample for potassium, sodium, calcium, phos- causes them to stiffen. This impairs breath-
ready to review phorus, glucose, bicarbonate, blood urea ni- ing, thereby reducing the amount of oxygen
common disorders. trogen, creatinine, protein, albumin, osmolali- in the capillaries that supply the lungs. When
ty, and alpha1-antitrypsin. severe, ARDS can cause an unmanageable
and ultimately fatal lack of oxygen. However,
Nursing actions people who recover may have little or no per-
• Withhold food and fluids before the proce- manent lung damage.
dure as directed.
• Check the site for bleeding after the proce- CAUSES
dure. • Aspiration
• Decreased surfactant production
Analyzing blood, part B • Fat emboli
With hematologic and coagulation stud- • Fluid overload
ies, a blood sample is used to analyze red • Near drowning
blood cells (RBCs), white blood cells • Neurologic injuries
(WBCs), prothrombin time, International • Oxygen toxicity
Normalized Ratio, partial thromboplastin • Respiratory infection
time, erythrocyte sedimentation rate (ESR), • Sepsis
platelets, hemoglobin (Hb), and hematocrit • Shock
(HCT). • Trauma
Nursing actions DATA COLLECTION FINDINGS

• Note current drug therapy before the pro- • Anxiety and restlessness
cedure. • Cough
• Check the venipuncture site for bleeding af- • Crackles, rhonchi, and decreased breath
ter the procedure. sounds
• Cyanosis
• Dyspnea or tachypnea
Polish up on patient DIAGNOSTIC FINDINGS

• ABG levels show respiratory acidosis and
care hypoxemia that doesn’t respond to increased
fraction of inspired oxygen.
Major respiratory disorders include acute res- • Blood culture results show an infectious or-
piratory distress syndrome (ARDS), acute ganism.
respiratory failure, asbestosis, asphyxia, asth- • Chest X-ray shows bilateral infiltrates (in
ma, atelectasis, bronchiectasis, chronic bron- early stages) and lung fields with a “ground-
chitis, cor pulmonale, emphysema, Legion- glass” appearance and, with irreversible
920104.qxd 8/7/08 3:52 PM Page 81
hypoxemia, massive consolidation of both emia, such as tachycardia, tachypnea, and irri-
lung fields (in later stages). tability.
• Sputum study identifies the infectious or- • Monitor electrocardiogram (ECG) to detect Memory
ganism. arrhythmias or ischemia. jogger
• Monitor pulse oximetry values continuously Remember
NURSING DIAGNOSES to determine the effectiveness of therapy. what hap-
• Impaired gas exchange • Monitor and record intake and output to de- pens in ARDS:
• Ineffective breathing pattern termine fluid status and hemodynamic vari- Assault to the pul-
• Ineffective tissue perfusion: Cardiopul- ables. monary system
monary • Maintain mechanical ventilation and pro-
vide suction, as needed, to aid in removal of
Respiratory dis-
tress
TREATMENT secretions.
• Oxygen therapy • Maintain bed rest, with alternating supine Decreased lung
• Intubation and mechanical ventilation using and prone positioning if possible, to promote compliance
positive end-expiratory pressure (PEEP) or oxygenation. Severe respiratory
pressure-controlled inverse ratio ventilation • Maintain fluid restrictions to reduce fluid failure.
• Bed rest with alternating supine and prone overload.
positioning, if possible; passive range-of- • Provide chest physiotherapy and postural
motion exercises drainage to promote drainage and keep air-
• Chest physiotherapy, postural drainage, and ways clear.
suction • Place the patient in high Fowler’s position to
• Dietary changes, including restricting fluid promote chest expansion.
intake or, if intubated, nothing by mouth • Maintain total parenteral nutrition or enteral
• Extracorporeal membrane oxygenation, if feedings, as appropriate, to prevent respiratory
available muscle impairment and maintain nutritional
• Transfusion therapy: platelets, packed status.
RBCs • Administer medications, as prescribed, to
optimize respiratory and hemodynamic status.
Drug therapy • Organize rest periods for the patient to con-
• Anesthetic: propofol (Diprivan) (if intubat- serve energy and avoid overexertion and fa-
ed) tigue.
• Analgesic: morphine • Weigh the patient daily to detect fluid reten-
• Antibiotics most effective in treating the tion.
causative organism • Encourage the patient to express fear of suf- Patients with
ARDS should be
• Anticoagulant: heparin focation to reduce anxiety and oxygen demand.
maintained in
• Antianxiety agent: lorazepam (Ativan) alternating supine and
• Diuretics: furosemide (Lasix), ethacrynic prone positions.
acid (Edecrin)
• Exogenous surfactant: beractant (Survanta)
• Mucosal barrier fortifier: sucralfate
(Carafate)
• Neuromuscular blocking agents: pancuroni-
um (Pavulon), vecuronium (Norcuron) (if in-
tubated) Teaching topics
• Steroids: hydrocortisone (Solu-Cortef), • Recognizing the signs and symptoms
methylprednisolone (Solu-Medrol) of respiratory distress
• Performing coughing and deep-breathing
INTERVENTIONS AND RATIONALES exercises
• Monitor respiratory, cardiovascular, and • Avoiding chemical irritants and pollutants
neurologic status to detect evidence of hypox-
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Acute respiratory failure DATA COLLECTION FINDINGS

• Adventitious breath sounds (crackles,
With acute respiratory failure, the respiratory rhonchi, wheezing, and pleural friction rub)
system can’t adequately supply the body with • Anxiety and change in mental activity
the oxygen it needs or adequately remove car- • Chest pain
bon dioxide. A patient is considered to be in • Cough, sputum production, hemoptysis
respiratory failure when his partial pressure • Cyanosis, diaphoresis
of arterial oxygen (PaO2) is 50 mm Hg or less, • Decreased respiratory excursion, accessory
his partial pressure of arterial carbon dioxide muscle use, retractions
(PaCO2) is 50 mm Hg or more, and his pH is • Dyspnea, tachypnea, orthopnea
7.25 or less. • Fatigue
Acute respiratory failure can be classified as • Nasal flaring
ventilatory failure or oxygenation failure. Ven- • Tachycardia
tilatory failure is characterized by alveolar hy-
poventilation. Oxygenation failure is charac-
· ·
DIAGNOSTIC FINDINGS
terized by V/Q mismatching (blood flow to • ABG levels show hypoxemia, acidosis, alka-
areas of the lung with reduced ventilation, or losis, and hypercapnia.
ventilation to lung tissue that’s experiencing • Chest X-ray shows pulmonary infiltrates, in-
reduced blood flow) or physiologic shunting terstitial edema, and atelectasis.
(blood moving from the right side of the • Hematology tests reveal increased WBC
heart to the left without being oxygenated). count and ESR.
· ·
• Lung scan shows V/Q ratio mismatching.
CAUSES • Pulse oximetry shows decreased levels
• Abdominal or thoracic surgery (< 90%).
• Anesthesia • Sputum study identifies causative organism.
• ARDS
• Atelectasis NURSING DIAGNOSES
• Brain tumor • Ineffective airway clearance
• Chronic obstructive pulmonary disease • Anxiety
(COPD) • Ineffective breathing pattern
• Drug overdose
• Encephalitis TREATMENT
• Flail chest • Supplemental oxygen therapy, intubation
The patient • Guillain-Barré syndrome and mechanical ventilation, possibly with
exhibits adventitious • Head trauma PEEP.
breath sounds and • Hemothorax • Chest physiotherapy, postural drainage, and
reports feeling “tired • Meningitis incentive spirometry
of breathing.” It could • Multiple sclerosis • Chest tube insertion if pneumothorax devel-
be acute respiratory • Muscular dystrophy ops from high PEEP administration
failure.
• Myasthenia gravis • Dietary and fluid changes based on the
• Pleural effusion cause of the disorder
• Pneumonia • Treatment of underlying cause
• Pneumothorax
• Poliomyelitis Drug therapy
• Polyneuritis • Analgesic: morphine
• Pulmonary edema • Anesthetic: propofol (Diprivan) (if intubat-
• Pulmonary embolism ed)
• Sepsis • Antianxiety agent: lorazepam (Ativan)
• Stroke • Antibiotics most effective in treating the
causative organism (for respiratory infection)
• Anticoagulants: heparin, warfarin
(Coumadin), enoxaparin (Lovenox)
920104.qxd 8/7/08 3:52 PM Page 83
• Bronchodilators: terbutaline (Brethine), Teaching topics

aminophylline (Phyllocontin); via nebulizer: • Recognizing the early signs and symptoms
albuterol (Proventil), ipratropium (Atrovent), of respiratory difficulty
metaproterenol (Alupent) • Performing deep-breathing and coughing
• Diuretic: furosemide (Lasix) if fluid over- exercises
load is the cause
• Histamine-2 blockers: famotidine (Pepcid),
ranitidine (Zantac), nizatidine (Axid) Asbestosis
• Neuromuscular blocking agents: pancuroni-
um (Pavulon), vecuronium (Norcuron), Asbestosis is characterized by widespread fill-
atracurium (Tracrium) (if intubated) ing and inflammation of lung spaces with as-
• Steroids: hydrocortisone (Solu-Cortef), bestos fibers. The asbestos fibers assume a
methylprednisolone (Solu-Medrol) longitudinal orientation in the airway, move in
the direction of airflow, and penetrate respira-
INTERVENTIONS AND RATIONALES tory bronchioles and alveolar walls. This
• Administer oxygen to reduce hypoxemia and causes diffuse interstitial fibrosis (tissue filled
relieve respiratory distress. with fibers).
• Monitor respiratory status to detect early Asbestosis can develop as long as 15 to
signs of compromise and hypoxemia. 20 years after regular exposure to asbestos
• Monitor and record intake and output to de- has ended. It increases the risk of lung cancer
tect fluid excess, which may lead to pulmonary in cigarette smokers.
edema.
• Monitor pulse oximetry values to detect a CAUSES
change in oxygen saturation. • Inhalation of asbestos fibers
• Monitor and record vital signs. Tachycardia
and tachypnea may indicate hypoxemia. DATA COLLECTION FINDINGS
• Record color, consistency, and amount of • Dry crackles at lung bases
sputum to determine hydration status, effective- • Dry cough
ness of therapy, and presence of infection. • Dyspnea on exertion (usually first symp-
• Provide suctioning; help the patient with tom)
turning, coughing, and deep breathing; and • Dyspnea at rest (with advanced disease)
perform chest physiotherapy and postural • Finger clubbing
drainage to facilitate removal of secretions. • Pleuritic chest pain
(See Performing oronasopharyngeal suction- • Tachypnea With asbestosis,
ing, page 84.) my spaces are filled
• Maintain prescribed mechanical ventilation DIAGNOSTIC FINDINGS with and inflamed by
to prevent complications and optimize PaO2 . • ABG analysis reveals decreased PaO2 and asbestos fibers!
• Maintain bed rest to reduce the amount of PaCO2.
oxygen required. • Chest X-rays show fine, irregular, and linear
• Place the patient in semi-Fowler’s or high diffuse infiltrates; extensive fibrosis results in
Fowler’s position to promote chest expansion a “honeycomb” or “ground-glass” appearance.
and ventilation. X-rays may also show pleural thickening and
• Maintain diet restrictions. Fluid restrictions calcification, with bilateral obliteration of
and a low-sodium diet may be necessary to costophrenic angles and, in later stages, an
avoid fluid overload. enlarged heart with a classic “shaggy” heart
• Administer medications, as prescribed, to border.
treat infection, dilate airways, and reduce in- • PFTs show decreased vital capacity, forced
flammation. vital capacity, total lung capacity, and diffusing
• Monitor chest tube system if indicated to as- capacity of the lungs.
sess for lung reexpansion.
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Stepping up
Performing oronasopharyngeal suctioning

WHY YOU DO IT For nasal insertion
Oronasopharyngeal suctioning removes secretions from the • Raise the tip of the patient’s nose with your nondominant
pharynx by a suction catheter inserted through the mouth or hand to straighten the passageway and facilitate insertion of
nostril. Used to maintain a patent airway, this procedure helps the catheter. Without applying suction, gently insert the suction
the patient who can’t clear his airway effectively by coughing catheter into the patient’s nostril. Roll the catheter between
and expectoration. Typically, these patients are unconscious or your fingers to help advance it through the turbinates. Continue
severely debilitated. The frequency and duration of suctioning to advance the catheter 5⬙ to 6⬙ (12.7 to 15.2 cm) until you reach
depend on the patient’s tolerance of the procedure and on the the pool of secretions or until the patient begins to cough.
occurrence of complications. For oral insertion
A catheter may inadvertently slip into the lower airway or • Without applying suction, gently insert the catheter into the
esophagus. For that reason, oronasopharyngeal suction is a patient’s mouth. Advance it 3⬙ to 4⬙ (7.6 to 10.2 cm) along the
sterile procedure that requires sterile equipment. Apply suction side of the patient’s mouth until you reach the pool of secre-
for only 10 to 15 seconds at a time to minimize tissue trauma tions or the patient begins to cough. Suction both sides of the
and prevent hypoxia. patient’s mouth and pharyngeal area.
GETTING READY SUCTIONING THE PATIENT
• Check for a doctor’s order if your facility requires one. • Using intermittent suction, withdraw the catheter from either
• Check vital signs and pulse oximetry values. Evaluate the the mouth or the nose with a continuous rotating motion. Be-
patient’s ability to cough and breathe deeply. tween passes, wrap the catheter around your dominant hand.
• Describe the procedure to the patient and explain that it may • If secretions are thick, clear the catheter tube by dipping it in
cause coughing or gagging. Reassure the patient throughout normal saline solution and applying suction.
the procedure. • Repeat the procedure until gurgling or bubbling sounds stop
• Position the patient in semi-Fowler’s or high Fowler’s position, and respirations are quiet.
if tolerated. • After completing suction, pull off your sterile glove over the
• Turn on the suction from the wall or portable unit, and set the coiled catheter and then remove your nonsterile glove. Discard
pressure (usually between 80 and 120 mm Hg). Block the end of both gloves and the container of water.
the connecting tubing momentarily to check suction pressure. • Flush the connecting tubing with normal saline solution.
• Using strict sterile technique, open the suction catheter kit or • If the patient has excessive oral secretions, consider using a
the packages containing the sterile catheter, disposable con- tonsil tip catheter. This allows the patient to remove oral secre-
tainer, gloves, saline solution, and lubricant. tions independently.
• Put on the gloves. Consider your dominant hand sterile and • Let the patient rest after suctioning while you continue to ob-
your nondominant hand nonsterile. Using your nondominant serve him.
hand, pour saline solution into the sterile container.
• With your nondominant hand, place a small amount of water- WHAT YOU SHOULD DOCUMENT
soluble lubricant on the sterile area. • Date, time, and reason for suctioning
• Pick up the catheter with your dominant (sterile) hand, and at- • Technique used
tach it to the connecting tubing. Use your nondominant hand to • Amount, color, consistency, and odor (if any) of the secretions
control the suction valve while your dominant hand manipu- • Patient's respiratory status before and after the procedure
lates the catheter. • Complications and the actions taken in response
• Patient's tolerance of the procedure
INSERTING THE CATHETER
The technique you’ll use depends on whether the catheter is
inserted nasally or orally.
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NURSING DIAGNOSES CAUSES

• Imbalanced nutrition: Less than body re- • Extrapulmonary obstruction, such as tra-
quirements cheal compression from a tumor, strangula-
• Fatigue tion, trauma, or suffocation
• Impaired gas exchange • Hypoventilation resulting from opioid
abuse, medullary disease, hemorrhage, pneu-
TREATMENT mothorax, respiratory muscle paralysis, or
• Chest physiotherapy cardiopulmonary arrest
• Fluid intake of at least 3 L/day • Inhalation of toxic agents, such as carbon
• Oxygen therapy or mechanical ventilation monoxide, smoke, and excessive oxygen
(with advanced cases) • Intrapulmonary obstruction caused by such
factors as airway obstruction, severe asthma,
Drug therapy foreign body aspiration, pulmonary edema,
• Antibiotics: most effective in treating the pneumonia, and near-drowning
causative organism (for respiratory tract in-
fection) DATA COLLECTION FINDINGS
• Cardiac glycoside: digoxin (Lanoxin) • Agitation
• Diuretic: furosemide (Lasix) • Altered mental status
• Mucolytic inhalation therapy: acetylcysteine • Altered respiratory rate (apnea, bradypnea,
(Mucomyst) and occasionally tachypnea)
• Anxiety
INTERVENTIONS AND RATIONALES • Central and peripheral cyanosis (cherry-red
• Provide chest physiotherapy techniques, mucous membranes in late-stage carbon
such as controlled coughing and segmental monoxide poisoning)
bronchial drainage, with chest percussion and • Decreased breath sounds
vibration to relieve respiratory symptoms. • Dyspnea
Aerosol therapy, inhaled mucolytics, and in- • Fast, slow, or absent pulse
creased fluid intake (at least 3 L daily) may • Seizures
also help relieve respiratory symptoms.
• Administer medications as ordered to treat DIAGNOSTIC FINDINGS
the disorder. • ABG measurement indicates decreased
• Administer oxygen by cannula or mask (1 PaO2 (less than 60 mm Hg) and increased Gasp! Treatment
to 2 L/minute), or by mechanical ventilation if PaCO2 (more than 50 mm Hg). for asphyxia focuses
PaO2 can’t be maintained above 40 mm Hg, to • Chest X-rays may show a foreign body, pul- on treating the cause
prevent complications of hypoxemia. monary edema, or atelectasis. and providing the
• PFTs may indicate respiratory muscle lungs with oxygen.
Teaching topics weakness.
• Preventing infections by avoiding crowds, • Pulse oximetry reveals decreased oxygen
avoiding people with infections, and receiving saturation.
influenza and pneumococcal vaccines • Toxicology tests may show drugs, chemi-
cals, or abnormal Hb.
Asphyxia NURSING DIAGNOSES

With asphyxia, interference with adequate • Impaired spontaneous ventilation
respiration leads to insufficient oxygen and • Risk for suffocation
accumulating carbon dioxide in the blood and
tissues. Asphyxia leads to cardiopulmonary TREATMENT
arrest and is fatal without prompt treatment. • Oxygen therapy, which may include endo-
tracheal (ET) intubation and mechanical ven-
tilation
920104.qxd 8/7/08 3:52 PM Page 86
• Bronchoscopy (for extraction of a foreign CAUSES

body) Extrinsic asthma
• Gastric lavage (for poisoning) • Allergens (pollen, dander, cockroach de-
bris, dust mites, dust, sulfite food additives)
Drug therapy
• Opioid antagonist: naloxone (Narcan) (for Intrinsic asthma
opioid overdose) • Endocrine changes
• Exercise
INTERVENTIONS AND RATIONALES • Noxious fumes
• Monitor cardiac and respiratory status to • Respiratory infection
detect early signs of compromise. • Stress
• Position the patient upright, if his condition • Temperature and humidity
allows, to promote lung expansion and improve
oxygenation. DATA COLLECTION FINDINGS
• Reassure the patient during treatment to • Absent or diminished breath sounds during
ease anxiety associated with respiratory dis- severe obstruction
tress. • Chest tightness
• Give prescribed medications to promote ven- • Dyspnea
tilation and oxygenation. • Productive cough that expels thick mucus
• Suction carefully, as needed, and encourage • Prolonged expiration
deep breathing to mobilize secretions and • Tachypnea, tachycardia
maintain a patent airway. • Use of accessory muscles
• Closely monitor vital signs and ECG to eval- • Lack of symptoms between attacks (com-
uate and guide the treatment plan. mon)
• Wheezing, primarily on expiration but
Teaching topics sometimes also on inspiration
• Understanding the need for follow-up med-
ical care DIAGNOSTIC FINDINGS
• Avoiding a combination of alcohol and other • ABG levels in acute severe asthma show de-
central nervous system (CNS) depressants creased PaO2 and decreased, normal, or in-
creased PaCO2 .
• Blood tests: Serum immunoglobulin (Ig) E
Patients with Asthma may increase because of an allergic reaction;
asthma should complete blood count (CBC) may reveal in-
receive 3,000 ml of Asthma is a form of COPD in which the creased eosinophil count.
fluids per day. bronchial linings overreact to various stimuli, • Chest X-ray shows hyperinflated lungs with
causing episodic spasms and inflammation air trapping during an attack.
that severely restrict the airways. Symptoms • PFTs during attacks show decreased forced
range from mild wheezing and labored expiratory volume that improves with therapy
breathing to life-threatening respiratory and increased residual volume and total lung
failure. capacity.
Asthma can be extrinsic or intrinsic (or a • Skin tests may identify allergens.
person may have both). Extrinsic (atopic)
asthma is caused by sensitivity to specific ex- NURSING DIAGNOSES
ternal allergens. Intrinsic (nonatopic) asth- • Ineffective airway clearance
ma is caused by a reaction to internal, nonal- • Impaired gas exchange
lergenic factors. • Ineffective therapeutic regimen manage-
ment
920104.qxd 8/7/08 3:52 PM Page 87
TREATMENT • Place the patient in high Fowler’s position to

• Desensitization to allergens (see An ounce improve ventilation. An ounce of
of prevention) • Maintain the patient’s diet and provide
• Oxygen therapy small, frequent meals and snacks to reduce prevention
• Intubation and mechanical ventilation if res- pressure on the diaphragm and increase caloric Many patients with
piratory status worsens intake. asthma can use pre-
• Fluids up to 3,000 ml/day as tolerated • Encourage fluids to treat dehydration and vention techniques to
liquefy secretions to facilitate their removal. avoid asthma attacks.
Drug therapy • Monitor and record the color, amount, and It’s important to edu-
• Antibiotics: most effective in treating the in- consistency of sputum. Changes in sputum cate the patient about
fection (for respiratory infections) characteristics may signal a respiratory infec- these techniques.
• Antileukotrienes: zileuton (Zyflo), zafir- tion. Begin by helping the
lukast (Accolate) • Monitor and record vital signs. Tachycardia patient identify attack
• Beta-adrenergic drugs: epinephrine (Adren- may indicate worsening asthma or drug toxici- triggers, such as exer-
alin), salmeterol (Serevent), formoterol ty. Hypertension may indicate hypoxemia. cise, stress, anxiety,
(Foradil) Fever may signal infection. and cold air. Then
• Bronchodilators: terbutaline (Brethine), • Provide chest physiotherapy, postural teach the patient about
aminophylline (Phyllocontin), theophylline drainage, incentive spirometry, and suction to how to avoid them. Ex-
(Theo-Dur); via metered-dose inhaler: albu- aid in the removal of secretions. plain that when the pa-
terol (Proventil), ipratropium (Atrovent), tient can’t avoid these
metaproterenol (Alupent) Teaching topics triggers, he should use
• Mast cell stabilizers: cromolyn (Intal), ne- • Recognizing the early signs and symptoms a metered-dose in-
docromil (Tilade) of respiratory infection and hypoxia haler to avoid an at-
• Anti-immunoglobulin E agent: omalizumab • Taking medications properly, including the tack. Also, teach the
(Xolair) use of a metered-dose inhaler patient how to use a
• Steroids: hydrocortisone (Solu-Cortef), • Using a peak flow meter peak flow meter to
methylprednisolone (Solu-Medrol) • Performing pursed-lip, diaphragmatic quickly identify when
• Steroids (via metered-dose inhaler): be- breathing and coughing and deep-breathing his respiratory status
clomethasone (Vanceril), triamcinolone (Az- exercises is deteriorating.
macort) • Avoiding exposure to allergens, chemical ir-
ritants, and pollutants
INTERVENTIONS AND RATIONALES • Avoiding spicy foods, extremely hot or cold
• Administer low-flow humidified oxygen to foods, and foods that produce gas Atelectasis is the
reduce inflammation of the airways, ease • Beginning a smoking-cessation program incomplete expansion
breathing, and increase oxygen saturation. (for patient and family members, if appropri- of lobules of a lung,
• Administer medications, as prescribed, to ate) which may cause
reduce inflammation and obstruction of air- • Increasing fluid intake to 3,000 ml/day partial or complete
ways. • Contacting the American Lung Association collapse.
• Encourage the patient to express his fear of
suffocation to reduce anxiety. As breathless-
ness and hypoxemia are relieved, anxiety Atelectasis
should be reduced.
• Allow activity, as tolerated, with rest periods Atelectasis is the incomplete expansion of
to reduce work of breathing and reduce oxygen lobules (clusters of alveoli) or lung segments,
demands. which may cause partial or complete
• Monitor respiratory status and pulse oxime- lung collapse. The collapsed areas are
try to evaluate the effects of therapy. unavailable for gas exchange; blood
• Assist the patient with turning, coughing, that lacks oxygen passes through un-
deep breathing, and breathing retraining to changed and produces hypoxemia.
mobilize and clear secretions. Atelectasis may be chronic or acute.
It occurs to some degree in many pa-
920104.qxd 8/7/08 3:52 PM Page 88
tients undergoing upper abdominal or tho- • Diaphoresis

racic surgery. The prognosis depends on • Severe dyspnea
prompt removal of any airway obstruction, re- • Substernal or intercostal retraction
lief of hypoxia, and reexpansion of the col- • Tachycardia
lapsed lung.
DIAGNOSTIC FINDINGS
CAUSES • Chest X-ray shows characteristic horizontal
• Bronchial occlusion by mucus plugs, as in lines in the lower lung zones and, with seg-
patients with COPD, bronchiectasis, or cystic mental or lobar collapse, characteristic dense
fibrosis or those who smoke heavily shadows (these are often associated with hy-
• CNS depression perinflation of neighboring lung zones in
• External compression applied from upper widespread atelectasis).
abdominal surgical incisions, rib fractures, • Bronchoscopy shows the area and cause of
pleuritic chest pain, tight dressings around obstruction.
the chest, obesity, or other factors
• Occlusion by foreign bodies, bronchogenic NURSING DIAGNOSES
carcinoma, and inflammatory lung disease • Impaired gas exchange
• Prolonged immobility • Ineffective breathing pattern
• Risk for infection
• Diminished or bronchial breath sounds TREATMENT
• Dyspnea • Bronchoscopy
• Low-grade fever • Chest physiotherapy
• Surgery or radiation therapy to remove an
In severe cases obstructing neoplasm
• Anxiety
• Cyanosis
Using an Stepping up
incentive spirometer
can help patients Using an incentive spirometer
become involved in
their own care. WHY YOU DO IT • Instruct the patient to insert the mouthpiece in
The purpose of incentive spirometry is for the his mouth and to close his lips tightly around it
patient to achieve maximum ventilation. Maxi- to create a seal.
mum ventilation is necessary to help prevent • Tell the patient to exhale normally and then in-
and reverse alveolar collapse, which can cause hale as slowly and as deeply as possible. In-
atelectasis and pneumonitis. struct him to retain the inhaled air for 3 seconds;
if he’s using a device with a light indicator, tell
HOW YOU DO IT
him to hold his breath until the light turns off.
• Evaluate the patient’s condition.
• Tell the patient to remove the mouthpiece from
• Explain the procedure and the importance of
his mouth and exhale normally.
regularly using an incentive spirometer to main-
• Repeat this sequence 5 to 10 times during
tain alveolar inflation.
every waking hour.
• Position the patient in a comfortable sitting or
• Document the patient’s response and tidal vol-
semi-Fowler’s position to promote optimal lung
umes.
expansion.
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Drug therapy Bronchiectasis The bad news:

• Analgesic: morphine Bronchiectasis is
• Bronchodilator: albuterol (Proventil) Bronchiectasis is the chronic abnormal dila- irreversible when
• Mucolytic inhalation therapy: acetylcysteine tion of the bronchi (large air passages of the established. The good
(Mucomyst) lungs) and destruction of the bronchial walls. news: Antibiotics have
Bronchiectasis has three forms: cylindrical drastically reduced
INTERVENTIONS AND RATIONALES (fusiform), varicose, and saccular (cystic). It the incidence of this
• Encourage postoperative and other high- can occur throughout the tracheobronchial disorder.
risk patients to cough and deep-breathe every tree, or it may be confined to one segment or
hour during their waking hours to prevent at- lobe. However, it’s usually bilateral and in-
electasis. volves the basilar segments of the lower
• Postoperatively, teach the patient to splint lobes.
his incision while breathing deeply and mov- The disorder affects people of both sexes
ing to minimize pain during coughing exercis- and all ages and, once established, is irre-
es. Gently reposition these patients often and versible. Because of the availability of antibi-
help them walk as soon as possible to prevent otics to treat acute respiratory tract infec-
atelectasis. tions, the incidence of bronchiectasis has dra-
• Administer analgesics to control pain. Pain matically decreased in the past 20 years.
may prevent the patient from taking deep
breaths, which leads to atelectasis. CAUSES
• Teach the patient to use an incentive • Inhalation of corrosive gas or repeated aspi-
spirometer to encourage deep inspiration ration of gastric juices into the lungs
through positive reinforcement. Encourage him • Immunologic disorders such as agamma-
to use it every hour during his waking hours. globulinemia
(See Using an incentive spirometer.) • Mucoviscidosis (in cases of cystic fibrosis)
• Humidify inspired air and encourage ade- • Obstruction (by a foreign body, tumor, or
quate fluid intake to mobilize secretions. Use stenosis) in association with recurrent infec-
postural drainage and chest percussion to pro- tion
mote loosening and clearance of secretions. • Recurrent, inadequately treated bacterial
• If the patient is intubated or uncooperative, respiratory tract infections, such as TB and
provide suctioning as needed. Use sedatives complications of measles, pneumonia, pertus-
with discretion because they suppress respira- sis, or influenza
tion, the cough reflex, and sighing.
• Monitor breath sounds and ventilatory sta- DATA COLLECTION FINDINGS
tus frequently and be alert for any changes to • Chronic cough that produces copious, foul-
prevent respiratory compromise. smelling, mucopurulent secretions, possibly
• Encourage the patient to stop smoking and totaling several cupfuls daily
lose weight, as needed. Refer him to appro- • Coarse crackles during inspiration over in-
priate support groups for help to modify risk volved lobes or segments
factors. • Dyspnea
• Provide reassurance and emotional support • Hemoptysis
because the patient may be frightened by his • Occasional wheezing
limited breathing capacity. • Weight loss
Teaching topics DIAGNOSTIC FINDINGS

• Performing respiratory care, such as pos- • Bronchoscopy helps to identify the source
tural drainage, coughing, and deep breathing of bleeding in hemoptysis or to remove secre-
• Stopping smoking and losing weight, if ap- tions.
propriate • Chest X-rays show peribronchial thicken-
• Performing relaxation techniques ing, areas of atelectasis, and scattered cystic
changes.
920104.qxd 8/7/08 3:52 PM Page 90
• CBC detects anemia and leukocytosis. • Properly disposing of secretions to prevent

• PFTs detect decreased vital capacity and ex- the spread of infection to others
piratory flow and hypoxemia.
• Sputum culture and Gram stain identify pre-
dominant organisms. Chronic bronchitis
NURSING DIAGNOSES Chronic bronchitis, a form of COPD, develops
• Imbalanced nutrition: Less than body re- from irritants and infections that increase mu-
quirements cus production, impair airway clearance, and
• Impaired gas exchange cause irreversible narrowing of the small air-
· ·
• Ineffective airway clearance ways. This causes a severe V/Q imbalance,
which leads to hypoxemia and carbon dioxide
TREATMENT retention.
• Bronchoscopy (to mobilize secretions)
• Chest physiotherapy CAUSES
• Oxygen therapy • Prolonged exposure to airborne irritants
and pollutants
Drug therapy • Chronic respiratory infections
• Antibiotics most effective in treating the • Smoking
causative organism (in bacterial respiratory
tract infection) DATA COLLECTION FINDINGS
• Bronchodilator: albuterol (Proventil) • Cyanosis
• Dyspnea
INTERVENTIONS AND RATIONALES • Finger clubbing (later in the disease)
• Monitor respiratory status and pulse oxime- • Increased sputum production
try values to detect early signs of decompensa- • Productive cough
tion. • Prolonged expiration
• Provide supportive care and help the pa- • Rhonchi and wheezing
tient adjust to the permanent changes in • Use of accessory muscles
lifestyle that irreversible lung damage neces- • Weight gain, edema, and jugular vein dis-
sitates to facilitate positive coping. tention
• Administer antibiotics, as needed, to eradi-
cate infection. DIAGNOSTIC FINDINGS
• Explain all diagnostic tests to the patient to • ABG analysis shows decreased PaO2 and
decrease anxiety. normal or increased PaCO2.
• Perform chest physiotherapy, including • Chest X-ray shows hyperinflation and in-
postural drainage and chest percussion decreased bronchovascular markings.
signed for involved lobes, several times per • ECG shows atrial arrhythmias; peaked
day. Tell the patient to maintain each position P waves in leads II, III, and aVF; and, occa-
for 10 minutes, perform percussion, and then sionally, right ventricular hypertrophy.
cough. These measures mobilize secretions. • PFTs may reveal increased residual volume,
decreased vital capacity and forced expiratory
Teaching topics volumes, and normal static compliance and
• Using home oxygen therapy diffusion capacity.
• Instructing family members on how to per- • Sputum culture may reveal many micro-
form chest physiotherapy organisms and neutrophils.
• Beginning a smoking-cessation program, if
appropriate NURSING DIAGNOSES
• Understanding dietary considerations, such • Activity intolerance
as avoiding milk products, which increase the • Ineffective airway clearance
viscosity of secretions • Ineffective breathing pattern
920104.qxd 8/7/08 3:52 PM Page 91
TREATMENT eating and reduce pressure on the diaphragm

• Chest physiotherapy, postural drainage, and from a full stomach.
incentive spirometry • Monitor and record the color, amount, and
• Dietary changes, including the adoption of consistency of sputum. Changes in sputum
a diet high in protein, vitamin C, calories, and characteristics may signal a respiratory infec-
nitrogen tion.
• Fluid intake up to 3,000 ml/day, if not con- • Monitor and record cardiovascular status
traindicated by other conditions and vital signs. Edema, jugular vein distention,
• Intubation and mechanical ventilation, if and tachycardia suggest right-sided heart fail-
respiratory status deteriorates ure. An irregular pulse may indicate an ar-
• Oxygen therapy at 2 to 3 L/minute rhythmia caused by altered oxygen status.
Tachycardia and tachypnea may indicate hy-
Drug therapy poxemia. You should
• Antibiotics most effective in treating the • Monitor intake and output and weigh the encourage patients
causative organism patient daily to detect fluid overload associated with chronic bronchitis
• Bronchodilators: terbutaline (Brethine), with right-sided heart failure. Dehydration im- to drink 3,000 ml of
aminophylline (Phyllocontin), theophylline pairs the removal of secretions. fluids a day, unless it’s
(Theo-Dur); via nebulizer or metered-dose in- • Provide chest physiotherapy, postural contraindicated by
haler: albuterol (Proventil), ipratropium drainage, incentive spirometry, and suction to other health
conditions.
(Atrovent), metaproterenol (Alupent) aid in removal of secretions.
• Diuretic: furosemide (Lasix) for edema
• Expectorant: guaifenesin (Robitussin) Teaching topics
• Influenza and Pneumovax vaccines • Participating in pulmonary rehabilitation
• Steroids: hydrocortisone (Solu-Cortef), • Recognizing the early signs and symptoms
methylprednisolone (Solu-Medrol) of respiratory infection and hypoxia
• Steroids (via nebulizer or metered-dose in- • Using home oxygen and nebulizer equip-
haler): beclomethasone (Vanceril), triamci- ment properly
nolone (Azmacort) • Performing pursed-lip, diaphragmatic
breathing and coughing and deep-breathing
INTERVENTIONS AND RATIONALES exercises
• Administer low-flow oxygen. Patients with • Avoiding exposure to chemical irritants
chronic bronchitis have chronic hypercapnia and pollutants
and, consequently, they have a hypoxic respira- • Avoiding spicy foods, extremely hot or cold
tory drive. Higher flow rates may eliminate this foods, and foods that produce gas
hypoxic respiratory drive. • Beginning a smoking-cessation program, if
• Administer medications, as prescribed, to appropriate
relieve symptoms and prevent complications. • Increasing fluid intake to 3,000 ml/day, if
• Allow activity, as tolerated, to avoid fatigue not contraindicated
and reduce oxygen demands. • Contacting the American Lung Association
• Monitor respiratory status and pulse oxime-
try values to detect respiratory compromise, se-
vere hypoxemia, and hypercapnia. Cor pulmonale
• Help the patient with turning, coughing,
and deep breathing to mobilize and facilitate With cor pulmonale, a chronic heart condi-
removal of secretions. tion, the heart’s right ventricle becomes en-
• Assist with diaphragmatic and pursed-lip larged from diseases affecting the function or
breathing to strengthen respiratory muscles. the structure of the lungs. To compensate for
• Place the patient in high Fowler’s position the extra work needed to force blood through
to improve ventilation. the lungs, the right ventricle dilates and hy-
• Maintain the patient’s diet and provide pertrophies.
small meals and snacks to avoid fatigue when
920104.qxd 8/7/08 3:52 PM Page 92
Invariably, cor pulmonale follows some dis- • Chest X-ray shows large central pulmonary
Cor pulmonale
patients with order of the lungs, pulmonary vessels, chest arteries and suggests right ventricular en-
underlying COPD wall, or respiratory control center. For in- largement by rightward enlargement of car-
shouldn’t receive high stance, COPD produces pulmonary hyperten- diac silhouette on an anterior chest film.
concentrations of sion, which leads to right ventricular hyper- • Echocardiography or angiography indicates
oxygen; this could lead trophy and right-sided heart failure. Because right ventricular enlargement, and angiogra-
to subsequent cor pulmonale generally occurs late during phy can estimate pulmonary artery pressure
respiratory the course of COPD and other irreversible (PAP).
depression. diseases, the prognosis is generally poor. • ECG commonly shows arrhythmias, such
as premature atrial and ventricular contrac-
CAUSES tions and atrial fibrillation, during severe hy-
• COPD (about 25% of patients with COPD poxia. It may also show right bundle-branch
eventually develop cor pulmonale) block, right axis deviation, prominent P waves
• Living at high altitudes (chronic mountain and an inverted T wave in right precordial
sickness) leads, and right ventricular hypertrophy.
• Loss of lung tissue after extensive lung • PAP measurements show increased right
surgery ventricular pressure as a result of increased
• Obesity hypoventilation syndrome (pick- pulmonary vascular resistance.
wickian syndrome) and upper airway obstruc- • PFTs show results consistent with the un-
tion derlying pulmonary disease.
• Obstructive lung diseases, such as bronchi-
ectasis and cystic fibrosis NURSING DIAGNOSES
• Pulmonary vascular diseases, such as recur- • Activity intolerance
rent thromboembolism, primary pulmonary • Excess fluid volume
hypertension, schistosomiasis, and pulmo- • Impaired gas exchange
nary vasculitis
• Respiratory insufficiency without pulmo- TREATMENT
nary disease, as seen in chest wall disorders, • Diet: low-sodium with restricted fluid intake
such as kyphoscoliosis, neuromuscular in- • Oxygen therapy by mask or cannula in con-
Pulmonary peril. In competence resulting from muscular dystro- centrations ranging from 24% to 40% (concen-
cor pulmonale, my phy or amyotrophic lateral sclerosis, poly- tration depends on PaO2) and, in acute cases,
right ventricle myositis, and spinal cord lesions above C6 mechanical ventilation
enlarges because of
• Restrictive lung diseases, such as pneumo- • Lung or heart and lung transplantation (pri-
diseases that affect
the lungs. coniosis, interstitial pneumonitis, scleroder- mary pulmonary hypertension)
ma, and sarcoidosis
Drug therapy
DATA COLLECTION FINDINGS • Angiotensin-converting enzyme inhibitor:
• Chronic productive cough captopril (Capoten)
• Dyspnea on exertion • Antibiotics: most effective in treating
• Edema causative organism (for respiratory infection)
• Fatigue • Anticoagulant: heparin (Heparin Sodium In-
• Orthopnea jection)
• Tachypnea • Calcium channel blocker: diltiazem
• Weakness (Cardizem)
• Wheezing respirations • Cardiac glycoside: digoxin (Lanoxin)
• Diuretic: furosemide (Lasix) to reduce ede-
DIAGNOSTIC FINDINGS ma
• ABG analysis shows decreased PaO2 (less • Vasodilators: diazoxide (Proglycem), hy-
than 70 mm Hg). dralazine (Apresoline), nitroprusside
• Blood tests show HCT greater than 50%. (Nipride)
920104.qxd 8/7/08 3:52 PM Page 93
INTERVENTIONS AND RATIONALES DATA COLLECTION FINDINGS Check it out. With

• Monitor respiratory status and pulse oxime- • Anorexia, weight loss emphysema, PFTs
try values to detect complications • Barrel chest show an increase in
• Monitor cardiovascular status to detect wors- • Decreased breath sounds my residual volume,
ening condition. • Dyspnea total capacity, and
• Provide small, frequent meals and snacks • Finger clubbing (late in the disease) compliance.
rather than three heavy meals because the • Prolonged expiration
patient may lack energy and tire easily when • Pursed-lip breathing
eating. • Use of accessory muscles for breathing
• Limit the patient’s fluid intake to 1,000 to • Weakness
2,000 ml/day and provide a low-sodium diet to
prevent fluid retention. DIAGNOSTIC FINDINGS
• Teach the patient to check his radial pulse • ABG analysis shows reduced PaO2, with
before taking a cardiac glycoside and to re- normal PaCO2 until late in the disease.
port any changes in pulse rate to avoid com- • Chest X-ray in advanced disease reveals a
plications of digoxin therapy. flattened diaphragm, reduced vascular mark-
• Reposition bedridden patients often to pre- ings in the lung periphery, enlarged antero-
vent atelectasis. posterior chest diameter, and a vertical heart.
• Provide meticulous respiratory care, includ- • CBC shows increased Hb levels late in dis-
ing oxygen therapy and, for COPD patients, ease when patient has severe persistent hy-
pursed-lip breathing exercises, to improve oxy- poxia.
genation. • ECG shows tall, symmetrical P waves in
• Watch for signs of respiratory failure, such leads II, III, and aVF; a vertical QRS axis; and
as a change in pulse rate; deep, labored respi- signs of right ventricular hypertrophy late in
rations; and increased fatigue produced by ex- the disease.
ertion. Monitoring these parameters helps de- • PFTs show increased residual volume, total
tect early signs of worsening respiratory status. lung capacity, and compliance as well as de-
creased vital capacity, diffusing capacity, and
Teaching topics expiratory volumes.
• Keeping follow-up appointments
• Using home oxygen therapy NURSING DIAGNOSES
• Beginning a smoking-cessation program, if • Fatigue
appropriate • Impaired gas exchange
Emphysema TREATMENT
• Oxygen therapy at 2 to 3 L/minute, transtra-
Emphysema is a form of COPD in which re- cheal therapy for home oxygen therapy
current pulmonary inflammation damages • Chest physiotherapy, postural drainage, and
and eventually destroys the alveolar walls, incentive spirometry
creating large air spaces. This breakdown • Dietary changes, including establishing a
leaves the alveoli unable to recoil normally af- diet high in protein, vitamin C, calories, and
ter expanding and, upon expiration, results in nitrogen
bronchiolar collapse. This traps air in the • Fluid intake up to 3,000 ml/day, if not con-
lungs, leading to overdistention and reduced traindicated by heart failure
gas exchange. • Intubation and mechanical ventilation if res-
piratory status deteriorates
CAUSES • Ultrasonic or mechanical nebulizer treat-
• Deficiency of alpha1-antitrypsin ments
• Smoking • Lung volume reduction surgery
920104.qxd 8/7/08 3:52 PM Page 94
Drug therapy • Monitor and record the color, amount, and

• Alpha1-antitrypsin therapy consistency of sputum. Changes in sputum
• Antibiotics most effective in treating the in- may signal a respiratory infection.
fection (for respiratory infections) • Monitor intake and output and daily weight
• Bronchodilators: terbutaline (Brethine), to detect fluid overload associated with right-
aminophylline (Phyllocontin), theophylline sided heart failure. Dehydration may impair
(Theo-Dur); via nebulizer: albuterol (Proven- the removal of secretions.
til), ipratropium (Atrovent), metaproterenol • Encourage fluids, unless contraindicated, to
(Alupent) liquefy secretions.
• Diuretics (for edema): furosemide (Lasix) • Provide chest physiotherapy, postural
• Expectorant: guaifenesin (Robitussin) drainage, incentive spirometry, and suction to
• Influenza and Pneumovax vaccine aid in removal of secretions.
• Steroids: hydrocortisone (Solu-Cortef),
methylprednisolone (Solu-Medrol) Teaching topics
• Steroids (via nebulizer): beclomethasone • Participating in pulmonary rehabilitation
(Vanceril), triamcinolone (Azmacort) • Recognizing the early signs and symptoms
of respiratory infection and hypoxia
INTERVENTIONS AND RATIONALES • Using home oxygen and nebulizer equip-
• Administer low-flow oxygen because emphy- ment properly
sema patients have chronic hypercapnia, which • Performing pursed-lip, diaphragmatic
means they have a hypoxic respiratory drive. breathing and coughing and deep-breathing
Higher flow rates may eliminate this hypoxic exercises
respiratory drive. • Avoiding exposure to chemical irritants and
• Administer medications, as prescribed, to pollutants
relieve symptoms and prevent complications. • Avoiding spicy foods, extremely hot or cold
• Allow activity, as tolerated, to avoid fatigue foods, and foods that produce gas
and reduce oxygen demands. • Beginning a smoking-cessation program, if
• Monitor respiratory status and pulse oxime- appropriate
try values to detect respiratory compromise, se- • Increasing fluid intake to 3,000 ml/day, if
vere hypoxemia, and hypercapnia. not contraindicated
• Monitor and record cardiovascular status • Avoiding people with respiratory infections
and vital signs. An irregular pulse may indi- • Receiving vaccinations (influenza, Pneumo-
cate an arrhythmia caused by altered oxygena- vax)
tion. Tachycardia and tachypnea may indicate • Contacting the American Lung Association
hypoxemia. Late in the disease, pulmonary hy-
pertension may lead to right ventricular hyper-
Legionnaires’
trophy and right-sided heart failure. Legionnaires’ disease
• Help the patient with turning, coughing,
disease is produced by
a fastidious, and deep breathing to mobilize secretions and Legionnaires’ disease is an acute broncho-
gram-negative facilitate removal. pneumonia, an inflammation of the lungs that
bacterium. • Assist with diaphragmatic and pursed-lip begins in the terminal bronchioles. It’s pro-
breathing to strengthen respiratory muscles. duced by a fastidious, gram-negative bacillus
• Place the patient in high Fowler’s position (rod-shaped bacterium).
to improve ventilation. Legionnaires’ disease derives its name from
• Maintain the patient’s diet and provide the peculiar, highly publicized disease that
small frequent meals and snacks to avoid tir- struck 182 people (29 of whom died) at an
ing him when he eats. Small meals relieve pres- American Legion convention in Philadelphia
sure on the diaphragm and allow fuller lung in July 1976.
movement. This disease may occur epidemically or spo-
radically, most often in late summer or early
fall. Its severity ranges from a mild illness,
920104.qxd 8/7/08 3:52 PM Page 95
with or without pneumonitis, to multilobar NURSING DIAGNOSES

pneumonia, with a mortality as high as 15%. A • Hyperthermia
milder, self-limiting form (Pontiac fever) sub- • Impaired gas exchange
sides within a few days but leaves the patient • Risk for injury
fatigued for several weeks; this form mimics
Legionnaires’ disease but produces few or no TREATMENT
respiratory symptoms, no pneumonia, and no • I.V. fluids as indicated
fatalities. No treatment is required for Pontiac • Oxygen therapy; possibly intubation and
fever. mechanical ventilation if the patient’s condi-
tion deteriorates
CAUSES
• Legionella pneumophila Drug therapy
• Antibiotics: erythromycin (Erythrocin), ri-
DATA COLLECTION FINDINGS fampin (Rifadin), tetracycline (Achromycin V)
• Amnesia • Antipyretics: acetaminophen (Tylenol), as-
• Anorexia pirin
• Bradycardia • Inotropic agent: dopamine (Intropin)
• Cough that’s initially nonproductive but that • Vasopressors: norepinephrine (Levophed), Erythromycin is
eventually can produce grayish, nonpurulent, phenylephrine (Neo-Synephrine) the antibiotic of
choice for
blood-streaked sputum • Anesthetic: propofol (Diprivan) if mechani-
Legionnaires’ disease.
• Diarrhea cal ventilation is necessary In severe cases,
• Diffuse myalgias rifampin may also be
• Fever INTERVENTIONS AND RATIONALES used.
• Generalized weakness • Monitor respiratory status. Evaluate chest
• Headache wall expansion, depth and pattern of respira-
• Malaise tions, cough, and chest pain to detect respirato-
• Mental sluggishness ry decompensation.
• Recurrent chills • Monitor vital signs, pulse oximetry, level of
consciousness, and dryness and color of the
DIAGNOSTIC FINDINGS lips and mucous membranes. Watch for
• Blood tests show leukocytosis, increased signs of shock (decreased blood pres-
ESR, increased liver enzyme levels (alanine sure, thready pulse, diaphoresis, clammy
aminotransferase, aspartate aminotrans- skin) to avoid crisis.
ferase, alkaline phosphatase), and hypona- • Provide mouth care frequently. If need-
tremia. ed, apply soothing cream to the nostrils
• Chest X-ray shows patchy, localized infiltra- to promote comfort and prevent skin break-
tion, which progresses to multilobar consoli- down.
dation (usually involving the lower lobes), • Administer I.V. fluids as ordered to provide
pleural effusion and, in fulminant disease, hydration.
opacification of the entire lung. • Maintain mechanical ventilation and pro-
• Direct immunofluorescence of L. pneu- vide respiratory therapy, as needed, to pro-
mophila and indirect fluorescent serum anti- mote oxygenation.
body testing compare findings from initial • Administer antibiotics, as needed, to eradi-
blood studies with findings from those done cate infection, and observe the patient careful-
at least 3 weeks later. A convalescent serum ly for adverse effects to prevent complications.
sample showing a fourfold or greater rise in
antibody titer for L. pneumophila confirms the Teaching topics
diagnosis. • Performing coughing and deep-breathing
• Sputum test eliminates other organisms. exercises
• Understanding the importance of continu-
ing treatment until recovery is complete
920104.qxd 8/7/08 3:52 PM Page 96
In lung cancer, Lung cancer • Sputum study reveals positive cytology for
unregulated cell cancer cells.
growth and In lung cancer, unregulated cell growth and
uncontrolled cell uncontrolled cell division result in the devel- NURSING DIAGNOSES
division result in the opment of a neoplasm. Cancer may also • Activity intolerance
development of a spread (metastasize) to the lungs from other • Anxiety
neoplasm. organs, mainly the liver, brain, bone, kidneys, • Impaired gas exchange
and adrenal glands.
The four histologic types of lung cancer are: TREATMENT
• Dietary changes, including the adoption of
squamous cell (epidermoid), a slow- a high-protein, high-calorie diet and providing
growing cancer that originates in the small, frequent meals or enteral nutrition if
bronchial epithelium (it metastasizes late to mechanical ventilation is indicated
the surrounding area and may cause bron- • Incentive spirometry
chial obstruction) • Laser photocoagulation
• Oxygen therapy, intubation and, if the con-
adenocarcinoma, a moderately growing
dition deteriorates, mechanical ventilation
cancer located in peripheral areas of the lung
• Radiation therapy
(it metastasizes through the bloodstream to
• I.V. fluids
other organs)
• Resection of the affected lobe (lobectomy)
large-cell anaplastic, a very fast- or lung (pneumonectomy)
growing cancer associated with early and ex-
tensive metastasis (it’s more common in Drug therapy
peripheral lung tissue) • Analgesics: morphine, fentanyl (Sublimaze)
• Antiemetics: prochlorperazine (Com-
small-cell (oat cell cancer), a very fast- pazine), ondansetron (Zofran), dolasetron
growing cancer that metastasizes very early (Anzemet)
through lymph vessels and the bloodstream • Antineoplastics: cyclophosphamide (Cytox-
to other organs. an), doxorubicin (Adriamycin), cisplatin
(Platinol), vincristine (Oncovin), vinorelbine
CAUSES (Novelbine), gemcitabine (Gemzar), paclitax-
• Cigarette smoking el (Taxol), docetaxel (Taxotere), irinotecan
• Exposure to environmental pollutants (Camptosor)
In a patient with • Exposure to occupational pollutants • Diuretics: furosemide (Lasix), ethacrynic
lung cancer, a chest • May be unknown acid (Edecrin)
X-ray shows the lesion
or mass. DATA COLLECTION FINDINGS INTERVENTIONS AND RATIONALES
• Chest pain • Monitor respiratory status to detect respira-
• Chills, fever tory complications. Cyanosis may suggest re-
• Cough, hemoptysis spiratory failure, and an increase in sputum
• Dyspnea, wheezing production may suggest an infection.
• Weakness, fatigue • Monitor pain level and administer anal-
• Weight loss, anorexia gesics, as prescribed, to control pain. Assess-
ment allows changes to care as needed.
DIAGNOSTIC FINDINGS • Monitor and record vital signs. Tachycardia
• Biopsy reveals malignant cells and identifies and tachypnea may indicate hypoxemia. An ele-
the type of cancer. vated temperature suggests an infection.
• Chest X-ray shows a lesion or mass. • Monitor and record intake and output to
• Lung scan shows a mass. evaluate fluid status.
• Open lung biopsy reveals lung cancer.
920104.qxd 8/7/08 3:52 PM Page 97
• Monitor for bleeding, infection, and elec- Pleural effusion and I need my space.
trolyte imbalance (especially hypercalcemia)
from the effects of chemotherapy. A low WBC empyema Pleural effusion is an
excess of fluid in the
count increases the risk of infection. A low pleural space.
platelet count increases the risk of bleeding. An Pleural effusion is an excess of fluid in the
electrolyte imbalance involving excessive calci- pleural space (the thin space between the
um can lead to a variety of symptoms and can lung tissue and the membranous sac that pro-
be severe or life-threatening. tects it). Normally, the pleural space contains
• Monitor pulse oximetry values, and report a small amount of extracellular fluid that lubri-
any drop in oxygen saturation, which suggests cates the pleural surfaces. Increased produc-
hypoxemia. tion or inadequate removal of this fluid results
• Administer oxygen to maintain tissue oxy- in pleural effusion.
genation. Empyema is the accumulation of pus and
• Encourage fluid intake and maintain I.V. flu- necrotic tissue in the pleural space. Blood
ids to provide hydration and liquefy secretions (hemothorax) and chyle (chylothorax) may
to facilitate removal. Drinking moistens mu- also collect in this space.
cous membranes.
• Provide suctioning and help the patient with CAUSES
turning, coughing, and deep breathing to fa- • Bacterial or fungal pneumonitis or em-
cilitate removal of secretions. pyema
• Place the patient in semi-Fowler’s position • Chest trauma
to maximize ventilation. • Collagen disease (lupus erythematosus and
• Administer enteral feedings as prescribed if rheumatoid arthritis)
the patient is receiving mechanical ventilation • Heart failure
to optimize nutritional status. • Hepatic disease with ascites
• Administer medications, as prescribed, to • Hypoalbuminemia
treat the cancer and provide pain relief. • Infection in the pleural space
• Encourage the patient to express feelings • Malignancy
about changes in body image and his fear of • Myxedema
dying to reduce anxiety. • Pancreatitis
• Perform mouth care to improve comfort and • Peritoneal dialysis
reduce risk of stomatitis (with chemotherapy). • Pulmonary embolism with or without infarc-
• Perform skin care to minimize adverse ef- tion
fects of radiation therapy. • Subphrenic abscess
• Provide rest periods to enhance tissue oxy- • TB
genation.
Teaching topics • Anorexia
• Performing deep-breathing and coughing • Decreased breath sounds
exercises • Dyspnea
• Alternating rest periods with activity • Fever
• Following dietary recommendations and re- • Malaise
strictions • Pleuritic chest pain
• Taking measures to prevent infection, such
as avoiding crowds and infected individuals, DIAGNOSTIC FINDINGS
especially children with communicable dis- • Chest X-ray shows radiopaque fluid in de-
eases pendent regions.
• Contacting the American Cancer Society • Thoracentesis shows lactate dehydrogenase
(LD) levels less than 200 IU and protein levels
less than 3 g/dl (in transudative effusions);
920104.qxd 8/7/08 3:52 PM Page 98
ratio of protein in pleural fluid to protein in him how to use an incentive spirometer to
serum greater than or equal to 0.5, LD in promote deep breathing.
pleural fluid greater than or equal to 200 IU, • Carefully provide chest tube care to avoid
and ratio of LD in pleural fluid to LD in serum dislodging the chest tube.
greater than 0.6 (in exudative effusions); and • Ensure chest tube patency by watching for
acute inflammatory WBCs and microorgan- bubbles in the underwater seal chamber to
isms (in empyema). prevent respiratory distress resulting from chest
• Tuberculin skin test rules out TB as the tube obstruction.
cause. • Record the amount, color, and consistency
of any tube drainage to monitor the effective-
NURSING DIAGNOSES ness of treatment.
• Hyperthermia • Refer patients who will be discharged with
• Impaired gas exchange the tube in place to visiting nurses because
• Risk for infection weeks of such drainage may be necessary to
eliminate the excessive fluid.
TREATMENT
• Thoracentesis (to remove fluid) Teaching topics
• Thoracotomy if thoracentesis isn’t effective • Seeking prompt medical attention for chest
• Possibly supplemental oxygen therapy colds (if pleural effusion was a complication of
pneumonia or influenza)
Drug therapy • Understanding the importance of continu-
• Antibiotics (for empyema): most effective in ing antibiotic therapy for the duration pre-
treating the causative organism scribed
• Performing chest tube care, if necessary, af-
INTERVENTIONS AND RATIONALES ter discharge
• Explain thoracentesis to the patient. Before
the procedure, tell the patient to expect a
stinging sensation from the local anesthetic Pleurisy
and a feeling of pressure when the needle is
inserted. These explanations may allay the Also known as pleuritis, pleurisy is an inflam-
patient’s anxiety. mation of the visceral and parietal pleurae, the
Pleurisy is an • Instruct the patient to tell you immediately serous membranes that line the inside of the
inflammation of the if he feels uncomfortable or has trouble thoracic cage and envelop the lungs.
membranes that line breathing during thoracentesis. Difficulty
the inside of the rib breathing may indicate pneumothorax, which CAUSES
cage and envelop the requires immediate chest tube insertion. • Cancer
lungs. • Reassure the patient during thoracentesis to • Chest trauma
allay anxiety. Remind him to breathe normally • Dressler’s syndrome
and to avoid sudden movements, such as • Pneumonia
coughing and sighing. Remaining still may • Pulmonary infarction
prevent improper placement of the needle. • Rheumatoid arthritis
• Monitor vital signs and watch for syncope to • Systemic lupus erythematosus
prevent injury. • TB
• Watch for respiratory distress or pneumoth- • Uremia
orax (sudden onset of dyspnea and cyanosis) • Viruses
after thoracentesis to detect complications.
• Administer oxygen to improve oxygenation. DATA COLLECTION FINDINGS
• Administer antibiotics to treat empyema. • Dyspnea
• Encourage the patient to do deep-breathing • Pleural friction rub (a coarse, creaky sound
exercises to promote lung expansion. Teach heard during late inspiration and early expira-
tion)
920104.qxd 8/7/08 3:52 PM Page 99
• Sharp, stabbing pain that increases with res- Pneumocystis carinii P. carinii is part of
piration
pneumonia the normal flora in
most healthy people.
DIAGNOSTIC FINDINGS However, in the
Although diagnosis generally rests on the The microorganism Pneumocystis carinii is immunocompromised
patient’s history and respiratory assessment, part of the normal flora in most healthy peo- patient, it becomes an
diagnostic tests help rule out other causes ple. However, in the immunocompromised aggressive pathogen.
and pinpoint the underlying disorder. patient, P. carinii becomes an aggressive
• ECG rules out coronary artery disease as pathogen. P. carinii pneumonia (PCP) is an
the source of the patient’s pain. opportunistic infection strongly associated
• Chest X-rays can identify pneumonia. with human immunodeficiency virus (HIV)
infection.
NURSING DIAGNOSES PCP occurs in up to 90% of HIV-infected pa-
• Activity intolerance tients in the United States at some point dur-
• Ineffective breathing pattern ing their lifetime. It’s the leading cause of
• Acute pain death in these patients. Disseminated infec-
tion doesn’t occur. PCP is also associated with
TREATMENT other immunocompromised conditions, in-
• Bed rest cluding organ transplantation, leukemia, and
• Thoracentesis (for pleurisy with pleural ef- lymphoma.
fusion)
CAUSES
Drug therapy • P. carinii
• Analgesic: acetaminophen with oxycodone
(Percocet) DATA COLLECTION FINDINGS
• Anti-inflammatories: indomethacin (Indo- • Anorexia
cin), ibuprofen (Motrin) • Dyspnea
• Generalized fatigue
INTERVENTIONS AND RATIONALES • Low-grade, intermittent fever
• Stress the importance of bed rest and allow • Nonproductive cough
the patient as much uninterrupted rest as pos- • Tachypnea
sible to prevent fatigue. • Weight loss
• Administer antitussive and pain medication,
as needed, to relieve cough and pain. DIAGNOSTIC FINDINGS
• If an opioid analgesic is prescribed, warn • ABG studies detect hypoxia and an in-
any patient about to be discharged to avoid creased alveolar-arterial gradient.
overuse. Too much of these medications de- • Chest X-ray may show slowly progressing,
press coughing and respiration. fluffy infiltrates and occasionally nodular le-
• Encourage the patient to cough. Apply firm sions or a spontaneous pneumothorax. These
pressure at the pain site during coughing ex- findings must be differentiated from findings
ercises to minimize pain. in other types of pneumonia or ARDS.
• Fiber-optic bronchoscopy confirms PCP.
Teaching topics • Gallium scan may show increased uptake
• Performing coughing and deep-breathing over the lungs even when the chest X-ray ap-
exercises pears relatively normal.
• Implementing all procedures, including tho- • Histologic studies confirm P. carinii. In pa-
racentesis if appropriate tients with HIV infection, initial examination
• Understanding the importance of regular of a first morning sputum specimen (induced
rest periods by inhaling an ultrasonically dispersed saline
mist) may be sufficient. This technique is usu-
ally ineffective in patients not infected by HIV.
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NURSING DIAGNOSES • Provide a relaxing environment, eliminate

• Ineffective protection excessive environmental stimuli, and allow
• Impaired gas exchange ample time for meals to reduce anxiety.
• Risk for infection • Give emotional support and help the patient
identify and use meaningful support systems
TREATMENT to promote emotional well-being.
• Diet modification, including maintaining ad-
equate nutrition Teaching topics
• Oxygen therapy, which may include ET in- • Practicing energy-conservation techniques
tubation and mechanical ventilation • Using home oxygen therapy
• I.V. fluids • Recognizing adverse reactions to medica-
tions
Drug therapy
• Antibiotics: co-trimoxazole (Bactrim), pen-
tamidine (NebuPent) Pneumonia
INTERVENTIONS AND RATIONALES Pneumonia refers to a bacterial, viral, para-
• Monitor respiratory status and pulse oxime- sitic, or fungal infection that causes inflamma-
try values to detect early signs of hypoxemia. tion of the alveolar spaces. In pneumonia, mi-
• Administer oxygen therapy as needed. En- croorganisms enter alveolar spaces through
courage ambulation, deep-breathing exercis- droplet inhalation, resulting in inflammation
es, and incentive spirometry. These measures and an increase in alveolar fluid. Ventilation
facilitate effective gas exchange. decreases as secretions thicken.
• Administer an antipyretic, as ordered, to re-
lieve fever. CAUSES
• Monitor intake and output and weigh the • Aspiration
patient daily to evaluate fluid balance. Replace • Chemical irritants
fluids as necessary to correct fluid deficit. • Organisms such as Escherichia coli, Haemo-
• Administer antimicrobial drugs as ordered. philus influenzae, Staphylococcus aureus, Pneu-
Never give pentamidine (NebuPent)I.M. be- mocystis carinii, Streptococcus pneumoniae,
cause it can cause pain and sterile abscesses. and Pseudomonas
• Monitor the patient for adverse reactions
to antimicrobial drugs. If he’s receiving co- DATA COLLECTION FINDINGS
trimoxazole (Bactrim), watch for nausea, • Chills, fever
vomiting, rash, bone marrow suppression, • Cough
thrush, fever, hepatotoxicity, and anaphylaxis. • Crackles, rhonchi, pleural friction rub on
If he’s receiving pentamidine, watch for car- auscultation
diac arrhythmias, hypotension, dizziness, • Malaise
azotemia, hypocalcemia, and hepatic distur- • Pleuritic pain
bances. These measures detect problems early • Restlessness, confusion
to avoid crisis. • Dyspnea, tachypnea, accessory muscle use
• Provide diversional activities and coordinate • Sputum that’s rusty, green, or bloody with
health care team activities to allow adequate pneumococcal pneumonia and yellow-green
rest periods between procedures. with bronchopneumonia
• Supply nutritional supplements as needed.
Encourage the patient to eat a high-calorie, DIAGNOSTIC FINDINGS
protein-rich diet. Offer small, frequent meals • ABG levels initially show hypoxemia and
if the patient can’t tolerate large amounts of respiratory alkalosis, which may progress to
food. These measures ensure that the patient’s respiratory acidosis.
nutritional intake meets metabolic needs. • Chest X-ray shows pulmonary infiltrates.
920104.qxd 8/7/08 3:52 PM Page 101
• Hematology results show increased WBC • Maintain the patient’s diet to offset hypermet-
Don’t stop now!
count and ESR. abolic state caused by infection. Just a few more
• Sputum study identifies the causative • Encourage fluids to 3,000 ml/day and main- respiratory disorders
organism. tain I.V. fluids to help liquefy secretions and aid to go!
in their removal.
NURSING DIAGNOSES • Perform suctioning and help the patient
• Ineffective airway clearance with turning, coughing, and deep breath-
• Risk for aspiration ing to promote mobilization and removal
• Impaired spontaneous ventilation of secretions.
• Perform chest physiotherapy to facili-
TREATMENT tate removal of secretions.
• Chest physiotherapy, postural drainage, and • Administer medications, as prescribed,
incentive spirometry to treat infection and improve ventilation.
• Dietary changes, including establishing a • Encourage the patient to express fear
high-calorie, high-protein diet and forcing of suffocation to reduce his anxiety.
fluids • Provide tissues and a bag for hygienic
• Supplemental oxygen therapy; intubation sputum disposal to prevent spread of infection.
and mechanical ventilation, if condition deteri- • Provide oral care to promote comfort and im-
orates prove nutrition.
• Nutritional support, including enteral nutri-
tion if the patient requires intubation Teaching topics
• I.V. fluids • Recognizing the early signs and symptoms
of respiratory infections
Drug therapy • Avoiding exposure to people with infections
• Antibiotics: most effective in treating • Increasing fluid intake to 3,000 ml/day
causative organism
• Antipyretics: aspirin, acetaminophen
(Tylenol) Pneumothorax and
• Bronchodilators: metaproterenol (Alupent),
isoetharine (Bronkosol), albuterol (Proventil) hemothorax
INTERVENTIONS AND RATIONALES With pneumothorax, loss of negative intra-
• Monitor and record intake and output. In- pleural pressure results in the collapse of a
sensible water loss secondary to fever may cause lung. Pneumothorax may be described as
dehydration. spontaneous, open, closed, or tension:
• Monitor pulse oximetry values to detect res- • Spontaneous pneumothorax results from
piratory compromise. the rupture of a bleb.
• Monitor respiratory status to detect early • Open pneumothorax occurs when an
signs of compromise. opening through the chest wall allows air to
• Monitor and record vital signs. An elevated flow between the pleural space and the out-
temperature increases oxygen demands. Hy- side of the body.
potension and tachycardia may suggest hypo- • Closed pneumothorax occurs when air
volemic shock. enters the pleural space from within the lung.
• Monitor and record color, consistency, and This causes increased pleural pressure and
amount of sputum. Sputum amount and con- prevents lung expansion during inspiration. It
sistency may indicate hydration status and ef- may be called traumatic pneumothorax
fectiveness of therapy. Foul-smelling sputum when blunt chest trauma causes lung tissue to
suggests respiratory infection. rupture, resulting in air leakage.
• Administer oxygen to help relieve respiratory • Tension pneumothorax results from a
distress. buildup of air in the pleural space that can’t
escape. Tension pneumothorax can develop
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from either spontaneous or traumatic pneu- NURSING DIAGNOSES

mothorax. • Ineffective breathing pattern
In all cases, the surface area for gas ex- • Impaired gas exchange
change is reduced, resulting in hypoxia and • Acute pain
hypercapnia.
In hemothorax, blood accumulates in the TREATMENT
pleural space when a rib lacerates lung tissue • Active range-of-motion (ROM) exercises
or an intercostal artery. This compresses the with affected arm
lung and limits respiratory capacity. Hemo- • Blood transfusions for hemothorax, as indi-
thorax can also result from rupture of large or cated
small pulmonary vessels. • Chest tube to water-seal drainage or emer-
gent needle thoracostomy for tension pneu-
CAUSES mothorax
• Blunt chest trauma • Incentive spirometry
• Central venous catheter insertion • Occlusive dressing (for open pneumotho-
• Penetrating chest injuries rax)
• Rupture of a bleb • Oxygen therapy
• Thoracentesis
• Thoracic surgeries Drug therapy
• Pacemaker insertion • Analgesic: morphine
• Tracheotomy
INTERVENTIONS AND RATIONALES
DATA COLLECTION FINDINGS • Monitor and record vital signs. Hypotension,
• Anxiety tachycardia, and tachypnea suggest tension
• Asymetrical chest expansion pneumothorax.
• Diaphoresis, pallor • Check the chest drainage system for air
• Diminished or absent breath sounds unilat- leaks that can impair lung expansion.
erally • Monitor respiratory status and pulse oxime-
• Dullness on chest percussion (in hemotho- try values. Monitor around chest tube site for
rax and tension pneumothorax) subcutaneous emphysema. Dyspnea, tachy-
• Dyspnea, tachypnea, subcutaneous emphy- pnea, diminished breath sounds, subcutaneous
sema, cough emphysema, and use of accessory muscles sug-
• Hypotension (in hemothorax) gest accumulation of air in pleural space.
• Sharp chest pain that increases with exer- • Monitor chest tube drainage. An increase in
tion the amount of bloody drainage suggests new
• Tachycardia bleeding or an increase in bleeding. Check tub-
• Tracheal shift (in tension pneumothorax) ing for kinks if there’s a sudden reduction in
drainage.
DIAGNOSTIC FINDINGS • Monitor and record vital signs. Hypotension,
• Chest X-rays confirm the diagnosis by re- tachycardia, and tachypnea suggest tension
vealing air in the pleural space and, possibly, pneumothorax.
a mediastinal shift. Sequential chest X-rays • Evaluate cardiovascular status. Tachycardia,
show whether thoracostomy was effective in hypotension, and jugular vein distention sug-
resolving pneumothorax. gest tension pneumothorax.
• ABG levels show respiratory acidosis and • Monitor pain level and administer medica-
hypoxemia. tions, as prescribed, to control pain.
• Pulse oximetry may initially show de- • Administer oxygen to relieve respiratory dis-
creased oxygen saturation, which typically tress caused by hypoxemia.
returns to normal within 24 hours. • Assist the patient with turning, coughing,
deep breathing, and incentive spirometry to
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enhance mobilization of secretions and prevent DIAGNOSTIC FINDINGS If the patient has
atelectasis. • ABG levels typically show decreased PaO2 a pulmonary embolism,
interventions are likely
• Maintain chest tube to water-seal drainage. and PaCO2.
to include
The water-seal chamber prevents air from en- • Blood chemistry tests reveal increased LD administering an
tering the chest tube when the patient inhales. level. anticoagulant such as
• Place the patient in high Fowler’s position to • Chest X-ray shows dilated pulmonary arter- heparin.
enhance chest expansion. ies, pneumoconstriction, and diaphragm ele-
vation on the affected side.
Teaching topics • ECG shows tachycardia, nonspecific ST-
• Recognizing the early signs and symptoms segment changes, and right axis devia-
of pneumothorax and respiratory infection tion.
• Avoiding heavy lifting • Pulmonary angiography shows location
of embolism and filling defect of pul-
monary artery.
· ·
Pulmonary embolism • Lung scan shows V/Q mismatch.
Pulmonary embolism results when an undis- NURSING DIAGNOSES

solved substance (such as fat, air, or throm- • Anxiety
bus) in the pulmonary vessels obstructs the • Impaired gas exchange
patient’s blood flow. The embolus travels from • Ineffective tissue perfusion: Cardiopul-
the venous circulation to the right side of the monary
heart and pulmonary artery, obstructing
blood flow and resulting in pulmonary hyper- TREATMENT
tension and possible infarction. • Bed rest with active and passive ROM and
isometric exercises
CAUSES • Vena cava filter insertion
• Abdominal, pelvic, or thoracic surgery • Oxygen therapy, intubation, and mechanical
• Central venous catheter insertion ventilation, if necessary
• Flat, long bone fractures • I.V. fluids
• Heart failure • Sequential compression device
• Hypercoagulability
• Malignant tumors Drug therapy
• Obesity • Analgesic: morphine
• Hormonal contraceptives • Anticoagulants: heparin (Heparin Sodium
• Polycythemia vera Injection), followed by warfarin (Coumadin)
• Pregnancy • Diuretic: furosemide (Lasix) if right ventric-
• Prolonged bed rest ular failure develops
• Sickle cell anemia • Fibrinolytics: streptokinase (Streptase), tis-
• Thrombophlebitis sue plasminogen activator (Activase)
• Venous stasis
DATA COLLECTION FINDINGS • Monitor respiratory status and pulse oxime-
• Anxiety try values to detect respiratory distress.
• Chest pain • Evaluate cardiovascular status and monitor
• Cough, hemoptysis ECG. An irregular pulse may signal arrhyth-
• Fever mia caused by hypoxemia. If pulmonary em-
• Hypotension bolism is caused by thrombophlebitis, tempera-
• Sudden onset of dyspnea, tachypnea, ture may be elevated.
crackles • Monitor and record intake and output to de-
• Tachycardia, arrhythmias tect fluid volume overload and renal perfusion.
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• Check for positive Homans’ sign to detect • Neuromuscular diseases, such as myasthe-
thromboembolism as a cause of pulmonary em- nia gravis, Guillain-Barré syndrome, and
bolus. poliomyelitis
Memory • Administer oxygen to enhance arterial oxy-
jogger genation. DATA COLLECTION FINDINGS
• Assist the patient with turning, coughing, • Cardiovascular abnormalities, such as
To remem- and deep breathing to mobilize secretions and tachycardia, hypertension, atrial and ventricu-
ber the
significance of pH, clear airways. lar arrhythmias and, in severe acidosis, hy-
think “percentage • Place the patient in high Fowler’s position to potension
hydrogen,” recalling enhance ventilation. • Coma
that H is the sym- • Perform suctioning, and monitor and • Confusion
bol for hydrogen. record color, consistency, and amount of spu- • Dyspnea and tachypnea with papilledema
The term pH refers tum. A productive cough and blood-tinged spu- and depressed reflexes
to the balance of tum may be present with pulmonary embolism. • Fine or flapping tremor (asterixis)
hydrogen ions • Maintain I.V. fluids to maintain hydration. • Headaches
(acids) and bicar- • Administer medications, as prescribed, to • Hypoxemia
bonate ions (base) enhance tissue oxygenation. • Restlessness
in a solution.
When H goes up, pH Teaching topics DIAGNOSTIC FINDINGS
goes down. Normal • Recognizing the early signs and symptoms • ABG measurements confirm respiratory
arterial pH is 7.35 of respiratory distress acidosis. PaCO2 exceeds the normal level of
to 7.45. In acidosis, • Avoiding activities that promote venous 45 mm Hg, and pH is usually below the nor-
hydrogen ions
(acids) accumulate thrombosis (prolonged sitting and standing, mal range of 7.35 to 7.45. The patient’s bicar-
and pH goes down. wearing constrictive clothing, crossing legs bonate level is normal in the acute stage and
In alkalosis, hydro- when seated, using hormonal contraceptives) elevated in the chronic stage.
gen ions decrease • Reporting signs of bleeding from excessive
and pH goes up. anticoagulant therapy NURSING DIAGNOSES
• Fear
Respiratory acidosis • Ineffective breathing pattern
Respiratory acidosis is an acid-base distur- TREATMENT

bance characterized by an excess of carbon Treatment of respiratory acidosis is designed
dioxide in the blood (hypercapnia), indicated to correct the underlying source of alveolar
by a PaCO2 greater than 45 mm Hg. It results hypoventilation. It may include:
from reduced alveolar ventilation and can be • I.V. fluids
acute (as from a sudden failure in ventilation) • incentive spirometry
or chronic (as from long-term pulmonary dis- • ET intubation and mechanical ventilation
ease). • dialysis to remove toxic drugs
• removal of foreign body, if appropriate.
CAUSES
• Airway obstruction or parenchymal lung Drug therapy
disease • Antibiotics if pneumonia is present
• Chest trauma • Bronchodilators: metaproterenol (Alupent),
• CNS trauma albuterol (Proventil)
• Chronic metabolic alkalosis • Sodium bicarbonate in severe cases
• Drugs, such as opioids, anesthetics, hyp-
notics, and sedatives INTERVENTIONS AND RATIONALES
• Be alert for critical changes in the patient’s
respiratory, CNS, and cardiovascular func-
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tions. Maintain adequate hydration. These Nonpulmonary causes

I overdo it
measures help detect life-threatening complica- • Anxiety sometimes. When I
tions. • Aspirin toxicity eliminate CO2 faster
• Maintain a patent airway and provide ade- • CNS disease (inflammation or tumor) than it’s produced at
quate oxygenation. Perform tracheal suction- • Fever the cellular level, it
ing regularly and vigorous chest physiothera- • Hepatic failure leads to respiratory
py to ensure adequate oxygenation. • Metabolic acidosis alkalosis—deficiency
• Closely monitor patients with COPD and • Pregnancy of CO2 in the blood—
chronic carbon dioxide retention for signs of • Sepsis which can lead to a
acidosis. Also, administer oxygen at low flow loss of hydrogen ions
and an increase in pH.
rates and closely monitor all patients who re- DATA COLLECTION FINDINGS
ceive opioids and sedatives to prevent respira- • Agitation
tory acidosis. • Cardiac arrhythmias that fail to respond to
• Instruct the patient who has received a gen- conventional treatment (in severe respiratory
eral anesthetic to use the incentive spirome- alkalosis)
ter once every hour during his waking hours. • Carpopedal spasms (spasms affecting the
Tell him to also turn, cough, and do deep- wrists and the feet)
breathing exercises frequently to prevent the • Circumoral or peripheral paresthesia (a
onset of respiratory acidosis. prickling sensation around the mouth or ex-
tremities)
Teaching topics • Deep, rapid breathing, possibly exceeding
• Using home oxygen therapy 40 breaths/minute (cardinal sign)
• Performing coughing and deep-breathing • Light-headedness or dizziness (from de-
exercises and using an incentive spirometer creased cerebral blood flow)
• Following the medication regimen and rec- • Muscle weakness
ognizing possible adverse reactions • Seizures with severe respiratory alkalosis
• Twitching, possibly progressing to tetany
Respiratory alkalosis DIAGNOSTIC FINDINGS

• ABG analysis confirms respiratory alkalosis
Respiratory alkalosis is characterized by a and rules out respiratory compensation for
deficiency of carbon dioxide in the blood metabolic acidosis. In the acute stage, PaCO2
(hypocapnia), as indicated by a decrease in is below 35 mm Hg and pH is elevated in pro-
PaCO2 to below 35 mm Hg (normal level is portion to the fall in PaCO2. In the chronic
45 mm Hg). stage, pH drops toward normal. Bicarbonate
This condition is caused by alveolar hyper- level is normal in the acute stage but below
ventilation. Elimination of carbon dioxide by normal in the chronic stage.
the lungs exceeds the production of carbon
dioxide at the cellular level, leading to defi- NURSING DIAGNOSES
ciency of carbon dioxide in the blood. • Anxiety
Uncomplicated respiratory alkalosis leads • Impaired gas exchange
to a decrease in hydrogen ion concentration, • Ineffective breathing pattern
which causes elevated blood pH.
TREATMENT
CAUSES Treatment seeks to eradicate the underlying
Pulmonary causes condition. It may include:
• Acute asthma • removal of ingested toxins
• Interstitial lung disease • treatment of CNS disease
• Pneumonia • treatment of fever or sepsis.
• Pulmonary vascular disease
920104.qxd 8/7/08 3:52 PM Page 106
With severe respiratory alkalosis DATA COLLECTION FINDINGS

• Having the patient breathe into a paper bag, Initial signs
which helps relieve acute anxiety and increas- • Arthralgia in the wrists, ankles, and elbows
es carbon dioxide levels • Fatigue
• Malaise
INTERVENTIONS AND RATIONALES • Weight loss
• Watch for and report any changes in neuro-
logic, neuromuscular, or cardiovascular func- Respiratory
tion to ensure prompt recognition and treat- • Breathlessness
ment of complications. • Cor pulmonale (in advanced pulmonary dis-
• Monitor respiratory status to detect worsen- ease)
ing condition. • Cough (usually nonproductive)
• Pulmonary hypertension (in advanced pul-
Teaching topics monary disease)
• Performing relaxation techniques • Substernal pain
• Breathing into a paper bag during an acute
anxiety attack Cutaneous
• Erythema nodosum
• Subcutaneous skin nodules with macu-
Sarcoidosis lopapular eruptions
• Extensive nasal mucosal lesions
Sarcoidosis is a multisystemic, granulomatous
disorder (this means it affects many body Ophthalmic
systems and produces nodules of chronically • Anterior uveitis (common)
inflamed tissue). Sarcoidosis may lead to • Glaucoma and blindness (rare)
lymphadenopathy (disease of the lymph
nodes), pulmonary infiltration, and skeletal, Lymphatic
liver, eye, or skin lesions. • Lymphadenopathy
Sarcoidosis occurs most often in young • Splenomegaly (enlarged spleen)
adults (ages 20 to 40). In the United States, it
occurs predominantly among blacks and af- Musculoskeletal
fects twice as many women as men. • Muscle weakness
Acute sarcoidosis usually resolves within • Polyarthralgia (pain affecting many joints)
2 years. Chronic, progressive sarcoidosis, • Pain
which is uncommon, is associated with pul- • Punched-out lesions on phalanges
monary fibrosis and progressive pulmonary
disability. Hepatic
• Granulomatous hepatitis (usually produces
CAUSES no symptoms)
Although the cause of sarcoidosis is un-
known, the following explanations are pos- Genitourinary
sible: • Hypercalciuria (excessive calcium in the
• hypersensitivity response (possibly from a urine)
T-cell imbalance) to such agents as mycobac-
teria, fungi, and pine pollen Cardiovascular
• genetic predisposition (suggested by a • Arrhythmias (premature beats, bundle-
slightly higher incidence of sarcoidosis within branch block, or complete heart block)
specific families) • Cardiomyopathy (rare)
• exposure to chemicals, such as zirconium
or beryllium, which can lead to illnesses re-
sembling sarcoidosis.
920104.qxd 8/7/08 3:52 PM Page 107
Central nervous system Drug therapy

Remember that a
• Cranial or peripheral nerve palsies • Corticosteroids: prednisone (Deltasone) patient on long-term
• Basilar meningitis (inflammation of the • Cytotoxic agents: methotrexate (Rheuma- or high-dose steroid
meninges at the base of the brain) trex), azathioprine (Imuran) therapy is vulnerable
• Seizures to infection.
• Pituitary and hypothalamic lesions produc- INTERVENTIONS AND RATIONALES
ing diabetes insipidus • Watch for and report complications. Be
aware of any abnormal laboratory results
DIAGNOSTIC FINDINGS that could alter patient care.
• A positive Kveim-Siltzbach skin test sup- • Administer analgesics as needed to pro-
ports the diagnosis. In this test, the patient remote patient comfort. Record signs of pro-
ceives an intradermal injection of an antigen gressive muscle weakness to detect deterio-
prepared from human sarcoidal spleen or ration in the patient’s condition.
lymph nodes from patients with sarcoidosis. If • Provide a nutritious, high-calorie diet and
the patient has active sarcoidosis, granuloma plenty of fluids to ensure that nutritional in-
develops at the injection site in 2 to 6 weeks. take meets the patient’s metabolic needs. If
This reaction is considered positive when a the patient has hypercalcemia, suggest a
biopsy of the skin at the injection site shows low-calcium diet to prevent the complications
discrete epithelioid cell granuloma. of hypercalcemia (muscle weakness, heart
• ABG analysis shows decreased PaO2. block, hypertension, and cardiac arrest).
• Chest X-ray shows bilateral hilar and right • Weigh the patient daily to detect weight loss.
paratracheal adenopathy with or without dif- • Monitor the patient’s respiratory function.
fuse interstitial infiltrates; occasionally, large Record increase in sputum. If the patient has
nodular lesions are present in lung paren- pulmonary hypertension or end-stage cor
chyma. pulmonale, administer oxygen as needed.
• Lymph node, skin, or lung biopsy reveals These measures promptly detect deterioration
noncaseating granulomas with negative cul- in the patient’s condition.
tures for mycobacteria and fungi. • Perform fingerstick glucose tests at least
• A negative tuberculin skin test, fungal every 12 hours at the beginning of steroid
serologies, sputum cultures for mycobacteria therapy because steroids may induce or worsen
and fungi, and negative biopsy cultures help diabetes mellitus.
rule out infection. • Evaluate for fluid retention, electrolyte im-
• Other laboratory data infrequently reveal in- balance (especially hypokalemia), moonface,
creased serum calcium level, mild anemia, hypertension, and personality change, which
leukocytosis, or hyperglobulinemia. are adverse effects of steroids.
• PFTs show decreased total lung capacity,
compliance, and diffusing capacity. Teaching topics
• Understanding the need for compliance
NURSING DIAGNOSES with prescribed steroid therapy and regular,
• Anxiety careful follow-up examinations and treatment
• Impaired gas exchange • Obtaining information on community sup-
• Risk for injury port and resource groups and contacting the
American Foundation for the Blind if neces-
TREATMENT sary
• Low-calcium diet and avoidance of direct ex-
posure to sunlight (in patients with hypercal-
cemia)
• Oxygen therapy
• No treatment (for sarcoidosis that produces
no symptoms)
920104.qxd 8/7/08 3:52 PM Page 108
Severe acute respiratory • Hyperthermia

syndrome
TREATMENT
Severe acute respiratory syndrome (SARS) is • Supplemental oxygen; possible ET intuba-
a viral respiratory illness caused by a corona- tion and mechanical ventilation
virus. After incubating for 2 to 10 days, the • Droplet precautions
SARS virus seems to spread by close person- • I.V. fluids
to-person contact. Experts believe that SARS
is transmitted via respiratory droplets pro- DRUG THERAPY
duced when an infected person coughs or • Antiviral agents: oseltamivir (Tamiflu), riba-
sneezes. Coughing or sneezing propels the virin (Vibrazole), interferon beta-1a (Avonex)
virus a short distance (typically up to 3 feet) • Antipyretic: acetaminophen (Tylenol)
through the air. It’s then deposited on the mu-
cous membranes of the mouth, nose, or eyes INTERVENTIONS AND RATIONALES
of a nearby person. The virus can also spread • Monitor respiratory status to detect respira-
when a person touches a surface or object tory complications.
contaminated with infectious droplets and • Administer supplemental oxygen as pre-
then touches his mouth, nose, or eyes. scribed to prevent hypoxemia.
• Monitor pulse oximetry values to detect hy-
CAUSES poxia.
• Coronavirus • Maintain infection control precautions to re-
duce the spread of infectious organisms.
DATA COLLECTION FINDINGS • Maintain droplet precautions to prevent the
• Chills spread of infection.
• Diarrhea • Administer medications as prescribed to al-
• Dry cough leviate symptoms.
• High fever (usually greater than 100.4° F • Monitor and record vital signs to detect indi-
[38° C]) cations of compromise.
• Malaise • Assist the patient with turning, coughing,
• Recent (within the past 10 days) travel to an and deep breathing, and provide suction as
area with documented SARS cases or close necessary to mobilize and remove secretions.
contact with a person suspected of having • Provide frequent oral hygiene to promote
SARS comfort.
• Dyspnea • Monitor and record intake and output to de-
tect early signs of dehydration.
DIAGNOSTIC FINDINGS
• Chest X-ray shows atypical pneumonia. Teaching topics
• ABG studies reveal hypoxia. • Completing the entire course of antiviral
• Reverse transcription polymerase chain re- therapy
action test detects the ribonucleic acid of the • Preventing the spread of infection
SARS virus.
• Fluids from nasopharyngeal or oropharyn-
geal secretions, blood, or stool specimens test Tuberculosis
positive for the virus.
• Serum test detects the antibodies IgM and TB is an airborne, infectious, communicable
IgG. disease that can occur acutely or chronically.
In TB, alveoli become the focus of infection
NURSING DIAGNOSES from inhaled droplets containing bacteria. Tu-
• Anxiety bercle bacilli multiply, spread through the
920104.qxd 8/7/08 3:52 PM Page 109
lymphatics, and drain into the systemic circu- • Standard and airborne precautions (while
lation. Cell-mediated immunity to the myco- the patient is contagious, everyone entering
bacteria, which develops 3 to 6 weeks later, his room must wear a respirator with a high-
usually contains the infection and arrests the efficiency particulate air filter)
disease. • Supplemental oxygen therapy
If the infection reactivates, the body’s re- • I.V. fluids as indicated
sponse characteristically leads to caseation—
the conversion of necrotic tissue to a cheese- Drug therapy
like material. The caseum may localize, un- • Antibiotic: streptomycin
dergo fibrosis, or excavate and form cavities. • Antitubercular agents: isoniazid (INH),
The walls of these cavities are studded with ethambutol (Myambutol), rifampin (Rifadin),
multiplying tubercle bacilli. If this occurs, in- pyrazinamide
fected caseous debris may spread throughout
the lungs via the tracheobronchial tree. INTERVENTIONS AND RATIONALES
• Monitor respiratory status and pulse oxime-
CAUSES try values to detect respiratory complications
• Mycobacterium tuberculosis such as pleural effusion.
• Monitor and record vital signs and laborato-
DATA COLLECTION FINDINGS ry studies to detect signs of compromise.
• Anorexia, weight loss • Maintain the patient’s diet and provide
• Cough, yellow and mucoid sputum, hemop- small, frequent meals to increase caloric in-
tysis take.
• Crackles • Perform chest physiotherapy and postural
• Dyspnea drainage to facilitate mobilization of secretions.
• Fatigue, malaise, irritability • Assist the patient with turning, coughing,
• Fever and deep breathing and provide suction, if
• Night sweats necessary, to mobilize and remove secretions.
• Tachycardia • Administer medications, as prescribed, to
avoid development of drug-resistant organisms.
DIAGNOSTIC FINDINGS • Maintain infection-control precautions to re-
• Chest X-ray shows active or calcified le- duce the spread of infectious organisms.
sions. • Tell the patient to cover his nose and mouth
• Hematology shows increased WBC count when sneezing to reduce transmission of virus
and ESR. by droplets.
• Mantoux skin test is positive. • Encourage fluids to liquefy secretions.
• Sputum study is positive for acid-fast bacil- • Provide frequent oral hygiene to promote
lus and M. tuberculosis. comfort and improve appetite.
• Provide a negative pressure room to prevent
NURSING DIAGNOSES the spread of infection.
• Ineffective airway clearance • Monitor vital signs. Fever, tachycardia, and
• Fatigue tachypnea may be present with TB.
• Social isolation • Monitor and record intake and output to as-
sess hydration. Adequate hydration is necessary
TREATMENT to facilitate removal of secretions.
• Chest physiotherapy, postural drainage, and
incentive spirometry Teaching topics
• Dietary changes, including the adoption of • Preventing the spread of droplets of sputum
a diet high in carbohydrates, protein, vitamins • Finishing the entire course of medication (6
B6 and C, and calories to 18 months)
• Contacting the American Lung Association
920104.qxd 8/7/08 3:52 PM Page 110
3. in a prone or supine position with the

foot of the bed elevated higher than the
head.
4. bent at the waist and leaning slightly
forward.
Answer: 3. The aim of percussion and postural
drainage is to mobilize pulmonary secretions
so they can be effectively expectorated. In
right-lower-lobe bronchopneumonia, the
nurse should position the client with the low-
er lobes elevated above the upper lobes. This
would employ gravity in mobilizing pulmo-
nary secretions. Semi-Fowler’s position and
being bent at the waist would hamper mobi-
Pump up on practice lization of secretions from the right lower
lobe.
questions Client needs category: Physiological
integrity
1. During the insertion of a rigid scope for Client needs subcategory: Physio-
bronchoscopy, a client experiences a vasova- logical adaptation
gal response. The nurse should expect: Cognitive level: Application
1. the client’s pupils to become dilated.
2. the client to experience bronchodila- 3. A client with acquired immunodeficiency
tion. syndrome (AIDS) develops Pneumocystis
3. a decrease in gastric secretions. carinii pneumonia. Which nursing diagnosis
4. a drop in the client’s heart rate. has the highest priority for this client?
Answer: 4. During a bronchoscopy, a vasova- 1. Impaired gas exchange
gal response may be caused by stimulating 2. Impaired oral mucous membrane
the pharynx which, in turn, may cause stimu- 3. Imbalanced nutrition: Less than body
lation of the vagus nerve. The client may ex- requirements
perience a sudden drop in the heart rate lead- 4. Activity intolerance
ing to syncope. Stimulation of the vagus nerve Answer: 1. While all these nursing diagnoses
doesn’t lead to mydriasis (pupillary dilation) are appropriate for a client with AIDS, im-
or bronchodilation. Stimulation of the vagus paired gas exchange is the priority nursing di-
nerve increases gastric secretions. agnosis for a client with P. carinii pneumonia.
Client needs category: Physiological Airway, breathing, and circulation take top
integrity priority for any client.
Client needs subcategory: Reduction of Client needs category: Physiological
risk potential integrity
Cognitive level: Comprehension Client needs subcategory: Physio-
logical adaptation
2. A client with right-lower-lobe pneumonia is Cognitive level: Analysis
prescribed percussion and postural drainage.
When performing these therapies, the nurse 4. A client has chronic bronchitis. A nurse is
should position the client: teaching him breathing exercises. Which in-
1. in semi-Fowler’s position with the struction should the nurse include in the
knees bent. teaching?
2. in a right side-lying position with the 1. Make exhalation longer than inhalation.
foot of the bed elevated. 2. Exhale through an open mouth.
3. Use diaphragmatic breathing.
4. Use chest breathing.
920104.qxd 8/7/08 3:52 PM Page 111
Answer: 3. With chronic bronchitis, the di- 2. hypocapnia, hyperventilation, and hy-
aphragm is flat and weak. Diaphragmatic peroxemia.
breathing helps to strengthen the diaphragm 3. hypercapnia, hyperventilation, and hy-
and maximizes ventilation. Exhalation should poxemia.
be no longer than inhalation to prevent col- 4. hypercapnia, hypoventilation, and hy-
lapse of the bronchioles. The client with poxemia.
chronic bronchitis should exhale through Answer: 4. Acute respiratory failure is marked
pursed lips to prolong exhalation, keep the by hypercapnia (elevated arterial carbon diox-
bronchioles from collapsing, and prevent air ide), hypoventilation, and hypoxemia (subnor-
trapping. Diaphragmatic breathing, not chest mal oxygen).
breathing, increases lung expansion. Client needs category: Physiological
Client needs category: Physiological integrity
integrity Client needs subcategory: Physio-
Client needs subcategory: Reduction of logical adaptation
risk potential Cognitive level: Comprehension
7. During an asthmatic episode, a client re-
ceives a beta2-adrenergic agonist. What’s the
best evidence that the drug is effective?
1. Normal drug serum levels
2. Productive cough
3. Clear breath sounds
4. Improved heart rate
5. In a client with emphysema, the initiative

to breathe is triggered by:
1. high carbon dioxide levels.
2. low carbon dioxide levels.
3. high oxygen levels. Answer: 3. Beta2-adrenergic agonists cause
4. low oxygen levels. bronchodilation, which is the opening up of
Answer: 4. Because of long-standing hyper- narrowed airways. In an asthmatic episode,
capnia, breathing in a client with emphysema the client wheezes. Treating the client with a
is triggered by low oxygen levels. In a client beta2-adrenergic agonist should decrease the
with a normal respiratory drive, the initiative wheezing. Beta2-adrenergic agonists aren’t
to breathe is triggered by increased carbon monitored for serum levels. Beta2-adrenergic
dioxide levels. agonists aren’t expectorants, so a productive
Client needs category: Physiological cough wouldn’t indicate the drug is effective.
integrity Beta2-adrenergic agonists are cardiac stimu-
Client needs subcategory: Physio- lants and cause tachycardia, which in itself
logical adaptation isn’t evidence of bronchodilation.
Cognitive level: Knowledge Client needs category: Physiological
integrity
6. A client experiencing acute respiratory Client needs subcategory: Pharmaco-
failure will most likely demonstrate: logical therapies
1. hypocapnia, hypoventilation, and hyper- Cognitive level: Analysis
oxemia.
920104.qxd 8/7/08 3:52 PM Page 112
8. A 40-year-old client is undergoing inser- 4. place the end of the chest tube in a con-
tion of a chest tube necessitated by pneumo- tainer of sterile water.
thorax. The nursing care in this case includes: Answer: 4. When a chest drainage system
1. maintaining a chest tube that’s attached cracks open, the closed system between the
to an underwater drainage system that al- pleural space and the device is broken. This
lows the escape of air or fluid. will allow air to move through the tubing into
2. milking the chest tube every 4 hours. the pleural space, exacerbating the pneumo-
3. emptying the drainage system every thorax. The nurse should immediately place
8 hours. the distal end of the tube in sterile water, clos-
4. positioning the client on the unaffected ing the system again. The tube shouldn’t be
side or the abdomen. clamped because this would increase the
pressure against the pleural space. It’s inap-
propriate to attach the drain directly to wall
suction. The nurse should call the physician
after correcting the problem.
integrity
Client needs subcategory: Physio-
logical adaptation
10. A client with clinically active pulmonary

Answer: 1. The underwater drainage system tuberculosis is prescribed isoniazid, rifampin,
in a chest tube creates a seal that prevents the pyrazinamide, and ethambutol. Which find-
reflux of air into the chest. The nurse needs ings best indicate the effectiveness of drug
to maintain the chest tube to ensure proper therapy?
functioning. The chest tube should be milked 1. Cavities are no longer evident on the
every 2 hours. The closed-drainage system chest X-ray.
isn’t emptied, but the amount of drainage is 2. Tuberculin skin test is negative.
noted on the output record. The client’s posi- 3. The client is afebrile and no longer
tion should be changed frequently to promote coughing.
comfort and drainage. 4. The sputum culture results convert to
Client needs category: Physiological negative.
integrity Answer: 4. A change in sputum culture from
Client needs subcategory: Physio- positive to negative is the best indication of
logical adaptation the effectiveness of antitubercular medica-
Cognitive level: Application tion. Cavities disappearing from the chest
X-ray aren’t a reliable indicator of drug effec-
9. Following a pneumothorax, a client tiveness. Tuberculin skin tests don’t convert
receives a chest tube attached to a three- from positive to negative. Disappearance of
chamber chest drainage system. During the symptoms isn’t the best indicator of the treat-
night, the client becomes disoriented, gets ment’s effectiveness.
out of bed, and steps on the drainage device, Client needs category: Physiological
causing it to crack open and lose its seal. The integrity
nurse should immediately: Client needs subcategory: Pharmaco-
1. clamp the chest tube close to the logical therapies
client’s thorax. Cognitive level: Application
2. attach the chest tube directly to low
wall suction.
3. place the device on a sterile field and
call the physician.
920105.qxd 8/7/08 3:53 PM Page 113
5 Hematologic &
immune systems
• axillary
In this chapter,
you’ll review:
Brush up on key • epitrochlear
• inguinal
✐ components of the concepts • femoral.
hematologic and im-
mune systems and The immune system and hematologic system Water plus
are closely related. The immune system con- Lymph is the fluid that’s found in interstitial
their functions
sists of specialized cells and structures that spaces and that circulates in the lymph ves-
defend the body against invasion by harmful sels. Lymph is composed of water and the
nose hematologic and organisms or chemical toxins. The hemato- end products of cell metabolism.
immune disorders logic system also functions as an important
✐ common hemato- part of the body’s defenses. Blood transports Bodyguards
logic and immune the components of the immune system The tonsils, which are located at the back of
disorders. throughout the body. In addition, blood deliv- the mouth in the oropharynx, fight off patho-
ers oxygen and nutrients to all tissues and re- gens entering the mouth and nose. They’re
moves wastes. Both immune system cells and made of lymphatic tissue and produce lym-
blood cells originate in the bone marrow. phocytes.
The key components of the immune system
are the lymph nodes, thymus, spleen, and ton- Filters blood, kills bacteria
sils. The key components of the hematologic The spleen is a major lymphatic organ that:
system are blood and bone marrow. Blood • destroys bacteria
components play a vital role in transporting • filters blood
electrolytes and regulating acid-base balance. • serves as a blood reservoir
At any time, you can review the major points • forms lymphocytes and monocytes
of this chapter by consulting the Cheat sheet • traps formed particles.
on pages 114 to 123.
Home of hematopoiesis
Fluid movers Bone marrow may be described as either
Lymphatic vessels consist of capillary-like red or yellow:
structures that are permeable to large mole- • Red bone marrow is a source of lympho-
cules. Lymphatic vessels prevent edema by cytes and macrophages. Hematopoiesis is car-
moving fluid and proteins from interstitial ried out by red bone marrow. Hematopoiesis
spaces to venous circulation. They also reab- is the process by which erythrocytes, leuko-
sorb fats from the small intestine. cytes, and thrombocytes are produced.
• Yellow bone marrow is red bone marrow
Bacteria filters that has changed to fat.
Lymph nodes are tissues that filter out bac-
teria and other foreign cells. They’re grouped Marrow makeup
by region: Bone marrow contains stem cells, which
• cervicofacial may develop into several different cell types
• supraclavicular during hematopoiesis:

920105.qxd 8/7/08 3:53 PM Page 114
114 Hematologic & immune systems
et
heat she
C
Hematologic and immunologic refresher
ACQUIRED IMMUNODEFICIENCY SYNDROME ANAPHYLAXIS
• Anorexia, weight loss, recurrent diarrhea • Cardiovascular symptoms (hypotension, shock,
• Disorientation, confusion, dementia cardiac arrhythmias) that may precipitate circu-
• History of night sweats latory collapse if untreated
• History of opportunistic infections • Sudden physical distress within seconds or
Key test results minutes after exposure to an allergen (may in-
• CD4+ T-cell level is less than 200 cells/µl. clude feeling of impending doom or fright, weak-
• Enzyme-linked immunosorbent assay shows ness, sweating, sneezing, shortness of breath,
positive human immunodeficiency virus antibody nasal pruritus, urticaria, and angioedema, fol-
titer. lowed rapidly by symptoms in one or more target
No time to • Western blot test is positive. organs)
study a long • Respiratory symptoms (nasal mucosal edema;
Key treatments
chapter? Just profuse, watery rhinorrhea; itching; nasal con-
• Transfusion therapy: fresh frozen plasma,
use this Cheat gestion; sudden sneezing attacks; edema of the
sheet. platelets, and packed red blood cells (RBCs)
upper respiratory tract that causes hoarseness,
• Antibiotic: co-trimoxazole (Bactrim)
stridor, and dyspnea [early sign of acute respira-
• Antiprotozoal agent: pentamidine (NebuPent)
tory failure])
Combination therapy
• Nonnucleoside reverse transcriptase inhibitors: Key test result
delavirdine (Rescriptor), nevirapine (Viramune), • Anaphylaxis can be diagnosed by the rapid on-
efavirenz (Sustiva) set of severe respiratory or cardiovascular symp-
• Nucleoside reverse transcriptase inhibitors: toms after an insect sting or after ingestion or in-
lamivudine (Epivir), zalcitabine (Hivid), zidovudine jection of a drug, vaccine, diagnostic agent, food,
(Retrovir), abacavir (Ziagen), didanosine (Videx), or food additive.
emtricitabine (Emtriva), stavudine (Zerit), teno- Key treatment
fovir (Viread) • Immediate subcutaneous (subQ) injection of
• Protease inhibitors: indinavir (Crixivan), nelfi- epinephrine 1:1,000 aqueous solution, 0.1 to
navir (Viracept), ritonavir (Norvir), saquinavir 0.5 ml, repeated every 10 to 15 minutes as nec-
(Invirase), amprenavir (Agenerase), atazanavir essary
(Reyataz), fosamprenavir (Lexiva) Key interventions
• Fusion inhibitor: enfuvirtide (Fuzeon) • In the early stages of anaphylaxis, give epi-
Key interventions nephrine I.M. or subQ and help it move into the
• Monitor for opportunistic infections. circulation faster by massaging the injection site.
• Maintain the patient’s diet. In severe reactions, epinephrine should be given
• Provide mouth care. I.V.
• Maintain standard precautions. • Maintain airway patency. Observe for early
• Make referrals to community agencies for signs of laryngeal edema (stridor, hoarseness,
support. and dyspnea), and prepare for endotracheal tube
• Monitor respiratory status. insertion or a tracheotomy and oxygen therapy.
• Monitor blood pressure and urine output.
920105.qxd 8/7/08 3:53 PM Page 115
Hematologic and immunologic refresher (continued)

ANKYLOSING SPONDYLITIS • Administer oxygen.
Key signs and symptoms • Monitor transfusion therapy as prescribed.
• Intermittent lower back pain (the first indication), usually most • Maintain protective precautions.
severe in the morning or after a period of inactivity • Avoid giving the patient I.M. injections.
• Mild fatigue, fever, anorexia, or weight loss; unilateral acute CALCIUM IMBALANCE
anterior uveitis
• Stiffness and limited motion of the lumbar spine
Hypocalcemia
Key test results • Cardiac arrhythmias
• Typical symptoms, a family history, and the presence of HLA- • Chvostek’s sign
B27 strongly suggest ankylosing spondylitis. • Tetany
• Confirmation requires characteristic X-ray findings: blurring of • Trousseau’s sign
the bony margins of joints in the early stage, bilateral sacroiliac Hypercalcemia
involvement, patchy sclerosis with superficial bony erosions, • Anorexia
eventual squaring of vertebral bodies, and “bamboo spine” with • Decreased muscle tone
complete ankylosis. • Lethargy
Key treatments • Muscle weakness
• Good posture, stretching and deep-breathing exercises and, in • Nausea
some patients, braces and lightweight supports to delay further • Polydipsia
deformity • Polyuria
• Anti-inflammatory agents: aspirin, ibuprofen (Motrin), indo- Key test results
methacin (Indocin), sulfasalazine (Azulfidine), sulindac (Clinoril) • A serum calcium level less than 4.5 mEq/L confirms hypocal-
to control pain and inflammation cemia; a level greater than 5.5 mEq/L confirms hypercalcemia.
Key interventions (Because approximately one-half of serum calcium is bound to
• Offer support and reassurance. Keep in mind that the patient’s albumin, changes in serum protein must be considered when in-
limited range of motion makes simple tasks difficult. terpreting serum calcium levels.)
• Administer medications as needed. • Electrocardiogram reveals a lengthened QT interval, a pro-
• Apply local heat and provide massage. Assess mobility and longed ST segment, and arrhythmias in hypocalcemia; in hyper-
degree of discomfort frequently. calcemia, a shortened QT interval and heart block.
APLASTIC ANEMIA Key treatments
Hypocalcemia
• Diet: adequate intake of calcium, vitamin D, and protein
• Dyspnea, tachypnea
• Ergocalciferol (vitamin D2), cholecalciferol (vitamin D3), cal-
• Epistaxis
citriol (Rocaltrol), dihydrotachysterol (synthetic form of vitamin
• Melena
D2) for severe deficiency
• Palpitations, tachycardia
• Immediate correction by I.V. calcium gluconate or calcium
• Purpura, petechiae, ecchymosis, pallor
chloride for acute hypocalcemia (an emergency)
Key test result Hypercalcemia
• Bone marrow biopsy shows a decrease in activity or no cell • Calcitonin (Calcimar)
production. • Loop diuretics: ethacrynic acid (Edecrin) and furosemide
Key treatments (Lasix) to promote calcium excretion (thiazide diuretics are con-
• Transfusion of platelets and packed RBCs traindicated in hypercalcemia because they inhibit calcium ex-
• Antithymocyte globulin (Atgam) cretion)
• Hematopoietic growth factor: epoetin alfa (Epogen)
Key interventions
• Monitor for infection, bleeding, and bruising.
(continued)
920105.qxd 8/7/08 3:53 PM Page 116

CALCIUM IMBALANCE (continued) Hyperchloremia
Key interventions • Monitor electrolyte levels.
Hypocalcemia DISSEMINATED INTRAVASCULAR COAGULATION
• Monitor serum calcium levels every 12 to 24 hours. When giv-
ing calcium supplements, frequently check the pH level. Check
for Trousseau’s and Chvostek’s signs. • Abnormal bleeding without an accompanying history of seri-
Hypercalcemia ous hemorrhagic disorder
• Monitor serum calcium levels frequently. • Oliguria
• Increase fluid intake. • Shock
Key test results
CHLORIDE IMBALANCE • Blood tests show PT greater than 15 seconds; PTT greater
Key signs and symptoms than 60 seconds; fibrinogen levels less than 150 mg/dl; platelets
Hypochloremia less than 100,000/µl; and fibrin degradation products commonly
• Muscle hypertonicity (in conditions related to loss of gastric greater than 100 µg/ml.
secretions) • A positive D-dimer test is specific for disseminated intravascu-
• Muscle weakness lar coagulation.
• Shallow, depressed breathing Key treatments
• Twitching • Anticoagulant: heparin I.V. (Heparin Sodium Injection)
Hyperchloremia • Bed rest
• Agitation • Transfusion therapy: fresh frozen plasma, platelets, packed
• Deep, rapid breathing RBCs
• Diminished cognitive ability
Key interventions
• Hypertension
• Pitting edema • Enforce complete bed rest during bleeding episodes. If the pa-
• Tachycardia tient is agitated, pad the side rails.
• Weakness • Check all I.V. and venipuncture sites frequently for bleeding.
Apply pressure to injection sites for at least 10 minutes. Alert
Key test results
other personnel to the patient’s tendency to hemorrhage.
• Serum chloride level less than 98 mEq/L confirms hypochlor- • Watch for transfusion reactions and signs of fluid overload.
emia; supportive values with metabolic alkalosis include a • Weigh the patient daily, particularly in renal involvement.
serum pH greater than 7.45 and a serum carbon dioxide level • Monitor the results of serial blood studies (particularly hemat-
greater than 32 mEq/L. ocrit [HCT], hemoglobin [Hb] level, and coagulation times).
• Serum chloride level greater than 108 mEq/L confirms hyper-
chloremia; with metabolic acidosis, serum pH is less than 7.35 HEMOPHILIA
and the serum carbon dioxide level is less than 22 mEq/L. Key signs and symptoms
Key treatments • Hematuria
Hypochloremia • Joint tenderness
• Acidifying agent: ammonium chloride • Pain and swelling in a weight-bearing joint
• Diet: salty broth • Prolonged bleeding after major trauma or surgery (in mild he-
• Saline solution I.V. mophilia)
Hyperchloremia • Spontaneous or severe bleeding after minor trauma (in severe
• Alkalinizing agent: sodium bicarbonate I.V. hemophilia)
• Lactated Ringer’s solution • SubQ and I.M. hematomas (in moderate hemophilia)
Key interventions • Tarry stools
Hypochloremia Key test results
• Monitor electrolyte levels. • Factor VIII assay reveals 0% to 25% of normal factor VIII (he-
• Watch for excessive or continuous loss of gastric secretions. mophilia A).
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HEMOPHILIA (continued) • Pain (if the sarcoma advances beyond the early stages or if a
• Factor IX assay shows deficiency (hemophilia B). lesion breaks down or impinges on nerves or organs)
Key treatments Key test result
• Administration of Factor VIII or cryoprecipitate antihemophilic • Tissue biopsy identifies the lesion’s type and stage.
factor (AHF) and lyophilized (dehydrated) AHF to encourage nor- Key treatments
mal hemostasis (for hemophilia A) • High-calorie, high-protein diet
• Administration of purified factor IX to promote hemostasis (for • Radiation therapy
hemophilia B) • Antineoplastics: doxorubicin (Adriamycin), etoposide
• Administration of analgesics to control joint pain (for both (VePesid), vinblastine (Velban), vincristine (Oncovin)
types) • Antiemetics: dolasetron (Anzemet), trimethobenzamide (Tigan)
Key interventions Key interventions
• During bleeding episodes, monitor clotting factor or plasma • Inspect the patient’s skin every shift. Look for new lesions and
administration. Also administer analgesics. skin breakdown. If the patient has painful lesions, help him into a
• Avoid I.M. injections. more comfortable position.
• Aspirin and aspirin-containing medications are contraindi- • Administer pain medications. Suggest distractions and help
cated. the patient with relaxation techniques.
• If the patient has bled into a joint, immediately elevate the joint. • Urge the patient to share his feelings and provide encourage-
IRON DEFICIENCY ANEMIA ment.
• Supply the patient with high-calorie, high-protein meals. If he
can’t tolerate regular meals, provide him with frequent smaller
• Pallor meals. Consult with the dietitian, and plan meals around the pa-
• Sensitivity to cold tient’s treatment.
• Weakness and fatigue • Be alert for adverse reactions to radiation therapy or
Key test result chemotherapy—such as anorexia, nausea, vomiting, and diar-
• Hematology shows decreased Hb, HCT, iron, ferritin, reticulo- rhea—and take steps to prevent or alleviate them.
cytes, red cell indices, transferrin, and saturation; absent hemo- • Explain infection-prevention techniques and, if necessary,
siderin; and increased iron-binding capacity. demonstrate basic hygiene measures. Advise the patient not to
Key treatments share his toothbrush, razor, or other items that may be contami-
• Diet: high in iron, fiber, and protein with increased fluids; avoid- nated with blood. These measures are especially important if the
ance of teas and coffee, which reduce absorption of iron patient also has human immunodeficiency virus infection or ac-
• Vitamins: pyridoxine (vitamin B6), ascorbic acid (vitamin C) quired immunodeficiency syndrome.
• Iron supplements: ferrous sulfate (Feosol), iron dextran LEUKEMIA
(DexFerrum)
Key interventions
• Enlarged lymph nodes, spleen, and liver
• Monitor cardiovascular and respiratory status. • Frequent infections
• Monitor stool, urine, and vomitus for occult blood. • Weakness and fatigue
• Administer medications as prescribed. Administer iron injec-
Key test result
tion deep into muscle using Z-track technique.
• Provide mouth, skin, and foot care. • Bone marrow biopsy shows large numbers of immature leuko-
cytes.
KAPOSI’S SARCOMA Key treatments
Key signs and symptoms • Antimetabolites: fluorouracil (Adrucil), methotrexate (Trexall)
• One or more obvious lesions in various shapes, sizes, and col- • Alkylating agents: busulfan (Myleran), chlorambucil (Leukeran)
ors (ranging from red-brown to dark purple) that appear most • Vinca alkaloids: vinblastine (Velban) , vincristine (Oncovin)
commonly on the skin, buccal mucosa, hard and soft palates,
lips, gums, tongue, tonsils, conjunctivae, and sclerae
(continued)
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LEUKEMIA (continued) MAGNESIUM IMBALANCE
• Antineoplastic antibiotics: doxorubicin (Adriamycin), plica- Key signs and symptoms
mycin (Mithracin) Hypomagnesemia
• Hematopoietic growth factor: epoetin alfa (Epogen) • Arrhythmias
Key interventions • Neuromuscular irritability
• Monitor for bleeding. • Chvostek’s sign
• Place the patient with epistaxis in an upright position, leaning • Mood changes
slightly forward. • Confusion
• Monitor for infection. Promptly report temperature over 101° F Hypermagnesemia
(38.3° C) and decreased white blood cell (WBC) counts. • Diminished deep tendon reflexes
• Monitor transfusion therapy for adverse reactions. • Weakness
• Provide gentle mouth and skin care. • Confusion
• Heart block
LYMPHOMA • Nausea
Key signs and symptoms • Vomiting
• Predictable pattern of spread (Hodgkin’s disease) Key test results
• Enlarged, nontender, firm, and movable lymph nodes in lower • Blood test that shows decreased serum magnesium levels
cervical regions (Hodgkin’s disease) (less than 1.5 mEq/L) confirms hypomagnesemia.
• Less predictable pattern of spread (malignant lymphoma) • Blood test that shows increased serum magnesium levels
• Prominent, painless, generalized lymphadenopathy (malignant (greater than 2.5 mEq/L) confirms hypermagnesemia.
lymphoma)
Key treatments
Key test results
Hypomagnesemia
• Lymph node biopsy is positive for Reed-Sternberg cells • Daily magnesium supplements I.M. or by mouth
(Hodgkin’s disease). • High-magnesium diet
• Bone marrow aspiration and biopsy reveals small, diffuse lym- • Magnesium sulfate I.V. (10 to 40 mEq/L diluted in I.V. fluid) for
phocytic or large, follicular-type cells (malignant lymphoma). severe cases
Key treatments Hypermagnesemia
• Radiation therapy • Diet: low magnesium with increased fluid intake
• Transfusion of packed RBCs • Loop diuretic: furosemide (Lasix)
• Chemotherapy for Hodgkin’s disease: mechlorethamine (Mus- • Magnesium antagonist: calcium gluconate (10%)
targen), vincristine (Oncovin), procarbazine (Matulane), doxoru- • Peritoneal dialysis or hemodialysis if renal function fails or if
bicin (Adriamycin), bleomycin (Blenoxane), vinblastine (Velban), excess magnesium can’t be eliminated
dacarbazine (DTIC-Dome) Key interventions
• Chemotherapy for malignant lymphoma: cyclophosphamide Hypomagnesemia
(Cytoxan), vincristine (Oncovin), doxorubicin (Adriamycin) • Monitor serum electrolyte levels (including magnesium, calci-
Key interventions um, and potassium) daily for mild deficits and every 6 to 12 hours
• Monitor for bleeding, infection, jaundice, and electrolyte imbal- during replacement therapy.
ance. • Measure intake and output frequently. (Urine output shouldn’t
• Provide mouth and skin care. fall below 25 ml/hour or 600 ml/day.)
• Encourage fluids. • Monitor vital signs during I.V. therapy. Infuse magnesium re-
• Administer medications as prescribed and monitor for adverse placement slowly, and watch for bradycardia, heart block, and
effects. decreased respiratory rate.
• Maintain transfusion therapy as prescribed and monitor for • Have calcium gluconate I.V. available to reverse hypermagne-
adverse reactions. semia from overcorrection.
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MAGNESIUM IMBALANCE (continued) MULTIPLE MYELOMA
Hypermagnesemia Key signs and symptoms
• Frequently check level of consciousness (LOC), muscle activi- • Anemia, thrombocytopenia, hemorrhage
ty, and vital signs. • Constant, severe bone pain
• Keep accurate intake and output records. Provide sufficient • Pathologic fractures, skeletal deformities of the sternum and
fluids. ribs, loss of height
• Correct abnormal serum electrolyte levels immediately.
Key test results
• Monitor the patient receiving cardiac glycosides and calcium
• Bence Jones protein assay is positive.
gluconate simultaneously.
• X-ray shows diffuse, round, punched-out bone lesions; osteo-
METABOLIC ACIDOSIS porosis; osteolytic lesions of the skull; and widespread deminer-
Key signs and symptoms alization.
• Central nervous system depression Key treatments
• Kussmaul’s respirations • Orthopedic devices: braces, splints, casts
• Lethargy • Alkylating agents: melphalan (Alkeran), cyclophosphamide
Key test result (Cytoxan)
• Arterial blood gas (ABG) analysis reveals pH below 7.35 and • Androgen: fluoxymesterone (Halotestin)
bicarbonate level less than 24 mEq/L. • Antibiotics: doxorubicin (Adriamycin), plicamycin (Mithracin)
• Antigout agent: allopurinol (Zyloprim)
Key treatments
• Antineoplastics: vinblastine (Velban), vincristine (Oncovin)
• Correction of underlying cause
• Glucocorticoid: prednisone (Deltasone)
• Sodium bicarbonate I.V. or orally for chronic metabolic
acidosis Key interventions
• Monitor renal status.
Key interventions
• Evaluate bone pain.
• Keep sodium bicarbonate ampules handy.
• Maintain I.V. fluids.
• Frequently monitor vital signs, laboratory results, and LOC.
• Record intake and output. PERNICIOUS ANEMIA
METABOLIC ALKALOSIS Key signs and symptoms
• Paresthesia of hands and feet
• Weight loss, anorexia, dyspepsia
• Atrial tachycardia
• Confusion Key test results
• Diarrhea • Bone marrow aspiration shows increased megaloblasts, few
• Hypoventilation maturing erythrocytes, and defective leukocyte maturation.
• Twitching • Peripheral blood smear reveals oval, macrocytic, hyper-
• Vomiting chromic erythrocytes.
Key test results Key treatment
• ABG analysis reveals pH greater than 7.45 and a bicarbonate • Vitamins: pyridoxine (vitamin B6), ascorbic acid (vitamin C),
level above 29 mEq/L. cyanocobalamin (vitamin B12), folic acid (vitamin B9)
Key treatments Key interventions
• Treatment of underlying cause • Monitor cardiovascular status.
• Acidifying agent: ammonium chloride I.V. • Administer medications as prescribed.
• Provide mouth care before and after meals.
Key interventions
• Prevent the patient from falling.
• Monitor ammonium chloride 0.9% infusion.
• Monitor vital signs, and record intake and output.
(continued)
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PHOSPHORUS IMBALANCE • Ruddy cyanosis of the nose
Key signs and symptoms • Thrombosis of smaller vessels
Hypophosphatemia • Visual disturbances (blurring, diplopia, engorged veins of fun-
• Anorexia dus and retina)
• Muscle weakness Key test result
• Paresthesia • Blood tests show elevated hemoglobin, RBC count, WBC
• Tremor count, platelet count, and leukocyte alkaline phosphatase,
Hyperphosphatemia serum B12, and uric acid levels.
• Usually produces no symptoms Key treatments
Key test results • Phlebotomy (typically, 350 to 500 ml of blood is removed every
• Serum phosphorus level less than 1.7 mEq/L (or 2.5 mg/dl) con- other day until the patient’s HCT is reduced to the low-normal
firms hypophosphatemia. A urine phosphorus level more than range)
1.3 g/24 hours supports this diagnosis. • Plasmapheresis
• Serum phosphorus level exceeding 2.6 mEq/L (or 4.5 mg/dl) • Antineoplastics: busulfan (Myleran), chlorambucil (Leukeran),
confirms hyperphosphatemia. Supportive values include de- melphalan (Alkeran)
creased levels of serum calcium (less than 9 mg/dl) and urine • Antigout agent: allopurinol (Zyloprim)
phosphorus (less than 0.9 g/24 hours). Key interventions
Key treatments • Check blood pressure, pulse rate, and respirations before and
Hypophosphatemia during phlebotomy.
• High-phosphorus diet • During phlebotomy, make sure the patient is lying down com-
• Phosphate supplements fortably.
Hyperphosphatemia • Stay alert for tachycardia, clamminess, or complaints of verti-
• Low-phosphorus diet go. If these effects occur, the procedure should be stopped.
• Calcium supplement: calcium acetate (PhosLo) • Immediately after phlebotomy, check blood pressure and pulse
Key interventions rate. Have the patient sit up for about 5 minutes before allowing
Hypophosphatemia him to walk. Also, administer 24 oz (710 ml) of juice or water.
• Record intake and output accurately. Assess renal function, • Tell the patient to watch for and report symptoms of iron defi-
and be alert for hypocalcemia when giving phosphate supple- ciency (pallor, weight loss, weakness, glossitis).
ments. • Give additional fluids, administer allopurinol, and alkalinize the
• Advise the patient to follow a high-phosphorus diet containing urine.
milk and milk products, kidney, liver, turkey, and dried fruits. • Warn an outpatient who develops leukopenia that his resis-
Hyperphosphatemia tance to infection is low; advise him to avoid crowds and to
• Monitor intake and output. If urine output falls below 25 ml/ watch for the symptoms of infection.
hour or 600 ml/day, notify the doctor immediately. • Tell the patient about possible adverse effects of alkylating
• Watch for signs of hypocalcemia, such as muscle twitching agents (nausea, vomiting, and risk of infection).
and tetany, which commonly accompany hyperphosphatemia. • Have the patient lie down during I.V. administration and for 15
• Advise the patient to eat foods low in phosphorus such as veg- to 20 minutes afterward.
etables. Obtain dietary consultation if the condition results from RHEUMATOID ARTHRITIS
chronic renal insufficiency.
POLYCYTHEMIA VERA • Painful, swollen joints; crepitus; morning stiffness
Key signs and symptoms • Symmetrical joint swelling (mirror image of affected joints)
• Clubbing of the digits Key test results
• Dizziness • Antinuclear antibody test is positive.
• Headache • Rheumatoid factor test is positive.
• Hypertension
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RHEUMATOID ARTHRITIS (continued) Key interventions
Key treatments • Evaluate motion restrictions, pain, vital signs, intake and out-
• Cold therapy during acute episodes put, respiratory function, and daily weight.
• Heat therapy to relax muscles and relieve pain in chronic dis- • Teach the patient to monitor blood pressure at home and to re-
ease port any increases above baseline.
• Antirheumatic: hydroxychloroquine (Plaquenil) • Whenever possible, let the patient participate in treatment.
• Cyclo-oxygenase-2 inhibitor: celecoxib (Celebrex) SEPTIC SHOCK
• Glucocorticoids: prednisone (Deltasone), hydrocortisone (Hy-
drocortone)
• Nonsteroidal anti-inflammatory drugs (NSAIDs): indomethacin Early stage
(Indocin), ibuprofen (Advil, Motrin), sulindac (Clinoril), piroxicam • Chills
(Feldene), flurbiprofen (Ansaid), diclofenac sodium (Voltaren), • Oliguria
naproxen (Naprosyn), diflunisal (Dolobid) • Sudden fever (over 101° F [38.3° C])
Late stage
Key interventions
• Altered LOC
• Check joints for swelling, pain, and redness. • Anuria
• Splint inflamed joints. • Hyperventilation
• Provide warm or cold therapy as prescribed. • Hypotension
SCLERODERMA • Hypothermia
Key signs and symptoms • Restlessness
• Tachycardia
• Pain
• Tachypnea
• Signs and symptoms of Raynaud’s phenomenon, such as
blanching, cyanosis, and erythema of the fingers and toes in Key test results
response to stress or exposure to cold • Blood cultures isolate the organism.
• Stiffness • Blood tests show decreased platelet count and leukocytosis
• Swelling of fingers and joints (15,000 to 30,000/µl), increased blood urea nitrogen and creati-
• Taut, shiny skin over the entire hand and forearm nine levels, decreased creatinine clearance, and abnormal PT
• Tight and inelastic facial skin, causing a masklike appearance and PTT.
and “pinching” of the mouth Key treatments
• Signs and symptoms of renal involvement, usually accompa- • Removing and replacing any I.V. or urinary drainage catheters
nied by malignant hypertension, the main cause of death that may be the source of infection
Key test results • Oxygen therapy (may require endotracheal intubation and me-
• Blood studies show slightly elevated erythrocyte sedimenta- chanical ventilation)
tion rate (ESR), positive rheumatoid factor in 25% to 35% of pa- • Colloid or crystalloid infusion to increase intravascular volume
tients, and positive antinuclear antibody test. • Diuretic: furosemide (Lasix) after sufficient fluid volume has
• Skin biopsy may show changes consistent with the progress of been replaced to maintain urine output above 20 ml/hour
the disease, such as marked thickening of the dermis and occlu- • Antibiotics: according to sensitivity of causative organism
sive vessel changes. • Human-activated protein C: drotrecogin alfa (Xigris)
Key treatments • Vasopressors: dopamine (Intropin), norepinephrine (Levo-
phed), or phenylephrine (Neo-Synephrine), if fluid resuscitation
• Physical therapy to maintain function and promote muscle
fails to increase blood pressure
strength
• Immunosuppressants: cyclosporine (Sandimmune), cyclo- Key interventions
phosphamide (Cytoxan), azathioprine (Imuran), mycophenolate • Remove any I.V. or urinary drainage catheters, and send them
(Cellcept) to the laboratory. New catheters can be reinserted.
(continued)
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SEPTIC SHOCK (continued) • Intense thirst
• Maintain an I.V. infusion with normal saline solution or lactated • Oliguria
Ringer’s solution, usually using a large-bore (14G to 18G) • Pitting edema
catheter. • Rough, dry tongue
• If the patient’s systolic blood pressure drops below 80 mm Hg, • Tachycardia
increase oxygen flow rate and call the doctor immediately. Key test results
• Keep accurate intake and output records. • Serum sodium level less than 135 mEq/L indicates hypo-
• Administer antibiotics I.V. and monitor drug levels. natremia.
SICKLE CELL ANEMIA • Serum sodium level greater than 145 mEq/L indicates
hypernatremia.
Key treatments
• Aching bones
• Jaundice (worsens during painful crisis), pallor Hyponatremia
• Unexplained dyspnea or dyspnea on exertion • I.V. infusion of saline solution
• Tachycardia • Potassium supplement: potassium chloride (K-Lor)
• Severe pain (during sickle cell crisis) Hypernatremia
• Diet: sodium restrictions
Key test results
• Salt-free solution (such as dextrose in water), followed by infu-
• Blood tests show low RBC counts, elevated WBC and platelet sion of 0.45% sodium chloride to prevent hyponatremia
counts, decreased ESR, increased serum iron levels, decreased
Key interventions
RBC survival, and reticulocytosis.
• Hb electrophoresis shows hemoglobin S. Hyponatremia
• Watch for extremely low serum sodium and accompanying
Key treatments
serum chloride levels. Monitor urine specific gravity and other
• Iron and folic acid supplements to prevent anemia laboratory results. Record fluid intake and output accurately,
• I.V. fluid therapy to prevent dehydration and vessel occlusion and weigh the patient daily.
• Analgesics: meperidine (Demerol) or morphine (to relieve pain • During administration of isosmolar or hyperosmolar saline so-
from vaso-occlusive crises) lution, watch closely for signs of hypervolemia (dyspnea, crack-
Key interventions les, engorged neck or hand veins).
• Apply warm compresses to painful areas, and cover the pa- Hypernatremia
tient with a blanket. • Measure serum sodium levels every 6 hours or at least daily.
• Maintain bed rest. Monitor vital signs for changes, especially for rising pulse rate.
• Encourage fluid intake, and maintain prescribed I.V. fluids. Watch for signs of hypervolemia, especially in the patient re-
ceiving I.V. fluids.
SODIUM IMBALANCE
• Record fluid intake and output accurately, checking for body
Key signs and symptoms fluid loss. Weigh the patient daily.
Hyponatremia
• Abdominal cramps SYSTEMIC LUPUS ERYTHEMATOSUS
• Cold, clammy skin Key signs and symptoms
• Cyanosis • Butterfly rash on face (rash may vary in severity from malar
• Hypotension erythema to discoid lesions)
• Oliguria or anuria • Fatigue
• Seizures • Migratory pain, joint stiffness and swelling
• Tachycardia Key test result
Hypernatremia • Lupus erythematosus cell preparation is positive.
• Dry, sticky mucous membranes
Key treatments
• Excessive weight gain
• Flushed skin • Cytotoxic drug: methotrexate (Trexall) to delay or prevent dete-
• Hypertension riorating renal status
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SYSTEMIC LUPUS ERYTHEMATOSUS (continued) • Loss of distal pulses
• Immunosuppressants: azathioprine (Imuran), cyclophos- • Malaise
phamide (Cytoxan) • Pain or paresthesia distal to affected area
• NSAIDs: indomethacin (Indocin), ibuprofen (Motrin), sulindac • Syncope
(Clinoril), piroxicam (Feldene), flurbiprofen (Ansaid), diclofenac • Weight loss
sodium (Voltaren), naproxen (Naprosyn), diflunisal (Dolobid) Key test results
Key interventions Wegener’s granulomatosis
• Evaluate musculoskeletal status. • Tissue biopsy shows necrotizing vasculitis with granulomatous
• Monitor renal status. inflammation.
• Provide prophylactic skin, mouth, and perineal care. Temporal arteritis
• Maintain seizure precautions. • Tissue biopsy shows panarteritis with infiltration of mononu-
• Minimize environmental stress, and provide rest periods. clear cells, giant cells within vessel wall, fragmentation of inter-
nal elastic lamina, and proliferation of intima.
VASCULITIS
Takayasu’s arteritis
Key signs and symptoms • Arteriography shows calcification and obstruction of affected
Wegener’s granulomatosis vessels.
• Cough • Tissue biopsy shows inflammation of adventitia and intima of
• Fever vessels and thickening of vessel walls.
• Malaise Key treatments
• Signs and symptoms of pulmonary congestion
• Removal of identified environmental antigen
• Weight loss
• Diet: elimination of antigenic food, if identifiable
Temporal arteritis
• Corticosteroid: prednisone (Deltasone)
• Fever
• Antineoplastic: cyclophosphamide (Cytoxan)
• Headache (associated with polymyalgia rheumatica syn-
drome) Key interventions
• Jaw claudication • Regulate environmental temperature.
• Myalgia • Monitor vital signs. Use a Doppler ultrasonic flowmeter, if
• Visual changes available.
Takayasu’s arteritis • Monitor intake and output. Check daily for edema. Keep the
• Arthralgias patient well hydrated (3 L daily).
• Bruits
• Some stem cells evolve into lymphocytes; Infection fighters

lymphocytes may become B cells or T cells. Leukocytes (also called white blood cells
• Other stem cells evolve into phagocytes. or WBCs) are formed in the bone marrow Memory
and lymphatic tissue and include granulo- jogger
Oxygen carriers cytes and agranulocytes. WBCs provide im- Think
Er ythrocytes (also called red blood cells or munity and protection from infection by PLATE to
RBCs) are formed in the bone marrow and phagocytosis (engulfing, digesting, and de- remember key blood
contain hemoglobin (Hb). Oxygen binds with stroying microorganisms). components:
Hb to form oxyhemoglobin, which is then car- Plasma
ried by RBCs throughout the body. Liquid partner Leukocytes
Plasma is the liquid portion of the blood, and
Clotting contributors its composition is water, protein (albumin and AB antigens
Thrombocytes (also called platelets) are globulin), glucose, and electrolytes. Thrombocytes
formed in the bone marrow and function in
the coagulation of blood. Erythrocytes.
920105.qxd 8/7/08 3:53 PM Page 124
Of donors and recipients secrete immunoglobulin (Ig; proteins with

A person’s blood type is determined by a sys- known antibody activity).
tem of antigens located on the surface of • Suppressor cells reduce the humoral re-
RBCs. The four blood types are: sponse.
• A antigen
• B antigen Don’t forget B cells
• AB (both A and B) antigens B cells act in a different way than T cells to
• O (no antigens). recognize and destroy antigens. B cells are
Because group O blood lacks both A and B responsible for humoral or Ig-mediated im-
antigens, it can be transfused in limited munity. B cells originate in the bone marrow
amounts in an emergency to any patient, and mature into plasma cells that produce an-
regardless of the recipient’s blood type, with tibodies (Ig molecules that interact with a spe-
little risk of adverse reaction. That’s why peo- cific antigen). Antibodies destroy bacteria and
ple with group O blood are called universal viruses, thereby preventing them from enter-
donors. A person with AB blood type has nei- ing host cells.
ther anti-A nor anti-B antibodies. This person
may receive A, B, AB, or O blood, which A word about immunoglobulins
makes him a universal recipient. Five major classes of Ig exist:
In addition, the antigen Rh factor is found • IgG makes up about 80% of plasma antibod-
on the RBCs of approximately 85% of people. ies. It appears in all body fluids and is the ma-
A person with the Rh factor is Rh positive. A jor antibacterial and antiviral antibody.
person without the factor is Rh negative. A • IgM is the first Ig produced during an im-
person may only receive blood from a person mune response. It’s too large to easily cross
with the same Rh factor. membrane barriers and is usually present
only in the vascular system.
T time • IgA is found mainly in body secretions,
In cell-mediated immunity, T cells respond di- such as saliva, sweat, tears, mucus, bile, and
rectly to antigens (foreign substances, such colostrum. It defends against pathogens on
as bacteria or toxins, that induce antibody for- body surfaces, especially those that enter the
mation). This response involves destruction respiratory and GI tracts.
of target cells—such as virus-infected cells • IgD is present in plasma and is easily bro-
and cancer cells—through secretion of ken down. It’s the predominant antibody on
lymphokines (lymph proteins). Examples of the surface of B cells and is mainly an antigen
cell-mediated immunity are rejection of trans- receptor.
planted organs and delayed immune respons- • IgE is the antibody involved in immediate
Wow! I can be a es that fight disease. hypersensitivity reactions, or allergic reac-
killer, helper, or About 80% of blood cells are T cells. They tions that develop within minutes of exposure
suppressor! probably originate from stem cells in the bone to an antigen. IgE stimulates the release of
marrow; the thymus gland controls their ma- mast cell granules, which contain histamine
turity. In the process, a large number of and heparin.
antigen-specific cells are produced.
Killer, helper, or suppressor

T cells can be killer, helper, or suppressor
T cells:
Keep abreast of
• Killer cells bind to the surface of the invad-
ing cell, disrupt the membrane, and destroy it
diagnostic tests
by altering its internal environment. Here are some important tests used to diag-
• Helper cells stimulate B cells to mature into nose hematologic and immune disorders,
plasma cells, which begin to synthesize and along with common nursing actions associat-
ed with each test.
920105.qxd 8/7/08 3:53 PM Page 125
Blood sample study #1 After the procedure

A blood chemistr y test uses a blood sample • Check the venipuncture site for bleeding.
to measure potassium, sodium, calcium,
blood urea nitrogen (BUN), creatinine, pro- Confirming the diagnosis
tein, albumin, and bilirubin levels. A Western blot test uses a blood sample to
detect the presence of specific viral proteins
Nursing actions to confirm HIV infection.
• Before the procedure, withhold food and
fluids as directed. Nursing actions
• After the procedure, check the venipunc- Before the procedure
ture site for bleeding. • Verify that informed consent has been ob-
• Handle the sample gently to prevent hemo- tained and documented.
lysis. • Provide the patient with appropriate pretest
counseling.
Blood sample study #2 After the procedure
A hematologic study uses a blood sample to • Check the venipuncture site for bleeding.
analyze WBCs, RBCs, erythrocyte sedimenta-
tion rate (ESR), Hb, hematocrit (HCT), Small specimen
platelet count, red cell indices, Hb electro- A urine test uses a small specimen of urine
phoresis, iron and total iron binding capacity, to analyze hemosiderin and Hb.
sickle cell test, and CD4 cell count.
Nursing actions
Nursing actions • Collect a random urine specimen of about
• Before the procedure, note the patient’s cur- 30 ml.
rent drug therapy.
• After the procedure, check the venipunc- Radiographic snapshot
ture site for bleeding. A lymphangiography involves an injection of Postdiagnostic
radiopaque dye through a catheter, which test monitoring, such
Check on immune status provides a radiographic picture of the lym- as checking the
Immunologic studies use a small sample of phatic system and the dissection of lymph venipuncture site, the
blood to analyze rheumatoid factor, lupus ery- vessels. catheter insertion
site, or the site of
thematosus cell preparation, antinuclear anti-
bone marrow
bodies, and serum protein electrophoresis. Nursing actions aspiration, is a key
Before the procedure nursing responsibility.
Nursing actions • Note the patient’s allergies to iodine,
• Before the procedure, note the patient’s cur- seafood, and radiopaque dyes.
rent drug therapy. • Inform the patient of possible throat irrita-
• After the procedure, check the venipunc- tion and flushing of his face after injection of
ture site for bleeding. the dye.
HIV detector has been obtained.
Enzyme-linked immunosorbent assay • Withhold food and fluids as directed.
(ELISA) uses a blood sample to detect the hu- After the procedure
man immunodeficiency virus (HIV) antibody. • Monitor vital signs and peripheral pulses.
• Check the catheter insertion site for
Nursing actions bleeding.
Before the procedure • Encourage oral fluids.
• Verify that informed consent has been ob- • Advise the patient that skin, stool, and
tained and documented. urine will have a blue discoloration for about
• Provide the patient with appropriate pretest 48 hours following the procedure.
counseling.
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Marrow removal After the procedure

A bone marrow examination, also called • Obtain vital signs.
aspiration or biopsy, involves the percuta- • Assess for reactions to gastric acid stimu-
neous removal of bone marrow and an exami- lant, if used.
nation of RBCs, WBCs, thrombocytes, and
precursor cells. No red meats or turnips
A fecal occult blood test involves a micro-
Nursing actions scopic analysis of Hb to detect occult blood in
Before the procedure stool.
has been obtained. Nursing actions
• Determine the patient’s ability to lie still • Before the test, instruct the patient to main-
during the procedure. tain a high-fiber diet and to refrain from eat-
• Tell the patient that he may experience a ing red meats, beets, turnips, and horseradish
burning sensation as the bone marrow is aspi- for 48 to 72 hours.
rated. • Tell the patient that the test requires collec-
After the procedure tion of three stool specimens.
• Maintain pressure dressing. • Withhold iron preparations, iodides, rau-
• Check the aspiration site for bleeding and wolfia derivatives, indomethacin, colchicine,
infection. salicylates, phenylbutazone, steroids, and
• Maintain bed rest as ordered. ascorbic acid for 48 hours before the test and
throughout the collection period.
Swallow this and wait
A Schilling test involves the administration RBC longevity measure
of an oral radioactive cyanocobalamin and an Er ythrocyte life span determination in-
intramuscular cyanocobalamin. Following this volves a reinjection of the patient’s blood that
is microscopic examination of a 24-hour urine has been tagged with chromium 51. Its pur-
specimen for cyanocobalamin (vitamin B12). pose is to measure the life span of circulating
RBCs.
Nursing actions
• Withhold food and fluids for 12 hours be- Nursing actions
fore the test. • Inform the patient that frequent blood sam-
• Withhold laxatives during the test. ples will be drawn over a 2-week period.
• After the test, instruct the patient to save all • Check the venipuncture site for bleeding.
In gastric analysis, voided urine for 24 hours and to keep the • Apply a pressure dressing to the venipunc-
my contents are urine at room temperature. ture site after the procedure.
aspirated through an
NG tube. What’s in the stomach? Balancing act
Gastric analysis involves the aspiration of The Romberg test is a physical test in which
stomach contents through a nasogastric (NG) the patient stands with his feet together, his
tube. A fasting analysis of gastric secretions is eyes open, and his arms at either side while
then performed to measure acidity and to di- the examiner stands and protects the patient
agnose pernicious anemia. from falling. The patient is then asked to close
his eyes. If he loses his balance or sways to
Nursing actions one side, the Romberg test is positive. This is
Before the procedure done to assess loss of balance in pernicious
• Withhold food and fluids for 12 hours. anemia.
• Instruct the patient not to smoke or chew
gum for at least 8 hours before the test. Nursing actions
• Withhold medications that can affect gastric • Explain the procedure to the patient.
secretions. • Monitor the patient for imbalance.
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• Prevent the patient from falling. • Check the venipuncture site for bleeding af-
ter the procedure.
How fast does it burst?
In the er ythrocyte fragility test, a blood
sample is used to measure the rate at which
RBCs burst in varied hypotonic solutions. Polish up on patient Most NCLEX
Nursing actions
care questions focus on
what a nurse should
do in a specific
• After the procedure, check the venipunc- Major hematologic and immune disorders in- situation. Always look
ture site for bleeding. clude acquired immunodeficiency syndrome for the patient care
• Send the sample to the laboratory. (AIDS), anaphylaxis, ankylosing spondylitis, angle.
aplastic anemia, calcium imbalance, chloride
Bone picture imbalance, disseminated intravascular coagu-
A bone scan permits imaging of the skeleton lation (DIC), hemophilia, iron deficiency ane-
by a scanning camera after I.V. injection of a mia, Kaposi’s sarcoma, leukemia, lymphoma,
radioisotope. This creates a visual image of magnesium imbalance, metabolic acidosis,
bone metabolism. metabolic alkalosis, multiple myeloma, perni-
cious anemia, phosphorus imbalance, poly-
Nursing actions cythemia vera, rheumatoid arthritis, sclero-
Before the procedure derma, septic shock, sickle cell anemia, sodi-
• Verify that informed consent has been ob- um imbalance, systemic lupus erythematosus
tained and documented. (SLE), and vasculitis.
• Determine the patient’s ability to lie still for
approximately 1 hour.
• Advise the patient to drink lots of fluids to Acquired immunodeficiency
maintain hydration and reduce the radiation
dose to the bladder. (Have the patient do this syndrome
during the interval between the injection of
the tracer and the actual scanning.) AIDS is a defect in T-cell–mediated immunity
After the procedure caused by HIV. AIDS places a patient at signif-
• Check the injection site for redness or icant risk for developing potentially fatal op-
swelling. portunistic infections. A diagnosis of AIDS is
• Avoid scheduling any other radionuclide based on laboratory evidence of HIV infection
test for 24 to 48 hours. coexisting with one or more indicator dis-
•Tell the patient to drink lots of fluids and eases, such as herpes simplex virus, cytomeg-
to empty his bladder frequently for 24 to alovirus, mycobacterial, or candidal infection;
48 hours. Pneumocystis carinii pneumonia; Kaposi’s sar-
• Provide analgesics for pain resulting from coma; wasting syndrome; or dementia.
positioning on the scanning table, as needed.
CAUSES
Clot measure • Exposure to blood containing HIV: transfu-
A coagulation study tests a blood sample to sions, tissue transplantation, contaminated
analyze platelet function, prothrombin time needles, handling of blood
(PT), International Normalized Ratio, partial • Exposure to semen and vaginal secretions
thromboplastin time (PTT), coagulation time, containing HIV: unprotected sexual inter-
and bleeding time. course, handling of semen and vaginal secre-
tions
Nursing actions • Transmission from an infected mother
• Note the patient’s current drug therapy be- across the placental barrier to the fetus
fore the procedure.
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• Transmission from an infected mother to • Antifungals: fluconazole (Diflucan), ampho-

the neonate through contact with the cervix tericin B (Fungizone) for opportunistic infec-
or maternal blood during delivery tions
• Transmission from an infected mother to • Antiprotozoal agent: pentamidine (Nebu-
the neonate through breast milk Pent)
•Interferon alfa-2a, recombinant (Roferon-A)
DATA COLLECTION FINDINGS •Antineoplastics: to combat associated can-
• Anorexia, weight loss, recurrent diarrhea cers
• Disorientation, confusion, dementia
• Fatigue and weakness Combination drug therapy to fight HIV
• Fever Highly active antiretroviral therapy combines
Combination • Lymphadenopathy three or more antiretroviral medications in a
therapy • Signs and symptoms of poor nutrition daily regimen. The Food and Drug Adminis-
to treat HIV and AIDS • History of night sweats tration has approved four classes of antiretro-
usually includes • History of opportunistic infections viral drugs:
nonnucleoside reverse
• Pallor • Nonnucleoside reverse transcriptase in-
transcriptase
inhibitors, nucleoside hibitors: delavirdine (Rescriptor), nevirapine
reverse transcriptase DIAGNOSTIC FINDINGS (Viramune), efavirenz (Sustiva)
inhibitors, and • Blood chemistry shows increased transami- • Nucleoside reverse transcriptase inhibitors:
protease inhibitors. nase, alkaline phosphatase, and gamma glob- lamivudine (Epivir), zalcitabine (Hivid), zi-
ulin levels and a decreased albumin level. dovudine (Retrovir), abacavir (Ziagen), di-
• CD4+ T-cell level is less than 200 cells/µl. danosine (Videx), emtricitabine (Emtriva),
• ELISA shows positive HIV antibody titer. stavudine (Zerit), tenofovir (Viread)
• Hematology shows decreased WBCs, • Protease inhibitors: indinavir (Crixivan),
RBCs, and platelets. nelfinavir (Viracept), ritonavir (Norvir),
• Western blot test is positive. saquinavir (Invirase), amprenavir (Agen-
erase), atazanavir (Reyataz), fosamprenavir
NURSING DIAGNOSES (Lexiva)
• Ineffective protection • Fusion inhibitor: enfuvirtide (Fuzeon)
• Hopelessness
• Social isolation INTERVENTIONS AND RATIONALES
• Monitor respiratory status to detect signs of
TREATMENT hypoxia.
• Activity: as tolerated, active and passive • Monitor neurologic status to detect AIDS-
range-of-motion (ROM) exercises related dementia.
• Diet: high calorie, high protein in small, fre- • Monitor and record vital signs to detect evi-
quent feedings dence of compromise.
• Nutritional support: total parenteral nutri- • Monitor for opportunistic infections because
tion (TPN), enteral feedings if needed early treatment may limit complications.
• Respiratory treatments: chest physio- • Administer oxygen to enhance oxygenation.
therapy, postural drainage, and incentive • Provide incentive spirometry and assist
spirometry with turning, coughing, and deep breathing to
• Specialized bed: air therapy bed mobilize and remove secretions.
• Standard precautions • Encourage fluids or maintain I.V. fluids to
• Transfusion therapy: fresh frozen plasma, prevent dehydration.
platelets, and packed RBCs • Maintain the patient’s diet to fight oppor-
tunistic infection and maintain weight.
Drug therapy • Maintain TPN and enteral feedings, if nec-
• Antibiotic: co-trimoxazole (Bactrim) for op- essary, to bolster nutritional reserves and the
portunistic infections immune system.
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• Administer medications, as prescribed, to • diagnostic chemicals (sulfobromophthalein,

Yikes! Anaphylaxis
reduce the risk of complications and halt repro- sodium dehydrocholate, and radiographic may cause vascular
duction of HIV. contrast media) collapse and lead to
• Maintain activity, as tolerated, to encourage • enzymes (such as L-asparaginase) systemic shock and,
independence. • foods (legumes, nuts, berries, seafood, and sometimes, death.
• Provide rest periods to reduce oxygen de- egg albumin) and sulfite-containing food addi-
mands and prevent fatigue. tives
• Provide mouth care to prevent infection, pro- • hormones
vide comfort, and enhance taste of meals. • insect venom (honeybees, wasps, hornets,
• Maintain standard precautions to avoid ex- yellow jackets, fire ants, mosquitoes, and cer-
posure to blood, body fluids, and secretions. tain spiders)
• Encourage the patient to express feelings • local anesthetics
about changes in body image, a fear of dying, • penicillin and other antibiotics
and social isolation to help him cope with • polysaccharides
chronic illness and reduce anxiety. • ruptured hydatid cyst (rarely)
• Suggest community agencies for support to • salicylates
enhance quality of life and independence. • serums (usually horse serum)
• Monitor intake and output, daily weight, • sulfonamides
and urine specific gravity for early recognition • vaccines.
and treatment of dehydration.
Teaching topics • Cardiovascular symptoms (hypotension,
• Refraining from donating blood shock, cardiac arrhythmias) that may precipi-
• Avoiding use of alcohol and recreational tate circulatory collapse if untreated
drugs • Sudden physical distress within seconds or
• Using latex condoms during sexual inter- minutes after exposure to an allergen (may in-
course clude feeling of impending doom or fright,
• Practicing safer sex practices weakness, sweating, sneezing, shortness of
• If using I.V. drugs, cleaning drug parapher- breath, nasal pruritus, urticaria, and angio-
nalia with bleach edema, followed rapidly by symptoms in one
• Taking prescribed medication exactly as or more target organs)
prescribed for as long as prescribed • GI and genitourinary (GU) symptoms (se-
vere stomach cramps, nausea, diarrhea, uri- Immediately after
exposure to an
nary urgency and incontinence)
allergen, the patient
Anaphylaxis • Respiratory symptoms (nasal mucosal ede- may report a feeling of
ma; profuse, watery rhinorrhea; itching; nasal impending doom
Anaphylaxis is a dramatic and widespread congestion; sudden sneezing attacks; edema or fright.
acute atopic reaction. It’s marked by the sud- of upper respiratory tract that causes hoarse-
den onset of rapidly progressive urticaria and ness, stridor, and dyspnea [early sign of acute
respiratory distress. The severity of the reac- respiratory failure])
tion is inversely related to the interval be-
tween the exposure to an allergen and the on- DIAGNOSTIC FINDINGS
set of symptoms—the longer the interval, the • Anaphylaxis can be diagnosed by the rapid
less severe the reaction. A severe anaphylac- onset of severe respiratory or cardiovascular
tic reaction may cause vascular collapse, lead- symptoms after ingestion or injection of a
ing to systemic shock and, sometimes, death. drug, vaccine, diagnostic agent, food, or food
additive, or after an insect sting.
CAUSES • If symptoms occur without a known allergic
Systemic exposure to or ingestion of sensitiz- stimulus, other possible causes of shock
ing drugs or other substances, such as: (such as acute myocardial infarction [MI],
• allergen extracts
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status asthmaticus, or heart failure) need to • After the initial emergency, administer oth-
be ruled out. er medications, such as subQ epinephrine,
longer-acting epinephrine, corticosteroids,
NURSING DIAGNOSES and diphenhydramine, for long-term manage-
• Risk for suffocation ment to prevent recurrence of symptoms.
• Decreased cardiac output • If a patient must receive a drug to which
• Anxiety he’s allergic, make sure he receives careful
desensitization with gradually increasing
TREATMENT doses of the antigen or advance administra-
• Cardiopulmonary resuscitation (CPR) in tion of steroids to prevent a severe reaction.
case of cardiac arrest • A person with a known history of allergies
• Endotracheal (ET) tube insertion or a should receive a drug with a high anaphylac-
tracheotomy and oxygen therapy in case of la- tic potential only after cautious pretesting for
ryngeal edema sensitivity. Closely monitor the patient during
• Other therapy as indicated by clinical re- testing and make sure that resuscitative
sponse equipment and epinephrine are ready to pre-
vent a severe reaction that may lead to car-
Drug therapy diopulmonary arrest.
• Immediate subcutaneous (subQ) injection • When any patient needs a drug with high
of epinephrine 1:1,000 aqueous solution, 0.1 to anaphylactic potential (particularly parenteral
0.5 ml, repeated every 10 to 15 minutes as drugs), make sure he receives each dose un-
necessary der close medical observation to prevent a se-
• Other medications given after initial emer- vere reaction.
gency (may include subQ epinephrine, • Closely monitor a patient undergoing diag-
longer-acting epinephrine, corticosteroids, nostic tests that use radiographic contrast
diphenhydramine [Benadryl] I.V. for long- dyes, such as cardiac catheterization, excreto-
term management) ry urography, and angiography, to detect early
• Vasopressors: norepinephrine (Levophed), signs of anaphylaxis.
phenylephrine (Neo-Synephrine), and dopa-
mine (Intropin), if hypotensive Teaching topics
• Understanding risks of delayed symptoms
INTERVENTIONS AND RATIONALES and need to report any recurrence of short-
• In the early stages of anaphylaxis, give epi- ness of breath, chest tightness, sweating, an-
nephrine I.M. or subQ and help it move into gioedema, or other symptoms
the circulation faster by massaging the injec- • Preventing anaphylaxis (avoiding exposure
tion site. In severe reactions, give epinephrine to known allergens, including all forms of the
I.V. to prevent crisis. offending food or drug; avoiding open fields
• Maintain airway patency. Observe for early and wooded areas during the insect season in
signs of laryngeal edema (stridor, hoarseness, case of reaction to insect bite or sting; carry-
and dyspnea), and prepare for ET tube inser- ing an anaphylaxis kit containing epinephrine,
tion or a tracheotomy and oxygen therapy to an antihistamine, and a tourniquet)
prevent cerebral anoxia. • Wearing a medical identification bracelet
• In case of cardiac arrest, begin CPR, includ- identifying the patient’s allergies
ing closed-chest heart massage and assisted • Using emergency medication such as epi-
ventilation, as well as other therapy as indicat- nephrine (Epi-Pen)
ed by clinical response. These measures are
necessary to prevent irreversible organ damage.
• Monitor blood pressure and urine output to
monitor response to treatment.
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Ankylosing spondylitis • Stiffness and limited motion of the lumbar

Typically,
spine ankylosing spondylitis
Ankylosing spondylitis is a chronic, usually • Tenderness over the site of inflammation begins in the lower
progressive inflammatory disease that primar- back and progresses
ily affects the spine and adjacent soft tissue. DIAGNOSTIC FINDINGS up the spine to the
Generally, the disease begins in the sacroiliac • Confirmation requires characteristic X-ray neck.
joints (between the sacrum and the ileum) findings: blurring of the bony margins of
and gradually progresses to the lumbar, tho- joints in the early stage, bilateral sacroiliac in-
racic, and cervical regions of the spine. Dete- volvement, patchy sclerosis with superficial
rioration of bone and cartilage can lead to fi- bony erosions, eventual squaring of vertebral
brous tissue formation and eventual fusion of bodies, and “bamboo spine” with complete
the spine or peripheral joints. Symptoms may ankylosis.
progress unpredictably; the disease can go • ESR and alkaline phosphatase and creatine
into remission, exacerbation, or arrest at any kinase levels may be slightly elevated. A nega-
stage. tive rheumatoid factor helps rule out rheuma-
Ankylosing spondylitis affects five times as toid arthritis, which produces similar symp-
many males as females. Progressive disease toms.
is well recognized in men, but the diagnosis is • Typical symptoms, a family history, and the
commonly overlooked in women, who tend to presence of HLA-B27 strongly suggest anky-
have more peripheral joint involvement. losing spondylitis.
CAUSES NURSING DIAGNOSES

• Familial tendency strongly suggested • Chronic pain
• Possible link to underlying infection • Impaired physical mobility
• Presence of histocompatibility antigen HLA- • Activity intolerance
B27 and circulating immune complexes sug-
gests immunologic activity TREATMENT
• If secondary, may be associated with reac- • Good posture, stretching and deep-
tive arthritis (Reiter’s syndrome), psoriatic breathing exercises and, in some patients,
arthritis, or inflammatory bowel disease braces and lightweight supports to delay fur-
ther deformity
DATA COLLECTION FINDINGS • Long-term daily exercise program The fact that
• Intermittent lower back pain (the first indi- • Spinal wedge osteotomy to separate and you’re studying for
cation) usually most severe in morning or af- reposition vertebrae in case of severe spinal the NCLEX shows
ter period of inactivity involvement (performed only on selected that you have the
• Kyphosis in advanced stages and associated patients because of risk of spinal cord damage ability to set a goal
limited ROM and long convalescence) for yourself. Give
• Mild fatigue, fever, anorexia, or loss of • Surgical hip replacement in case of severe yourself credit for
weight; unilateral acute anterior uveitis hip involvement setting achievable
• Pain and limited expansion of the chest goals.
• Pain or tenderness at tendon insertion sites Drug therapy
(enthesitis), especially the Achilles or patellar • Anti-inflammatory agents: aspirin,
tendon ibuprofen (Motrin), indomethacin (In-
• Peripheral arthritis involving the shoulders, docin), sulfasalazine (Azulfidine),
hips, and knees sulindac (Clinoril) to control pain and
• Signs and symptoms of severe neurologic inflammation
complications, such as cauda equina syn- • Cyclo-oxygenase-2 (Cox-2)-
drome or paralysis, secondary to fracture of a inhibitor: celecoxib (Celebrex)
rigid cervical spine or C1-C2 subluxation • Tumor necrosis factor alpha in-
hibitor: etanercept (Enbrel)
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Ankylosing
INTERVENTIONS AND RATIONALES Aplastic anemia
spondylitis can be an • Offer support and reassurance. Ankylosing
extremely painful and spondylitis can be an extremely painful and Aplastic anemia, also known as pancytopenia,
debilitating disease. crippling disease; the caregiver’s main responsi- results from suppression, destruction, or apla-
Promote the patient’s bility is to promote the patient’s comfort while sia of the bone marrow. This damage to the
comfort while preserving as much mobility as possible. Keep bone marrow makes it unable to produce ade-
preserving as much in mind that the patient’s limited ROM makes quate amounts of erythrocytes, leukocytes,
mobility as possible. simple tasks difficult. and platelets.
• Administer medications as needed, to de-
crease inflammation and pain. CAUSES
• Apply local heat and provide massage to re- • Chemotherapy
lieve pain. Evaluate mobility and degree of • Drug-induced from chloramphenicol
discomfort frequently to monitor for disease (Chloromycetin) or phenytoin (Dilantin)
progression. • Exposure to chemicals
• Teach and assist with daily exercises, as • Idiopathic
needed, to maintain strength and function. • Radiation
Stress the importance of maintaining good • Viral hepatitis
posture to prevent kyphosis.
• If treatment includes surgery, provide post- DATA COLLECTION FINDINGS
operative care to prevent such postoperative • Anorexia
complications as wound infection, throm- • Dyspnea, tachypnea
bophlebitis, and pneumonia. • Epistaxis
• Fever
Teaching topics • Fatigue, weakness
• Avoiding any physical activity that places • Gingivitis
undue stress on the back, such as lifting • Headache
heavy objects • Bleeding from gums, rectum, or vagina
• Standing upright; sitting upright in a high, • Melena
straight chair; and avoiding leaning over a • Palpitations, tachycardia
desk • Purpura, petechiae, ecchymosis, pallor
• Sleeping in a prone position on a hard mat-
tress and avoiding use of pillows under the DIAGNOSTIC FINDINGS
neck or knees • Bone marrow biopsy shows a decrease in
• Avoiding prolonged walking, standing, sit- activity or no cell production.
ting, or driving • Fecal occult blood test is positive.
Aplastic • Performing regular stretching and deep- • Hematology shows decreased granulocytes,
anemia results breathing exercises and swimming regularly, thrombocytes, and RBCs.
when damaged if possible • Peripheral blood smear shows pancyto-
bone marrow is • Having height measured every 3 to penia.
unable to 4 months to detect any tendency toward • Urine chemistry reveals hematuria.
produce new kyphosis
blood cells.
• Seeking vocational counseling if the NURSING DIAGNOSES
patient’s work requires standing or prolonged • Activity intolerance
sitting at a desk • Risk for deficient fluid volume
• Contacting the local Arthritis Foundation • Risk for infection
chapter for a support group or the Spondylitis
Association of America TREATMENT
• Reversal of the underlying cause
• Bone marrow transplantation
• Transfusion of platelets and packed RBCs
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Drug therapy • Provide mouth care before and after meals

• Analgesic: acetaminophen (Tylenol) to enhance the taste of meals.
• Androgens: fluoxymesterone (Halotestin), • Provide skin care to prevent skin breakdown
oxymetholone (Anadrol-50) due to bed rest, dehydration, and fever.
• Antibiotics: according to the sensitivity of • Protect the patient from falls to reduce the
the infecting organism risk of hemorrhage.
• Antithymocyte globulin (Atgam) • Avoid giving the patient I.M. injections to re-
• Hematopoietic growth factor: epoetin alfa duce the risk of hemorrhage.
(Epogen) • Avoid using hard toothbrushes and straight
• Human granulocyte colony-stimulating fac- razors on the patient to reduce the risk of hem-
tor: filgrastim (Neupogen) orrhage.
INTERVENTIONS AND RATIONALES Teaching topics

• Monitor respiratory status to detect hypox- • Recognizing the early signs and symptoms
emia caused by low Hb levels. of bleeding and infection
• Monitor vital signs for signs of hemorrhage, • Avoiding contact sports
infection, and activity intolerance. • Wearing a medical identification bracelet
• Monitor and record intake and output and • Refraining from using over-the-counter
urine specific gravity to determine fluid bal- (OTC) medications
ance. • Monitoring stool for occult blood
• Check stool, urine, and vomitus for occult • Using an electric razor to avoid bleeding
blood loss caused by reduced platelet levels. • Refraining from taking aspirin or non-
• Monitor for infection, bleeding, and bruis- steroidal anti-inflammatory drugs (NSAIDs)
ing caused by reduced levels of WBCs and
platelets.
• Encourage fluids and maintain I.V. fluids to Calcium imbalance
replace fluids lost by fever and bleeding.
• Administer oxygen to improve tissue oxy- Calcium plays an indispensable role in cell
genation because low Hb levels reduce the oxy- permeability, formation of bones and teeth,
gen-carrying capacity of the blood. blood coagulation, transmission of nerve im-
• Assist with turning, coughing, and deep pulses, and normal muscle contraction.
Together with
breathing to mobilize and remove secretions. Nearly all (99%) of the body’s calcium is
phosphorus, calcium is
• Monitor transfusion therapy, as prescribed, found in the bones. The remaining 1% exists responsible for the
to replace low blood components. in ionized form in serum; maintaining ionized formation and
• Administer medications, as prescribed, to calcium in the serum is critical to healthy neu- structure of bones
treat the patient’s disorder and prevent compli- rologic function. and teeth.
cations. The parathyroid glands regulate ionized cal-
• Maintain the patient’s diet to promote RBC cium and determine its resorption into bone,
production and fight infection. absorption from the GI mucosa, and excretion
• Encourage verbalization of concerns and in urine and stool. Severe calcium imbalance
fears to allay the patient’s anxiety. requires emergency treatment because a defi-
• Alternate rest periods with activity to con- ciency (hypocalcemia) can lead to tetany and
serve energy and reduce weakness caused by seizures; an excess (hypercalcemia), to
anemia. cardiac arrhythmias and coma.
• Provide cooling blankets and tepid sponge
baths for fever to promote comfort and reduce CAUSES
metabolic demands. Hypocalcemia
• Maintain protective precautions to prevent • Hypomagnesemia
infection and hemorrhage. • Hypoparathyroidism
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• Inadequate intake of calcium and vitamin D approximately one-half of serum calcium is

Hypocalcemia can
occur when the body • Malabsorption or loss of calcium from the bound to albumin, changes in serum protein
doesn’t take in enough GI tract must be considered when interpreting serum
calcium, doesn’t • Overcorrection of acidosis calcium levels.)
absorb the mineral • Pancreatic insufficiency • Sulkowitch urine test shows increased urine
properly, or loses • Renal failure calcium precipitation in hypercalcemia.
excessive amounts of • Severe infections or burns • Electrocardiogram (ECG) reveals a length-
calcium. ened QT interval, a prolonged ST segment,
Hypercalcemia and arrhythmias in hypocalcemia; in hyper-
• Hyperparathyroidism calcemia, a shortened QT interval and heart
• Hypervitaminosis D block.
• Multiple fractures and prolonged immobi-
lization NURSING DIAGNOSES
• Multiple myeloma Hypocalcemia
• Tumors • Imbalanced nutrition: Less than body re-
• Other causes (milk-alkali syndrome, sar- quirements
coidosis, hyperthyroidism, adrenal insuffi- • Acute pain
ciency, and thiazide diuretics)
Hypercalcemia
DATA COLLECTION FINDINGS • Impaired physical mobility
Hypocalcemia • Impaired urinary elimination
• Cardiac arrhythmias
• Carpopedal spasm TREATMENT
• Chvostek’s sign Hypocalcemia
• Perioral paresthesia • Diet: adequate intake of calcium, vitamin D,
• Seizures and protein
• Tetany
• Trousseau’s sign Drug therapy
• Twitching • Ergocalciferol (vitamin D2), cholecalciferol
(vitamin D3), calcitriol (Rocaltrol), dihydro-
Hypercalcemia tachysterol (synthetic form of vitamin D2) for
• Anorexia severe deficiency
Hypercalcemia
• Cardiac arrhythmias and eventual coma • Immediate correction by I.V. calcium glu-
occurs when the rate
of calcium entry into with severe hypercalcemia (serum levels conate or calcium chloride for acute hypocal-
the extracellular fluid greater than 5.7 mEq/L) cemia (an emergency)
exceeds the rate of • Constipation • Vitamin D in multivitamin preparation for
calcium excretion by • Decreased muscle tone mild hypocalcemia
the kidneys. • Dehydration • Vitamin D supplements to facilitate GI ab-
• Lethargy sorption of calcium to treat chronic hypocal-
• Muscle weakness cemia
• Nausea
• Polydipsia Hypercalcemia
• Polyuria • Hydration with normal saline solution to
• Vomiting eliminate excess serum calcium through
urine excretion
DIAGNOSTIC FINDINGS • Diet: Low calcium with increased oral fluid
• A serum calcium level less than 4.5 mEq/L intake
confirms hypocalcemia; a level greater than
5.5 mEq/L confirms hypercalcemia. (Because
920105.qxd 8/7/08 3:53 PM Page 135
Drug therapy sion, and cardiac arrhythmias). Administer

• Calcitonin (Calcimar) oral calcium supplements 1 to 11⁄2 hours after
• Corticosteroids: prednisone (Deltasone), meals or with milk to promote absorption. Because nearly
hydrocortisone (Solu-Cortef) for treating sar- • Provide a quiet, stress-free environment for one-half of all calcium
coidosis, hypervitaminosis D, and certain tu- the patient with tetany to prevent seizure activ- is bound to the
mors ity. Observe seizure precautions for patients protein albumin, serum
protein abnormalities
• Loop diuretics: ethacrynic acid (Edecrin), with severe hypocalcemia that may lead to
can influence total
furosemide (Lasix) to promote calcium excre- seizures, to prevent patient injury. serum calcium levels.
tion (thiazide diuretics are contraindicated in
hypercalcemia because they inhibit calcium For hypercalcemia
excretion) • Monitor serum calcium levels frequently.
• Plicamycin (Mithracin) to lower serum cal- Increase fluid intake to dilute calcium in
cium level (especially in hypercalcemia sec- serum and urine and to prevent renal damage
ondary to certain tumors) and dehydration.
• Sodium phosphate solution administered by • Watch for signs of heart failure in patients
mouth or by retention enema (promotes calci- receiving normal saline solution diuresis ther-
um deposits in bone and inhibits absorption apy. Infusion of large volumes of normal saline
from GI tract) may cause excess fluid volume, leading to heart
failure.
INTERVENTIONS AND RATIONALES • Monitor intake and output, and check the
• Watch for hypocalcemia in patients receiv- urine for renal calculi and acidity. Provide
ing massive transfusions of citrated blood and acid-ash drinks, such as cranberry or prune
in those with chronic diarrhea, severe infec- juice, because calcium salts are more soluble in
tions, and insufficient dietary intake of calci- acid than in alkali.
um and protein (especially elderly patients). • Check the patient’s vital signs frequently. In
Identifying patients at risk can ensure early the patient receiving cardiac glycosides,
treatment. watch for signs of toxicity, such as anorexia,
nausea, vomiting, and bradycardia (often with
For hypocalcemia arrhythmias). Fatal arrhythmias may result
• Monitor serum calcium levels every 12 to when digoxin is administered in hypercalcemia.
24 hours; a calcium level below 4.5 mEq/L • Help the patient walk as soon as possible.
requires immediate attention. When giving Handle the patient with chronic hypercal-
Take note! Calcium
calcium supplements, frequently check the cemia gently to prevent pathologic fractures. supplements may
pH level; an alkalotic state that exceeds 7.45 • If the patient is bedridden, reposition him cause synergistic
pH inhibits calcium ionization. Check for frequently and encourage ROM exercises to effects in patients
Trousseau’s and Chvostek’s signs, which indi- promote circulation and prevent urinary stasis taking digoxin.
cate hypocalcemia. and calcium loss from bone.
• When the patient is receiving calcium solu-
tions, watch for anorexia, nausea, and vomit- Teaching topics
ing, which are possible signs of overcorrection • Stressing the importance of calcium for nor-
to hypercalcemia. mal bone formation and blood coagulation
• Monitor the patient closely for a possible • Eating foods rich in calcium, vitamin D, and
drug interaction if he’s receiving digoxin protein, such as fortified milk and cheese, to
(Lanoxin) with large doses of oral calcium prevent hypocalcemia
supplements. Administration of digoxin con- • Avoiding chronic laxative use and overuse
comitantly with calcium supplements may of antacids to prevent hypocalcemia
cause synergistic effects of digoxin that precipi- • Eating a low-calcium diet and increasing flu-
tate arrhythmias. Watch for signs of digoxin id intake to prevent recurrence of hypercal-
toxicity (anorexia, nausea, vomiting, yellow vi- cemia
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Chloride is quite Chloride imbalance • Deep, rapid breathing

an anion. It helps • Diminished cognitive ability
maintain acid-base Hypochloremia and hyperchloremia are, re- • Dyspnea
balance and spectively, conditions of deficient or excessive • Hypertension
assists in carbon serum levels of the anion chloride (an anion • Pitting edema
dioxide transport in is a negatively charged ion). Chloride appears • Tachycardia
red blood cells. predominantly in extracellular fluid (ECF; • Weakness
fluid outside the cells) and accounts for two-
thirds of all serum anions. DIAGNOSTIC FINDINGS
Secreted by stomach mucosa as hydrochlo- • Serum chloride level less than 98 mEq/L
ric acid, chloride provides an acid medium confirms hypochloremia; supportive values
conducive to digestion and activation of en- with metabolic alkalosis include a serum pH
zymes. It also participates in maintaining acid- greater than 7.45 and a serum carbon dioxide
base and body water balances, influences the level greater than 32 mEq/L.
osmolality or tonicity of ECF, plays a role in • Serum chloride level greater than
the exchange of oxygen and carbon dioxide in 108 mEq/L confirms hyperchloremia; with
RBCs, and helps activate salivary amylase metabolic acidosis, serum pH is less than
(which, in turn, activates the digestive 7.35 and the serum carbon dioxide level is
process). less than 22 mEq/L.
CAUSES NURSING DIAGNOSES

Hypochloremia Hypochloremia
• Administration of dextrose I.V. without elec- • Ineffective breathing pattern
trolytes • Risk for injury
• Loss of hydrochloric acid in gastric secre-
tions from vomiting, gastric suctioning, or Hyperchloremia
gastric surgery • Excess fluid volume
• Low dietary sodium intake • Disturbed thought processes
• Metabolic alkalosis
Sodium
imbalance? Or chloride
• Potassium deficiency TREATMENT
imbalance? These two • Prolonged diarrhea or diaphoresis Hypochloremia
conditions commonly • Sodium deficiency • Diet: salty broth
produce similar data • Saline solution I.V.
collection findings, Hyperchloremia
such as muscle • Hyperingestion of ammonium chloride Drug therapy
twitching, weakness, • Ureterointestinal anastomosis, which can • Acidifying agent: ammonium chloride
and dyspnea. lead to hyperchloremia by allowing reabsorp-
tion of chloride by the bowel Hyperchloremia
• Lactated Ringer’s solution
Hypochloremia Drug therapy
• Muscle hypertonicity (in conditions related • Alkalinizing agent: sodium bicarbonate I.V.
to loss of gastric secretions)
• Muscle weakness INTERVENTIONS AND RATIONALES
• Shallow, depressed breathing • Monitor serum chloride levels frequently,
• Tetany particularly during I.V. therapy, to guide the
• Twitching treatment plan.
• Watch for signs of hyperchloremia or hypo-
Hyperchloremia chloremia. Be alert for respiratory difficulty
• Agitation to prevent respiratory distress.
• Coma
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For hypochloremia DIC is generally an acute condition but may

• Monitor serum electrolyte levels and fluid be chronic in cancer patients. The prognosis
intake and output of patients who are vulnera- depends on early detection and treatment, the DIC causes
ble to chloride imbalance, particularly those severity of the hemorrhage, and treatment of blockages in the small
recovering from gastric surgery, to prevent the underlying disease or condition. blood vessels,
hypochloremia. depletes the body’s
• Watch for excessive or continuous loss of CAUSES supply of clotting
gastric secretions as well as prolonged infu- • Disorders that produce necrosis, such as factors and platelets,
sion of dextrose in water without saline to pre- extensive burns and trauma, brain tissue de- and destroys fibrin.
vent chloride imbalance. struction, transplant rejection, and hepatic
necrosis
For hyperchloremia • Infection (the most common cause of DIC),
• Check serum electrolyte levels every 3 to including gram-negative or gram-positive sep-
6 hours. If the patient is receiving high doses ticemia; viral, fungal, or rickettsial infection;
of sodium bicarbonate, watch for signs of and protozoal infection (falciparum malaria)
overcorrection (metabolic alkalosis, respirato- • Neoplastic disease, including acute leuke-
ry depression) or lingering signs of hyper- mia and metastatic carcinoma
chloremia, which indicate inadequate treat- • Obstetric complications, such as abruptio
ment. Frequent monitoring of electrolyte levels placentae, amniotic fluid embolism, and re-
helps guide the treatment plan and avoids com- tained dead fetus
plications of chloride imbalance.
Teaching topics • Abnormal bleeding (petechiae, hematomas,
• Explanation of all tests and procedures ecchymosis, cutaneous oozing) without an ac-
• Dietary sources of sodium, potassium, and companying history of a serious hemorrhagic
chloride for the patient experiencing hypo- disorder
chloremia • Abdominal distention
• Coma
• Dyspnea
Disseminated intravascular • Nausea
• Oliguria
coagulation • Seizures
• Severe muscle, back, and abdominal pain Abnormal bleeding
DIC, also called consumption coagulopathy • Shock with no accompanying
and defibrination syndrome, occurs as a com- • Vertigo hemorrhagic disorder?
plication of diseases and conditions that accel- • Vomiting That sounds like DIC.
erate clotting. This accelerated clotting
process causes small blood vessel occlusion, DIAGNOSTIC FINDINGS
organ necrosis, depletion of circulating clot- • Blood tests show prolonged PT greater
ting factors and platelets, and activation of the than 15 seconds; prolonged PTT greater
fibrinolytic system—which, in turn, can pro- than 60 seconds; fibrinogen levels less than
voke severe hemorrhage. 150 mg/dl; platelets less than 100,000/µl;
Clotting in the microcirculation usually af- and fibrin degradation products commonly
fects the kidneys and extremities but may oc- greater than 100 µg/ml.
cur in the brain, lungs, pituitary and adrenal • Positive D-dimer test is specific for DIC.
glands, and GI mucosa. Other conditions,
such as vitamin K deficiency and hepatic dis- NURSING DIAGNOSES
ease, and anticoagulant therapy may cause a • Risk for deficient fluid volume
similar hemorrhage. • Ineffective tissue perfusion: Peripheral
• Fatigue
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• Treatment of the underlying cause • Explaining the disorder and treatment op-
• Bed rest tions to the patient and family
• Transfusion therapy: fresh frozen plasma, • Bleeding prevention
platelets, packed RBCs
Drug therapy Hemophilia

• Anticoagulant: heparin I.V. (Heparin Sodi-
um Injection) A hereditary bleeding disorder that typically
affects males, hemophilia produces mild to
INTERVENTIONS AND RATIONALES severe abnormal bleeding. After a platelet
• Don’t scrub bleeding areas, to prevent clots plug develops at a bleeding site, the lack of
from dislodging and causing fresh bleeding. Use clotting factor prevents a stable fibrin clot
pressure, cold compresses, and topical hemo- from forming. Although hemorrhaging
static agents to control bleeding. doesn’t usually happen immediately, delayed
• Enforce complete bed rest during bleeding bleeding is common. Two types of hemophilia
episodes. If the patient is agitated, pad the exist:
side rails to protect him from injury. • hemophilia A, or classic hemophilia (defi-
• Check all I.V. and venipuncture sites fre- ciency or nonfunction of factor VIII)
quently for bleeding. Apply pressure to injec- • hemophilia B, or Christmas disease (defi-
tion sites for at least 10 minutes. Alert other ciency or nonfunction of factor IX).
personnel to the patient’s tendency to hemor- Severity and prognosis of hemophilia vary
rhage. These measures prevent hemorrhage. with the degree of deficiency and the site of
• Monitor intake and output hourly in acute bleeding.
DIC, especially when administering blood
products, to monitor the effectiveness of volume CAUSES
replacement. • Genetic inheritance: both types of hemo-
• Watch for transfusion reactions and signs of philia inherited as X-linked recessive traits
fluid overload. Weigh dressings and linen and
record drainage to measure the amount of DATA COLLECTION FINDINGS
blood lost. • Hematemesis (bloody vomitus)
• Weigh the patient daily, particularly in renal • Hematomas on the extremities, torso, or
involvement, to monitor for excess fluid both
volume. • Hematuria (bloody urine)
• Watch for bleeding from the GI and GU • History of prolonged bleeding after small
tracts to detect early signs of hemorrhage. Mea- cuts, surgery, dental extractions, or trauma
sure the patient’s abdominal girth at least • Joint tenderness
every 4 hours and monitor closely for signs of • Limited ROM
shock to detect intra-abdominal bleeding. • Pain and swelling in a weight-bearing joint
• Monitor the results of serial blood studies (such as the hip, knee, or ankle)
(particularly HCT, Hb, and coagulation times) • Signs of decreased tissue perfusion: chest
to guide the treatment plan. pain, confusion, cool and clammy skin, de-
• Provide emotional support for the patient creased urine output, hypotension, pallor,
and family. As needed, enlist the aid of a so- restlessness, anxiety, tachycardia
cial worker, a chaplain, and other members of • Signs of internal bleeding such as abdomi-
the health care team in providing such sup- nal, chest, or flank pain
port. Providing support in a crisis situation re- • Tarry stools
duces the family’s anxiety.
Severe hemophilia
• Excessive bleeding following circumcision
(commonly the first sign of the disease)
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• Large subQ and deep I.M. hematomas Drug therapy (both types)
Hemophilia is
• Spontaneous or severe bleeding after minor • Non-aspirin-containing analgesics to control inherited as an
trauma joint pain X-linked recessive
trait…
Moderate hemophilia INTERVENTIONS AND RATIONALES
• Occasional spontaneous bleeding • Provide emotional support because hemo-
• SubQ and I.M. hematomas philia is a chronic disorder.
• Refer new patients to a hemophilia treat-
Mild hemophilia ment center for education, evaluation, and de-
• No spontaneous bleeding velopment of a treatment plan.
• Prolonged bleeding after major trauma or • Refer patients and carriers for genetic coun-
surgery (blood may ooze slowly or intermit- seling to determine the risk of passing the dis-
tently for up to 8 days following surgery) ease to offspring.
DIAGNOSTIC FINDINGS During bleeding episodes

Hemophilia A • Apply pressure to cuts and during epistaxis
• PTT is prolonged. to stop bleeding. In many cases, pressure is the
• Factor VIII assay reveals 0% to 25% of nor- only treatment needed for surface cuts.
mal factor VIII. • Apply cold compresses or ice bags and ele-
• Platelet count and function, bleeding time, vate the injured part to control bleeding.
and PT are normal. • Give sufficient clotting factor or plasma, as
ordered, to promote hemostasis. The body
Hemophilia B uses AHF in 48 to 72 hours, so repeat infu-
• Baseline coagulation result is similar to that sions may be necessary.
of hemophilia A, with normal factor VIII. • Administer analgesics to control pain. Avoid
• Factor IX assay shows deficiency. I.M. injections because they may cause hema-
tomas at the injection site. Aspirin and aspirin-
NURSING DIAGNOSES containing medications are contraindicated …this means
• Impaired gas exchange because they decrease platelet adherence and that female carriers
• Acute pain may increase bleeding. have a 50% chance of
• Parental role conflict transmitting the gene
If the patient has bled into a joint to a daughter, making
her a carrier, and a
TREATMENT • Immediately elevate the joint to control
50% chance of
Hemophilia A bleeding. transmitting the gene
• Administration of Factor VIII or cryoprecip- • Begin ROM exercises, if ordered, at least to a son, who would be
itate antihemophilic factor (AHF) and lyo- 48 hours after the bleeding has been con- born with the disease.
philized (dehydrated) AHF to encourage nor- trolled to restore joint mobility.
mal hemostasis (arrest of bleeding) • Don’t allow the patient to bear weight on
• Immediate notification of doctor following the affected joint until bleeding stops and
injury, especially to the head, neck, or ab- swelling subsides to prevent deformities due to
domen hemarthrosis.
Hemophilia B After bleeding episodes and surgery

• Administration of purified factor IX to pro- • Watch for signs of further bleeding to detect
mote hemostasis and control bleeding as soon as possible.
• Immediate notification of doctor following • Closely monitor PTT. Prolonged times in-
injury, especially to the head, neck, or ab- crease risk of bleeding.
domen
Teaching topics
• Recognizing signs of severe internal
bleeding
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Creating NCLEX
• Notifying the primary care provider even DIAGNOSTIC FINDINGS
question scenarios after a minor injury • Hematology shows decreased Hb, HCT,
while you study can • Wearing medical identification bracelet iron, ferritin, reticulocytes, red cell indices,
help you remember • Protecting a child from injury transferrin, and saturation; absent hemo-
important info… • Importance of medical follow-up siderin; and increased iron-binding capacity.
• Risk of infection, such as hepatitis, from • Peripheral blood smear reveals microcytic
blood component administration and hypochromic RBCs.
• Caring for injuries
• Administering blood factor components at NURSING DIAGNOSES
home, as appropriate • Activity intolerance
• Contacting the National Hemophilia Foun- • Imbalanced nutrition: Less than body re-
dation quirements
Iron deficiency anemia TREATMENT

• Diet: high in iron, fiber, and protein with in-
Iron deficiency anemia is a chronic, slowly creased fluids; avoidance of teas and coffee,
progressing disease involving circulating which reduce absorption of iron
RBCs. Iron deficiency results when an individ- • Transfusion therapy with packed RBCs, if
ual absorbs inadequate amounts of iron, has necessary
an inadequate dietary intake of iron, or loses • Vitamins: pyridoxine (vitamin B6), ascorbic
excessive amounts of iron (such as through acid (vitamin C)
chronic bleeding). This decreased iron affects
formation of Hb and RBCs, which, in turn, de- Drug therapy
…for example, creases the capacity of the blood to transport • Iron supplements: ferrous sulfate (Feosol),
imagine that you’re oxygen. iron dextran (DexFerrum)
teaching a patient
with iron deficiency CAUSES INTERVENTIONS AND RATIONALES
anemia about dietary • Acute and chronic bleeding • Monitor intake and output to detect fluid im-
changes. What would • Alcohol abuse balances.
you teach? • Use of certain drugs • Monitor cardiovascular and respiratory sta-
• Gastrectomy tus to detect decreased activity intolerance and
• Inadequate intake of iron-rich foods dyspnea on exertion.
• Malabsorption syndrome • Monitor and record vital signs to determine
• Menstruation activity intolerance.
• Pregnancy • Monitor stool, urine, and vomitus for occult
• Vitamin B6 deficiency blood to identify the cause of anemia.
• Administer oxygen, as necessary, to treat
DATA COLLECTION FINDINGS hypoxemia caused by reduced Hb.
• Cheilosis (fissures and redness of the an- • Provide a diet high in iron to replace iron
gles of the lips) stores in the body.
• Dizziness • Administer medications, as prescribed, to
• Dyspnea replace iron stores in the body. Administer iron
• Koilonychia (spoon-shaped nails) injection deep into muscle using Z-track tech-
• Pale, dry mucous membranes nique to avoid subcutaneous irritation and dis-
• Pallor coloration from leaking drug. Administer liq-
• Palpitations uid preparations with a straw to prevent stain-
• Papillae atrophy of the tongue ing of the teeth.
• Sensitivity to cold • Encourage fluids to avoid dehydration.
• Stomatitis • Provide rest periods to avoid fatigue and re-
• Weakness and fatigue duce oxygen demands.
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• Provide mouth, skin, and foot care because • Pain (if the sarcoma advances beyond the
the tongue or lips may be dry or inflamed and early stages or if a lesion breaks down or im-
the nails may be brittle. pinges on nerves or organs)
• Protect the patient from falls caused by
weakness and fatigue. Falls may result in DIAGNOSTIC FINDINGS
bleeding and bruising. • Computed tomography scan detects and
• Keep the patient warm to enhance comfort. evaluates metastasis.
• Tissue biopsy identifies the lesion’s type
Teaching topics and stage.
• Eating foods rich in iron and vitamin C
• Recognizing signs and symptoms of NURSING DIAGNOSES
bleeding • Ineffective protection
• Monitoring stools for occult blood • Risk for infection
• Recognizing stool color changes caused by • Disturbed body image
oral iron supplementation (stools will be
black) TREATMENT
• Refraining from using hot pads and hot wa- • High-calorie, high-protein diet
ter bottles • Radiation therapy
• Preventing constipation • I.V. fluid therapy
Drug therapy
Kaposi’s sarcoma • Antineoplastics: doxorubicin (Adriamycin),
etoposide (VePesid), vinblastine (Velban), vin-
At one time, this cancer of the lymphatic cell cristine (Oncovin)
wall was rare, occurring mostly in elderly • Biological response modifier: interferon
Italian and Jewish men. The incidence of alfa-2b (ineffective in advanced disease)
Kaposi’s sarcoma has risen dramatically along • Antiemetics: dolasetron (Anzemet),
with the incidence of AIDS. Currently, it’s the trimethobenzamide (Tigan)
most common AIDS-related cancer. • Analgesics to control pain
Kaposi’s sarcoma causes structural and
functional damage. When associated with INTERVENTIONS AND RATIONALES
AIDS, it progresses aggressively, involving • Suggest a referral for psychological coun-
the lymph nodes, the viscera and, possibly, GI seling to assist the patient who’s coping poorly.
structures. Family members may also need help in cop-
One or more
ing with the patient’s disease and with any as-
obvious lesions in
CAUSES sociated demands that the disorder places on conjunction with an
• Unknown; possibly related to immunosup- them. AIDS diagnosis? I
pression • Allow the patient to participate in self-care think they’re asking
decisions and encourage him to participate in about Kaposi’s
DATA COLLECTION FINDINGS self-care measures whenever possible. Involv- sarcoma.
• Dyspnea (in cases of pulmonary involve- ing the patient in the treatment plan helps him
ment), wheezing, hypoventilation, and respi- gain some sense of control over his situation.
ratory distress from bronchial blockage • Inspect the patient’s skin every shift. Look
• Edema from lymphatic obstruction for new lesions and skin breakdown. If the pa-
• One or more obvious lesions in various tient has painful lesions, help him into a more
shapes, sizes, and colors (ranging from comfortable position to alleviate pain and pro-
red-brown to dark purple) appearing most mote patient comfort.
commonly on the skin, buccal mucosa, hard • Administer pain medications. Suggest dis-
and soft palates, lips, gums, tongue, tonsils, tractions and help the patient with relaxation
conjunctivae, and sclerae techniques to divert the patient from his pain
and promote comfort.
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• Urge the patient to share his feelings and • As appropriate, refer the patient to support
Need a diversion
from the pain of provide encouragement to help him adjust to groups offered by the social services depart-
NCLEX studying? changes in his appearance. ment to promote emotional well-being.
Take a break! • Monitor the patient’s weight daily to evalu- • If the patient’s prognosis is poor (less than
ate whether nutritional needs are being met. 6 months to live), suggest hospice care.
• Supply the patient with high-calorie, high- Hospice care provides much-needed support to
protein meals. If he can’t tolerate regular caregivers and helps the patient through the
meals, provide him with frequent smaller dying process.
meals. Consult with the dietitian, and plan
meals around the patient’s treatment. Adverse Teaching topics
reactions to medications and the disease itself • Employing energy-conservation techniques
may make it difficult for the patient’s nutrition- • Consuming a high-calorie, high-protein diet,
al intake to meet his metabolic needs. in small, frequent amounts if necessary
• If the patient can’t take food by mouth, • Following appropriate infection-control
maintain I.V. fluids to prevent dehydration. measures
Also, provide antiemetics to combat nausea • Understanding the importance of following
and encourage nutritional intake. ongoing treatment and care
• Be alert for adverse reactions to radiation • Knowing the benefits of initiating and exe-
therapy or chemotherapy—such as anorexia, cuting advance directives and a durable pow-
nausea, vomiting, and diarrhea—and take er of attorney
steps to prevent or alleviate them. Adverse re-
actions are common and can further compro-
mise the patient’s condition. Leukemia
• Reinforce the explanation of treatments.
Make sure the patient understands which ad- Leukemia is characterized by an uncontrolled
verse reactions to expect and how to manage proliferation of WBC precursors that fail to
them to ensure prompt intervention and treat- mature. Leukemia occurs when normal hemo-
ment. For example, during radiation therapy, poietic cells are replaced by leukemic cells in
instruct the patient to keep irradiated skin bone marrow. Immature forms of WBCs cir-
dry to avoid breakdown and subsequent infec- culate in the blood, infiltrating the liver,
tion. spleen, and lymph nodes. Types of leukemia
• Explain all prescribed medications, includ- include:
ing any possible adverse effects and drug in- • acute lymphocytic
teractions, to promote compliance with the • acute myelogenous
medication regimen. • chronic lymphocytic
• Explain infection-prevention techniques • chronic myelocytic.
and, if necessary, demonstrate basic hygiene
measures to prevent infection. Advise the pa- CAUSES
tient not to share his toothbrush, razor, or • Altered immune system
other items that may be contaminated with • Exposure to chemicals
blood. These measures are especially impor- • Genetics
tant if the patient also has HIV infection or • Radiation
AIDS. These measures prevent the spread of in- • Virus
fection to others.
• Encourage the patient to set priorities, ac- DATA COLLECTION FINDINGS
cept the help of others, and delegate nones- • Enlarged lymph nodes, spleen, and liver
sential tasks. Help the patient plan daily peri- • Epistaxis
ods of alternating activity and rest to help him • Fever
cope with fatigue. • Frequent infections
• Explain the proper use of assistive devices, • Generalized pain
when appropriate, to ease ambulation and pro- • Gingivitis and stomatitis
mote independence. • Hematemesis
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• Hypotension • Monitor for bleeding. Regular assessment

Frequent
• Jaundice may help anticipate or alleviate problems. infections and easy
• Joint, abdominal, and bone pain • Place the patient with epistaxis in an up- bruising are key signs
• Melena right position leaning slightly forward to re- of leukemia.
• Night sweats duce vascular pressure and prevent aspiration.
• Petechiae and ecchymoses • Monitor for infection. Damage to bone mar-
• Prolonged menses row may suppress WBC formation. Promptly
• Tachycardia report temperature over 101° F (38.3° C) and
• Weakness and fatigue decreased WBC counts so that antibiotic ther-
apy may be initiated.
DIAGNOSTIC FINDINGS • Monitor oxygen therapy. Oxygen therapy in-
• Bone marrow biopsy reveals a large num- creases alveolar oxygen concentration and en-
ber of immature leukocytes. hances arterial blood oxygenation.
• Hematology shows decreased HCT, Hb, • Encourage fluids to maintain adequate hy-
RBCs, and platelets; increased ESR; and im- dration.
mature WBCs. • Maintain I.V. fluids to replace fluid loss.
• Coagulation studies reveal a prolonged • Encourage turning every 2 hours to prevent
bleeding time. venous stasis and skin breakdown.
• Encourage coughing and deep breathing to
NURSING DIAGNOSES help remove secretions and prevent pulmonary
• Imbalanced nutrition: Less than body re- complications.
quirements • Place the patient in semi-Fowler’s position
• Chronic pain when in bed to promote chest expansion and
• Risk for infection ventilation of basilar lung fields.
• Maintain the patient’s diet to provide neces-
TREATMENT sary nutrition.
• Diet: high-protein, high-vitamin, and high- • Monitor TPN, if needed, to provide the pa-
mineral diet consisting of soft, bland foods in tient with electrolytes, amino acids, and other
small, frequent feedings nutrients tailored to his needs.
• Stem cell transplant • Monitor transfusion therapy for adverse re-
• Transfusion of platelets, packed RBCs, and actions. Transfusion reactions may occur dur-
whole blood ing blood administration and may further com-
promise the patient’s condition.
Drug therapy • Administer medications, as prescribed, to
• Alkylating agents: busulfan (Myleran), combat disease and promote wellness.
chlorambucil (Leukeran) • Provide gentle mouth and skin care to pre-
• Antineoplastic antibiotics: doxorubicin vent oral mucous membrane or skin break-
(Adriamycin), plicamycin (Mithracin) down.
• Antimetabolites: fluorouracil (Adrucil), • Encourage the patient to express his feel-
methotrexate (Trexall) ings about changes in his body image and
• Vinca alkaloids: vinblastine (Velban), vin- fear of dying to reduce anxiety. (See Alleviat-
cristine (Oncovin) ing anxiety, page 144.)
• Hematopoietic growth factor: epoetin alfa • Avoid giving the patient I.M. injections and
(Epogen) enemas and taking rectal temperature to pre-
vent bleeding and infection.
• Monitor and record vital signs to promptly Teaching topics
detect deterioration in patient’s condition. • Recognizing signs and symptoms of occult
• Monitor intake, output, and daily weight be- bleeding
cause body weight may decrease as a result of • Preventing constipation
fluid loss. • Using an electric razor
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Alleviating anxiety
Anxiety can be overwhelming for the patient REST AND RELAXATION
with leukemia. It can also aggravate complica- Teaching the patient relaxation techniques can
tions of the disease. Therefore, it’s important to help reduce anxiety. Explain that resting fre-
allow the patient time to verbalize his concerns quently throughout the day is also helpful. Pro-
about the disease and its effect on him and his vide comfort measures, and encourage the fam-
family as well as his fears about death. ily’s participation.
STRATEGIC PLANNING KNOWLEDGE FACTOR
Help the patient and his family find coping You can also reduce the patient’s anxiety level
strategies that can effectively deal with their by teaching him what to expect from the disease
anxiety. Make sure to allow ample time for their process and his treatment plan. After a teaching
questions. session, allow plenty of time for questions. In
addition, provide the patient and his family with
uninterrupted time alone when needed.
• Refraining from using OTC medications • Cough

(unless cleared by the patient’s doctor) • Hepatomegaly
• Increasing fluid intake • Malaise and lethargy
• Contacting the American Cancer Society • Night sweats
• Recurrent infection
• Recurrent, intermittent fever
Lymphoma • Severe pruritus
• Splenomegaly
Lymphoma can be classified as either • Abdominal pain
Hodgkin’s disease or malignant lymphoma
(also called non-Hodgkin’s lymphoma). Hodgkin’s disease
In Hodgkin’s disease, Reed-Sternberg cells • Bone pain
Placing the
proliferate in a single lymph node and travel • Dysphagia
lymphoma patient
in semi-Fowler’s contiguously through the lymphatic system to • Dyspnea
position promotes other lymphatic nodes and organs. (See • Edema and cyanosis of face and neck
ventilation and Stages of Hodgkin’s disease.) • Enlarged, nontender, firm, and movable
chest expansion. In malignant lymphoma, tumors occur lymph nodes in lower cervical regions
throughout lymph nodes and lymphatic or-
gans in unpredictable patterns. Malignant Malignant lymphoma
lymphoma may be categorized as: • Nausea
• lymphocytic • Prominent, painless, generalized lymph-
• histiocytic adenopathy
• mixed cell types. • Vomiting
CAUSES DIAGNOSTIC FINDINGS

• Environmental (Hodgkin’s disease) Hodgkin’s disease
• Genetic (Hodgkin’s disease) • Blood chemistry shows increased alkaline
• Immunologic phosphatase.
• Viral • Chest X-ray reveals lymphadenopathy.
• Hematology shows decreased Hb, HCT, and
DATA COLLECTION FINDINGS platelets and increased ESR, immature leuko-
• Anorexia and weight loss cytes, and gammaglobulin.
920105.qxd 8/7/08 3:53 PM Page 145
Remember, in
Stages of Hodgkin’s disease Hodgkin’s disease,
tumors follow a
Hodgkin’s disease occurs in four stages: pattern; in malignant
lymphoma, tumors
Stage I: Disease Stage II: Disease Stage III: Disease Stage IV: Disease occur more randomly.
occurs in a single occurs in two or more spreads to both sides disseminates.
lymph node region or nodes on same side of of the diaphragm and
single extralymphatic the diaphragm or in an perhaps to an extra-
organ. extralymphatic organ. lymphatic organ, the
spleen, or both.
• Lymph node biopsy is positive for Reed- INTERVENTIONS AND RATIONALES

Sternberg cells. • Monitor and record vital signs to allow for
• Lymphangiogram shows positive lymph early detection of complications.
node involvement. • Monitor intake and output and specific grav-
ity. Low urine output and high specific gravity
Malignant lymphoma indicate hypovolemia.
• Bone marrow aspiration and biopsy reveals • Monitor for bleeding, infection, jaundice,
small, diffuse lymphocytic or large, follicular- and electrolyte imbalance to detect complica-
type cells. tions associated with lymphoma.
• Place the patient in semi-Fowler’s position
NURSING DIAGNOSES when in bed to promote chest expansion and
• Ineffective protection ventilation of basilar lung fields.
• Impaired tissue integrity • Administer oxygen. Supplemental oxygen
• Risk for infection helps reduce hypoxemia.
• Encourage turning every 2 hours to prevent
TREATMENT skin breakdown and coughing and deep
• Establishing a diet high in protein, calories, breathing to help remove secretions and pre-
vitamins, minerals, iron, and calcium that vent pulmonary complications.
should consist of bland, soft foods • Provide mouth and skin care to prevent
• Radiation therapy breakdown of oral mucous membrane and skin.
• Transfusion of packed RBCs • Help the patient maintain his diet to ensure
nutritional requirements are met.
Drug therapy • Encourage fluids to prevent dehydration and
• Antiemetics: aprepitant (Emend), dolase- complications associated with chemotherapy
tron (Anzemet) drugs.
• Maintain I.V. fluids, as prescribed, to replace
Chemotherapy fluid loss.
• Hodgkin’s disease: mechlorethamine (Mus- • Administer medications, as prescribed, and
targen), vincristine (Oncovin), procarbazine monitor for adverse effects to prevent further
(Matulane), doxorubicin (Adriamycin), bleo- complications.
mycin (Blenoxane), vinblastine (Velban), • Monitor transfusion therapy for adverse re-
dacarbazine (DTIC-Dome) actions. Transfusion reactions during blood ad-
• Malignant lymphoma: cyclophosphamide ministration may further compromise the pa-
(Cytoxan), vincristine (Oncovin), doxorubicin tient’s condition.
(Adriamycin) • Provide rest periods to enhance immune
function and decrease weakness caused by
anemia.
920105.qxd 8/7/08 3:53 PM Page 146
• Encourage the patient to express his feel- tients with renal failure and excessive intake
ings about changes in his body image and a of antacids containing magnesium.
fear of dying to allay the patient’s anxiety.
CAUSES
Teaching topics Hypomagnesemia usually results from im-
• Recognizing early signs and symptoms of paired absorption of magnesium in the in-
By acting on the motor and sensory deficits testines or excessive excretion in the urine or
myoneural junctions, • Increasing fluid intake stools. Hypermagnesemia results from the
magnesium affects
• Using an electric razor only kidneys’ inability to excrete magnesium that
the irritability and
contractility of • Refraining from using OTC medications was either absorbed from the intestines or
skeletal muscles… (unless cleared by the patient’s doctor) was infused.
• Contacting the American Cancer Society
Hypomagnesemia
• Chronic alcoholism
Magnesium imbalance • Excessive loss of magnesium, as in severe
dehydration and diabetic acidosis
Magnesium is the second most common • Decreased magnesium intake or absorp-
cation (positively charged ion) in intracellular tion, as in malabsorption syndrome, chronic
fluid. Its major function is to enhance neuro- diarrhea, or postoperative complications after
muscular integration. Magnesium regulates bowel resection
muscle contractions. By acting on the myo- • Hyperaldosteronism and hypoparathy-
neural junctions (the sites where nerve and roidism, which result in hypokalemia and
muscle fibers meet), magnesium affects the hypocalcemia
irritability and contractility of skeletal and car- • Hyperparathyroidism and hypercalcemia,
diac muscles. excessive release of adrenocortical hormones
Magnesium also stimulates parathyroid hor- • Prolonged diuretic therapy, NG suctioning,
mone (PTH) secretion, thus regulating intra- or administration of parenteral fluids without
cellular fluid calcium levels. Therefore, mag- magnesium salts; starvation or malnutrition
nesium deficiency (hypomagnesemia) may re-
sult in transient hypoparathyroidism and may Hypermagnesemia
also interfere with the peripheral action of • Chronic renal insufficiency
PTH. • Overcorrection of hypomagnesemia
In addition, magnesium activates many en- • Overuse of antacids containing magnesium
zymes for proper carbohydrate and protein • Severe dehydration (resulting oliguria can
metabolism, aids in cell metabolism and the cause magnesium retention)
…and
cardiac transport of sodium and potassium across cell • Use of laxatives (magnesium sulfate, milk of
muscles, too. membranes, and influences sodium, potassi- magnesia, and magnesium citrate solutions),
um, calcium, and protein levels. especially with renal insufficiency
Approximately one-third of the magnesium
taken into the body is absorbed through the DATA COLLECTION FINDINGS
small intestine and is eventually excreted in Hypomagnesemia
urine; the remaining unabsorbed magnesium • Arrhythmias
is excreted in stool. • Neuromuscular irritability
Because many common foods contain mag- • Leg and foot cramps
nesium, a dietary deficiency is rare. Hypo- • Chvostek’s sign
magnesemia generally follows impaired ab- • Mood changes
sorption, too-rapid excretion, or inadequate • Confusion
intake during TPN. It frequently coexists with • Delusions
other electrolyte imbalances, especially low • Hallucinations
calcium and potassium levels. Magnesium ex- • Seizures
cess (hypermagnesemia) is common in pa-
920105.qxd 8/7/08 3:53 PM Page 147
Hypermagnesemia INTERVENTIONS AND RATIONALES

• Diminished deep tendon reflexes For hypomagnesemia
• Weakness • Monitor serum electrolyte levels (including
• Flaccid paralysis magnesium, calcium, and potassium) daily for
• Respiratory muscle paralysis (severe hyper- mild deficits and every 6 to 12 hours during
magnesemia) replacement therapy to guide the treatment
• Drowsiness plan.
• Confusion • Measure intake and output frequently.
• Diminished sensorium that may progress to (Urine output shouldn’t fall below 25 ml/hour
coma or 600 ml/day.) The kidneys excrete excess mag-
• Bradycardia nesium, and hypermagnesemia could occur
• Weak pulse with renal insufficiency.
• Hypotension • Monitor vital signs during I.V. therapy. In-
• Heart block fuse magnesium replacement slowly and
• Cardiac arrest (severe hypermagnesemia) watch for bradycardia, heart block, and de-
• Nausea creased respiratory rate to prevent complica-
• Vomiting tions that may occur with rapid infusion.
• Have calcium gluconate I.V. available to re-
DIAGNOSTIC FINDINGS verse hypermagnesemia from overcorrection.
• Blood test that shows decreased serum • Advise patients to eat foods high in magne-
magnesium levels (less than 1.5 mEq/L) con- sium, such as grains, nuts, and legumes, to
firms hypomagnesemia. help raise magnesium level with dietary
• Blood test that shows increased serum sources.
magnesium levels (greater than 2.5 mEq/L) • Watch for and report signs of hypomagne-
confirms hypermagnesemia. semia in patients with predisposing diseases
or conditions, especially those not permitted
NURSING DIAGNOSES anything by mouth or who receive I.V. fluids
The best
• Risk for injury without magnesium, to prevent complications treatment for
• Decreased cardiac output associated with magnesium deficiency. hypomagnesemia is
• Impaired gas exchange prevention. Keep a
For hypermagnesemia watchful eye on
TREATMENT • Frequently check level of consciousness patients at risk for
Hypomagnesemia (LOC), muscle activity, and vital signs to de- this imbalance, such
• Daily magnesium supplements I.M. or by tect complications of magnesium excess. as those who can’t
mouth • Keep accurate intake and output records. tolerate oral intake.
• High-magnesium diet Provide sufficient fluids for adequate hydra-
• I.V. fluid therapy tion and maintenance of renal function.
• Magnesium sulfate I.V. (10 to 40 mEq/L di- • Correct abnormal serum electrolyte levels
luted in I.V. fluid) for severe cases immediately to prevent complications of mag-
nesium excess.
Hypermagnesemia • Monitor the patient receiving cardiac glyco-
• Diet: low magnesium with increased fluid sides and calcium gluconate simultaneously
intake because excessive calcium enhances cardiac gly-
• Loop diuretic: furosemide (Lasix) coside action, predisposing the patient to digox-
• Magnesium antagonist: calcium gluconate in toxicity.
(10%) • Watch for signs of hypermagnesemia in pre-
• Peritoneal dialysis or hemodialysis if renal disposed patients. Observe closely for respira-
function fails or if excess magnesium can’t be tory distress if serum magnesium levels ex-
eliminated ceed 10 mEq/L to prevent respiratory decom-
pensation.
920105.qxd 8/7/08 3:53 PM Page 148
Teaching topics for hypomagnesemia DIAGNOSTIC FINDINGS

• Consuming foods high in magnesium, such • Arterial blood gas (ABG) analysis reveals
as seed grains, nuts, and legumes (fresh pH below 7.35 and bicarbonate level less than
meat, fish, and fresh fruits usually contain 24 mEq/L.
small amounts of magnesium)
• Avoiding laxative and diuretic abuse (this NURSING DIAGNOSES
You win some; you practice may result in loss of magnesium) • Ineffective breathing pattern
lose some. Metabolic • Disturbed thought processes
acidosis is
Teaching topics for hypermagnesemia • Decreased cardiac output
characterized by a
gain in acid and a loss • For patients with renal failure, checking
of bicarbonate in with the doctor before taking any OTC med- TREATMENT
the plasma. ications • Correction of underlying cause
• Avoiding abuse of laxatives and antacids • ET intubation and mechanical ventilation to
containing magnesium, particularly if the pa- ensure adequate respiratory compensation
tient is elderly or has impaired renal function (in severe cases)
Drug therapy
Metabolic acidosis • Sodium bicarbonate I.V. or orally for chron-
ic metabolic acidosis
Metabolic acidosis refers to a state of excess • Insulin administration and I.V. fluid adminis-
acid accumulation and deficient base bicar- tration if diabetic ketoacidosis is the cause
bonate. It’s produced by an underlying patho-
logic disorder. Symptoms result from the INTERVENTIONS AND RATIONALES
body’s attempts to correct the acidotic condi- • Keep sodium bicarbonate ampules handy
tion through compensatory mechanisms in for emergency administration.
the lungs, kidneys, and cells. • Frequently monitor vital signs, laboratory
Metabolic acidosis is more prevalent among results, and LOC because changes can occur
children, who are vulnerable to acid-base im- rapidly.
balance because their metabolic rates are • In diabetic acidosis, watch for secondary
faster and their ratios of water to total body changes due to hypovolemia, such as decreas-
weight are lower. Severe or untreated meta- ing blood pressure, to prevent complications of
bolic acidosis can be fatal. hypoperfusion.
• Record intake and output to monitor renal
CAUSES function.
• Anaerobic carbohydrate metabolism • Watch for signs of excessive serum potassi-
• Chronic alcoholism um—weakness, flaccid paralysis, and arrhyth-
• Diabetic ketoacidosis mias, possibly leading to cardiac arrest. After
• Diarrhea or intestinal malabsorption treatment, check for overcorrection to hypo-
• Low-carbohydrate, high-fat diet kalemia to prevent complications of potassium
• Malnutrition imbalance.
• Renal insufficiency and failure • Prepare for possible seizures with seizure
precautions to prevent injury.
DATA COLLECTION FINDINGS • Provide good oral hygiene. Use sodium bi-
• Central nervous system (CNS) depression carbonate washes to neutralize mouth acids,
• Drowsiness and lubricate the patient’s lips to prevent skin
• Headache breakdown.
• Kussmaul’s respirations • Carefully observe patients receiving I.V.
• Lethargy therapy or who have intestinal tubes in place
• Stupor as well as those suffering from shock, hyper-
thyroidism, hepatic disease, circulatory fail-
920105.qxd 8/7/08 3:53 PM Page 149
ure, or dehydration to prevent metabolic acido- • Twitching

sis. • Vomiting

• Testing urine for sugar and acetone • ABG analysis reveals pH greater than 7.45
• Encouraging strict adherence to insulin or and a bicarbonate level above 29 mEq/L.
oral antidiabetic therapy You lose some; you
• Undergoing medication therapy and possi- NURSING DIAGNOSES win some. Metabolic
alkalosis is
ble adverse reactions • Disturbed thought processes
characterized by a
• Decreased cardiac output loss of acid, a gain
• Risk for injury in bicarbonate,
Metabolic alkalosis or both.
TREATMENT
Metabolic alkalosis is a clinical state marked • Treatment of underlying cause
by decreased amounts of acid or increased
amounts of base bicarbonate. It causes meta- Drug therapy
bolic, respiratory, and renal responses, pro- • Acidifying agent: ammonium chloride I.V.
ducing characteristic symptoms—most no- • Potassium supplement: potassium chloride
tably, hypoventilation. This condition always I.V.
occurs secondary to an underlying cause.
With early diagnosis and prompt treatment, INTERVENTIONS AND RATIONALES
the prognosis is good; however, untreated • Monitor ammonium chloride 0.9% infusion
metabolic alkalosis may lead to coma and (should infuse in 11⁄4 hours); faster administra-
death. tion may cause hemolysis of RBCs. Avoid over-
dosage because it may cause overcorrection to
CAUSES metabolic acidosis. Don’t give ammonium
• Loss of acid from vomiting, NG tube chloride to a patient with signs of hepatic or
drainage, or lavage without adequate electro- renal disease to avoid toxicity.
lyte replacement; fistulas; the use of steroids • Monitor vital signs frequently and record in-
and certain diuretics (furosemide, thiazides, take and output to evaluate respiratory, fluid,
and ethacrynic acid); or hyperadrenocorti- and electrolyte status. Respiratory rate usually
cism decreases in an effort to compensate for alkalo-
• Retention of base from excessive intake of sis. Hypotension and tachycardia may indicate
bicarbonate of soda or other antacids (usually electrolyte imbalance, especially hypokalemia.
for treatment of gastritis or peptic ulcer), ex- • Irrigate NG tubes with isotonic saline solu-
cessive intake of absorbable alkali (as in tion instead of plain water to prevent loss of
milk-alkali syndrome), administration of ex- gastric electrolytes. Monitor I.V. fluid concen-
cessive amounts of I.V. fluids with high con- trations of bicarbonate or lactate to prevent
centrations of bicarbonate or lactate, or respi- acid-base imbalance.
ratory insufficiency
Teaching topics
DATA COLLECTION FINDINGS • For patients with ulcers, recognizing signs
• Apnea of milk-alkali syndrome: a distaste for milk,
• Atrial tachycardia anorexia, weakness, and lethargy
• Confusion • Avoiding overuse of alkaline agents
• Cyanosis
• Diarrhea
• Hypoventilation Multiple myeloma
• Irritability
• Nausea Multiple myeloma involves the abnormal pro-
• Picking at bedclothes (carphology) liferation of plasma cells. These plasma cells
920105.qxd 8/7/08 3:53 PM Page 150
are immature and malignant and invade the • Peritoneal dialysis or hemodialysis
bone marrow, lymph nodes, liver, spleen, and • Radiation therapy
Because multiple kidneys, triggering osteoblastic activity and • Transfusion therapy: packed RBCs
myeloma causes bone leading to bone destruction throughout the
destruction, bone pain body. Drug therapy
and fractures are • Alkylating agents: melphalan (Alkeran), cy-
data collection
findings to remember
CAUSES clophosphamide (Cytoxan)
for this disorder. • Environmental • Analgesic: morphine
• Genetic • Androgen: fluoxymesterone (Halotestin)
• Unknown • Antibiotics: doxorubicin (Adriamycin), pli-
camycin (Mithracin)
DATA COLLECTION FINDINGS • Antiemetics: prochlorperazine (Com-
• Anemia, thrombocytopenia, hemorrhage pazine), aprepitant (Emend), dolasetron
• Constant, severe bone pain (Anzemet)
• Headaches • Antigout agent: allopurinol (Zyloprim)
• Hepatomegaly • Antineoplastics: vinblastine (Velban), vin-
• History of multiple infections cristine (Oncovin)
• History of pathologic fractures, skeletal de- • Diuretic: furosemide (Lasix)
formities of sternum and ribs, loss of height • Glucocorticoid: prednisone (Deltasone)
• History of renal calculi • Histamine-2 (H2)–receptor antagonists:
• Splenomegaly famotidine (Pepcid), nizatidine (Axid)
• Vascular insufficiency
DIAGNOSTIC FINDINGS • Monitor renal status to detect renal calculi
• Bence Jones protein assay is positive. and renal failure secondary to hypercalcemia.
• Blood chemistry tests show increased calci- • Monitor and record vital signs to allow for
um, uric acid, BUN, and creatinine. early detection of complications.
• Bone marrow biopsy shows increased num- • Monitor intake and output, urine specific
ber of immature plasma cells. gravity, and daily weight to identify fluid vol-
• Bone scan reveals increased uptake. ume excess or deficit.
• Hematology shows decreased HCT, WBCs, • Monitor laboratory studies. RBCs, WBCs,
and platelets and increased ESR. Hb, HCT, and platelets may be affected by
• Immunoelectrophoresis shows monoclonal chemotherapy.
spike. • Monitor cardiovascular and respiratory sta-
• Urine chemistry shows increased calcium tus to detect signs of compromise.
and uric acid. • Evaluate bone pain to determine patient’s re-
• X-rays show diffuse, round, punched-out sponse to analgesics.
bone lesions; osteoporosis; osteolytic lesions • Monitor for infection and bruising to detect
of the skull; and widespread demineralization. complications.
• Maintain the patient’s diet to ensure nutri-
NURSING DIAGNOSES tional requirements are met.
• Chronic pain • Encourage fluids to prevent dehydration and
• Impaired physical mobility dilute calcium.
• Risk for infection • Maintain I.V. fluids to replace fluid loss, di-
lute calcium, and prevent renal protein precipi-
TREATMENT tation.
• Allogenic bone marrow transplantation • Assist with turning, coughing, and deep
• Diet: high protein, high carbohydrate, high breathing to mobilize and remove secretions.
vitamin, and high mineral in small, frequent • Monitor transfusion therapy, as prescribed,
feedings to replace blood components.
• Orthopedic devices: braces, splints, casts
920105.qxd 8/7/08 3:53 PM Page 151
• Administer medications, as prescribed, and DATA COLLECTION FINDINGS

monitor for adverse effects to prevent compli- • Constipation or diarrhea
cations. • Depression
• Maintain seizure precautions to prevent • Delirium
injury. • Dyspnea
• Provide skin and mouth care to prevent • Glossitis, sore mouth
breakdown of oral mucous membrane and skin. • Mild jaundice of sclera
• Alternate rest periods with activity to pre- • Pallor
vent fatigue. • Paralysis, gait disturbances
• Prevent the patient from falling because he’s • Tachycardia, palpitations
vulnerable to fractures. • Paresthesia of hands and feet
• Move the patient gently, keeping the body • Weakness, fatigue
in alignment, to prevent injury. • Weight loss, anorexia, dyspepsia
• Apply and maintain braces, splints, and
casts to prevent injury and reduce pain. DIAGNOSTIC FINDINGS
• Blood chemistry tests reveal increased
Teaching topics bilirubin and lactate dehydrogenase levels.
• Exercising regularly, with particular atten- • Bone marrow aspiration shows increased
tion to muscle-strengthening exercises megaloblasts, few maturing erythrocytes, and
If you remember
• Recognizing signs and symptoms of renal defective leukocyte maturation. that pernicious
calculi, fractures, and seizures • Gastric analysis shows hypochlorhydria. anemia results from a
• Avoiding lifting, constipation, and OTC • Hematology shows decreased HCT and Hb. lack of B12 absorption,
medications • Peripheral blood smear reveals oval, macro- then it’s easy to recall
• Monitoring stool for occult blood cytic, hyperchromic erythrocytes. that vitamins are a
• Using braces, splints, and casts • Romberg’s test is positive. big part of treating
• Contacting the American Cancer Society • Schilling test is positive. this disorder.
• Upper GI series shows atrophy of gastric
mucosa.
Pernicious anemia
NURSING DIAGNOSES
Pernicious anemia is a chronic, progressive, • Activity intolerance
macrocytic anemia caused by a deficiency of • Imbalanced nutrition: Less than body re-
intrinsic factor, a substance normally secreted quirements
by the stomach. Without intrinsic factor, di- • Risk for injury
etary vitamin B12 can’t be absorbed by the
ileum, inhibiting normal deoxyribonucleic TREATMENT
acid (DNA) synthesis and resulting in defec- • Establishing a diet high in iron and protein
tive maturation of RBCs. and restricting highly seasoned, coarse, or ex-
tremely hot foods
CAUSES • Transfusion therapy with packed RBCs
• Autoimmune disease • Vitamins: pyridoxine (vitamin B6), ascorbic
• Bacterial or parasitic infections acid (vitamin C), cyanocobalamin (vitamin
• Lack of intrinsic factor B12), folic acid (vitamin B9)
• Gastric mucosal atrophy
• Genetics Drug therapy
• Failure to administer vitamin B12 after • Iron supplements: ferrous sulfate (Feosol),
small-bowel resection or total gastrectomy iron dextran (DexFerrum)
• Malabsorption
• Prolonged iron deficiency INTERVENTIONS AND RATIONALES
• Vegetarian diets (especially strict vegan • Monitor cardiovascular status to detect signs
diets) of compromise as the heart works harder to
920105.qxd 8/7/08 3:53 PM Page 152
compensate for the reduced oxygen-carrying ca- transmission of hereditary traits, and metabo-
pacity of the blood. lism of carbohydrates, proteins, and fats.
• Monitor and record vital signs to allow for Renal tubular reabsorption of phosphate is
early detection of compromise. inversely regulated by calcium levels—an in-
• Monitor and record amount, consistency, crease in phosphorus causes a decrease in
and color of stool to allow for early detection calcium. An imbalance causes hypophos-
and treatment of diarrhea and constipation. phatemia or hyperphosphatemia. Incidence of
• Maintain the patient’s diet to ensure ade- hypophosphatemia varies with the underlying
quate intake of vitamins, iron, and protein. cause; hyperphosphatemia occurs most com-
• Administer medications as prescribed. Vita- monly in patients who tend to consume large
min B12 injections are given monthly and are amounts of phosphorus-rich foods and bever-
lifelong. ages and in those with renal insufficiency.
• Maintain activity, as tolerated, to avoid
fatigue. CAUSES
• Provide mouth care before and after meals Hypophosphatemia
Phosphorus plays to provide comfort and reduce the risk of oral • Chronic diarrhea
a crucial role in cell mucous membrane breakdown. • Vitamin D deficiency
membrane integrity…
• Use soft toothbrushes to avoid injuring mu- • Hyperparathyroidism with resultant hyper-
cous membranes. calcemia
• Maintain a warm environment for patient • Hypomagnesemia
comfort. • Inadequate dietary intake, such as from
• Provide foot and skin care because sensation malnutrition resulting from a prolonged cata-
to the feet may be reduced. bolic state or chronic alcoholism
• Prevent the patient from falling because of • Intestinal malabsorption
reduced coordination, paresthesia of the feet,
and reduced thought processes. Hyperphosphatemia
• Monitor neurologic status because poor • Hypervitaminosis D
memory and confusion increase the risk of in- • Hypocalcemia
jury. • Hypoparathyroidism
• Overuse of phosphate enemas or laxatives
Teaching topics with phosphates
• Recognizing the signs and symptoms of • Renal failure
skin breakdown
…and bone • Altering activities of daily living (ADLs) to DATA COLLECTION FINDINGS
formation. compensate for paresthesia Hypophosphatemia
• Complying with lifelong, monthly injections • Anorexia
of vitamin B12 • Muscle weakness
• Avoiding the use of heating pads and elec- • Osteomalacia (inadequate mineralization of
tric blankets bone)
• Recognizing dietary sources of vitamin B12 • Paresthesia
• Tremor
Phosphorus imbalance Hyperphosphatemia

• Usually produces no symptoms
Phosphorus exists primarily in inorganic • Tetany and seizures (with hypocalcemia)
combination with calcium in teeth and bones.
In ECF, the phosphate ion supports several DIAGNOSTIC FINDINGS
metabolic functions: utilization of B vitamins, • Serum phosphorus level less than 1.7 mEq/
acid-base homeostasis, bone formation, nerve L (or 2.5 mg/dl) confirms hypophosphatemia.
and muscle activity, cell membrane integrity, A urine phosphorus level more than 1.3 g/
24 hours supports this diagnosis.
920105.qxd 8/7/08 3:53 PM Page 153
• Serum phosphorus level exceeding For hyperphosphatemia

2.6 mEq/L (or 4.5 mg/dl) confirms hyper- • Monitor intake and output. If urine output
phosphatemia. Supportive values include de- falls below 25 ml/hour or 600 ml/day, notify Is your blood
creased levels of serum calcium (less than the doctor immediately because decreased out- boiling from too
9 mg/dl) and urine phosphorus (less than put can seriously affect renal clearance of excess much studying?
Time for a break!
0.9 g/24 hours). serum phosphorus.
• Watch for signs of hypocalcemia, such as
NURSING DIAGNOSES muscle twitching and tetany, which common-
• Imbalanced nutrition: Less than or more ly accompany hyperphosphatemia, to ensure
than body requirements timely intervention.
• Risk for injury • Advise the patient to eat foods with low
• Deficient knowledge (phosphorus balance) phosphorus content, such as vegetables, to
prevent recurrence. Obtain dietary consulta-
TREATMENT tion if the condition results from chronic renal
Hypophosphatemia insufficiency to aid the patient in making
• High-phosphorus diet sound nutritional choices that help prevent hy-
perphosphatemia.
Drug therapy
• Phosphate supplements Teaching topics for hypophosphatemia
• Potassium phosphate I.V. (in severe defi- • Consuming a high-phosphorus diet
ciency) • Taking phosphate supplements
Hyperphosphatemia Teaching topics for hyperphosphatemia

• Low-phosphorus diet • Following the medication regimen and rec-
• Peritoneal dialysis or hemodialysis (in se- ognizing possible adverse reactions
vere cases) • Avoiding OTC drugs that contain phospho-
rus, such as laxatives and enemas
Drug therapy
• Calcium supplement: calcium acetate
(PhosLo) Polycythemia vera
INTERVENTIONS AND RATIONALES Polycythemia vera is a chronic myeloprolifer-
• Carefully monitor serum electrolyte levels, ative disorder characterized by increased
including calcium, magnesium, and phospho- RBC mass, leukocytosis, thrombocytosis, and
rus. Report any changes immediately to guide increased Hb concentration, with normal or
the treatment plan. increased plasma volume. It usually occurs
between ages 40 and 60, most commonly
For hypophosphatemia among males of Jewish ancestry; it rarely af-
• Record intake and output accurately to eval- fects children or blacks and doesn’t appear to
uate renal function. Be alert for hypocalcemia be familial. It may also be known as primary
when giving phosphate supplements. If phos- polycythemia, erythremia, polycythemia
phate salt tablets cause nausea, use capsules rubra vera, splenomegalic polycythemia, or
instead to encourage compliance with the treat- Vaquez-Osler disease.
ment regimen. The prognosis depends on age at diagnosis,
• Advise the patient to follow a high- the treatment used, and complications. Mor-
phosphorus diet containing milk and milk tality is high if polycythemia is untreated or
products, kidney, liver, turkey, and dried is associated with leukemia or myeloid meta-
fruits to prevent recurrence. plasia.
920105.qxd 8/7/08 3:53 PM Page 154
CAUSES • Myelosuppressive drugs: hydroxyurea (Hy-

• Unknown (possibly due to a multipotential drea), radioactive phosphorus (32P)
Phlebotomy is
usually the first stem cell defect) • Antigout agent: allopurinol (Zyloprim)
treatment for
polycythemia vera. DATA COLLECTION FINDINGS INTERVENTIONS AND RATIONALES
The patient may • Clubbing of the digits • Check blood pressure, pulse rate, and respi-
have 350 to 500 ml • Dizziness rations before and during phlebotomy to mon-
of blood removed • Dyspnea itor the patient’s tolerance of the procedure.
every other day. • Feeling of fullness in the head • During phlebotomy, make sure the patient
• Headache is lying down comfortably to prevent vertigo
• Hypertension and syncope.
• Ruddy cyanosis of the nose • Stay alert for tachycardia, clamminess, or
• Thrombosis of smaller vessels complaints of vertigo. If these effects occur,
• Visual disturbances (blurring, diplopia, en- the procedure should be stopped. These signs
gorged veins of fundus and retina) and symptoms indicate hypovolemia.
• Weight loss • Immediately after phlebotomy, check blood
pressure and pulse rate. Have the patient sit
DIAGNOSTIC FINDINGS up for about 5 minutes before allowing him to
• Blood tests show elevated Hb, RBC count, walk to prevent vasovagal attack and orthostat-
WBC count, platelet count, and leukocyte al- ic hypotension. Also, administer 24 oz (710 ml)
kaline phosphatase, serum B12, and uric acid of juice or water to replace fluid volume lost
levels. during the procedure.
• Tell the patient to watch for and report
NURSING DIAGNOSES symptoms of iron deficiency (pallor, weight
• Ineffective tissue perfusion: Cardiopul- loss, weakness, glossitis). After repeated phle-
monary botomies, the patient will develop iron deficien-
• Imbalanced nutrition: Less than body re- cy, which stabilizes RBC production and re-
quirements duces the need for phlebotomy.
• Disturbed sensory perception (visual) • Keep the patient active and ambulatory to
prevent thrombosis. If bed rest is absolutely
TREATMENT necessary, recommend a daily program of
• I.V. fluids to decrease the viscosity of the both active and passive ROM exercises to pre-
blood vent thrombosis and maintain joint mobility.
• Phlebotomy (typically, 350 to 500 ml of • Watch for complications, such as hypervo-
blood is removed every other day until the lemia, thrombocytosis, and signs of an im-
Patients receiving patient’s HCT is reduced to the low-normal pending stroke, to ensure early treatment in-
myelosuppressive range) tervention.
treatment should • Plasmapheresis • Give additional fluids, administer allopuri-
avoid crowds to nol, and alkalinize the urine to compensate for
decrease their risk of Drug therapy increased uric acid production and prevent
infection. • Antineoplastics: busulfan (Myleran), chlor- uric acid calculi.
ambucil (Leukeran), melphalan (Alkeran) • If the patient has symptomatic spleno-
megaly, suggest or provide small, frequent
meals, followed by a rest period, to prevent
nausea and vomiting.
• Report acute abdominal pain immediately to
avoid treatment delay. Acute pain may signal
splenic infarction, renal calculi, or abdominal
organ thrombosis.
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During myelosuppressive treatment Inflammation of the synovial membranes is

• Monitor complete blood count and platelet followed by formation of pannus (granulation
count before and during therapy. Warn an out- tissue) and destruction of cartilage, bone,
patient who develops leukopenia that his re- and ligaments. Pannus is replaced by fibrotic
sistance to infection is low; advise him to tissue and calcification, which causes sublux-
avoid crowds and to watch for the symptoms ation of the joint. The joint becomes anky-
of infection. These measures protect the patient losed—or fused—leaving a very painful joint
from developing life-threatening infection. and limited ROM.
• If leukopenia develops in a hospitalized pa-
tient who needs protective isolation, follow fa- CAUSES
cility guidelines. If thrombocytopenia devel- • Autoimmune disease
ops, tell the patient to watch for signs of • Genetic transmission
bleeding (blood in urine, nosebleeds, black
stools) to prevent hemorrhage. DATA COLLECTION FINDINGS
• Tell the patient about possible adverse ef- • Anorexia and weight loss
fects of alkylating agents (nausea, vomiting, • Dry eyes and mucous membranes
and risk of infection) to allay the patient’s anxi- • Enlarged lymph nodes
ety and ensure early treatment. • Fatigue
• Watch for adverse reactions. If nausea and • Fever
vomiting occur, begin antiemetic therapy and • History of leukopenia and anemia
adjust the patient’s diet to promote patient • Limited ROM
comfort. • Malaise
• Use of 32P requires radiation precautions to • Painful, swollen joints; crepitus; and morn-
prevent contamination. ing stiffness
• Paresthesia of the hands and the feet
Teaching topics • Signs and symptoms of pericarditis
• Learning about the disease process and • Signs and symptoms of Raynaud’s phenom-
treatment options enon With rheumatoid
• Understanding the importance of remaining • Splenomegaly arthritis, antibodies
as active as possible • Subcutaneous nodules attack the synovial
lining of the joints, the
• Avoiding infection • Symmetrical joint swelling (mirror image of
membrane that lines
• Keeping the environment free from hazards affected joints) the joint space
that could cause falls between the bones
• Using an electric razor to prevent bleeding DIAGNOSTIC FINDINGS and allows bones to
• Following measures to prevent adverse re- • Antinuclear antibody (ANA) test is positive. move against one
action to treatment, such as using antiemetics • Hematology shows increased ESR, WBC another.
to prevent nausea and vomiting and platelets as well as anemia.
• Contacting available community resources • Rheumatoid factor test is positive.
• Serum protein electrophoresis shows ele-
vated serum globulins.
Rheumatoid arthritis • Synovial fluid analysis shows increased
WBC count, increased volume and turbidity,
Believed to be an autoimmune disorder, rheu- and decreased viscosity and complement
matoid arthritis is a systemic inflammatory (C3 and C4 levels).
disease that affects the synovial lining of the • X-rays reveal bone demineralization and
joints. Antibodies first attack the synovium of soft-tissue swelling in early stages; in later
the joint, causing it to become inflamed and stages, X-rays reveal a loss of cartilage, a
swollen. Eventually, the articular cartilage narrowing of joint spaces, cartilage and bone
and surrounding tendons and ligaments are destruction, and erosion, subluxations, and
affected. deformity.
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Use cold
NURSING DIAGNOSES • Provide warm or cold therapy, as pre-
therapy for acute • Activity intolerance scribed, to help alleviate pain.
episodes but heat • Disturbed body image • Provide skin care to prevent skin breakdown.
therapy for chronic • Chronic pain • Minimize environmental stress and plan
aches and pains. rest periods to help the patient cope with the
TREATMENT disease.
• Cold therapy during acute episodes • Encourage the patient to express his feel-
• Heat therapy to relax muscles and relieve ings about changes in his body image to help
pain in chronic disease the patient express doubts and resolve concerns.
• Physical therapy (to forestall loss of joint
function), passive ROM exercises, and obser- Teaching topics
vance of rest periods • Identifying ways to reduce stress
• Weight control because obesity adds stress • Needing 8 to 10 hours of sleep every night
to joints • Avoiding cold, stress, and infection
• Well-balanced diet • Performing complete skin and foot care
• Protein A immunoadsorption therapy daily
• Contacting groups such as the Arthritis
Drug therapy Foundation
• Analgesic: aspirin
• Biological response modifiers: etanercept
(Enbrel), infliximab (Remicade), adalimumab Scleroderma
(Humira), anakinra (Kineret)
• Antimetabolite: methotrexate (Rheumatrex) Scleroderma is a diffuse connective tissue dis-
• Antirheumatic: hydroxychloroquine ease characterized by inflammatory and then
(Plaquenil) degenerative and fibrotic changes in skin,
• Cox-2 inhibitor: celecoxib (Celebrex) blood vessels, synovial membranes, skeletal
• Glucocorticoids: prednisone (Deltasone), muscles, and internal organs (especially the
hydrocortisone (Hydrocortone) esophagus, intestinal tract, thyroid, heart,
• Gold therapy: gold sodium thiomalate (Au- lungs, and kidneys). The disease, also known
rolate) as progressive systemic sclerosis, affects
• NSAIDs: indomethacin (Indocin), ibuprofen more women than men, especially those be-
(Advil, Motrin), sulindac (Clinoril), piroxicam tween ages 30 and 50.
(Feldene), flurbiprofen (Ansaid), diclofenac
sodium (Voltaren), naproxen (Naprosyn), di- CAUSES
flunisal (Dolobid) • Unknown
INTERVENTIONS AND RATIONALES DATA COLLECTION FINDINGS

• Monitor vital signs to allow for early detec- • Pain
tion of complications. • Signs and symptoms of Raynaud’s phenom-
• Monitor neuromuscular status to determine enon, such as blanching, cyanosis, and ery-
patient’s capabilities. thema of the fingers and toes in response to
• Check joints for swelling, pain, and redness stress or exposure to cold
to determine the extent of disease and effective- • Slowly healing ulcerations on the tips of the
ness of treatment. fingers or toes that may lead to gangrene
• Administer medications, as prescribed, to • Stiffness
enhance the treatment regimen. • Swelling of fingers and joints
• Provide passive ROM exercises to prevent • Taut, shiny skin over the entire hand and
joint contractures and muscle atrophy. forearm
• Splint inflamed joints to maintain joints in a • Tight and inelastic facial skin, causing a
functional position and prevent musculoskeletal masklike appearance and “pinching” of the
deformities. mouth
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• Signs and symptoms of cardiac and pulmo- • H2-receptor antagonists: famotidine (Pep-
nary fibrosis (in advanced disease) cid), nizatidine (Axid)
• Signs and symptoms of renal involvement • Proton pump inhibitors: omeprazole
such as malignant hypertension, the main (Prilosec), lansoprazole (Prevacid), esome-
cause of death prazole (Nexium)
• NSAIDs: flurbiprofen (Ansaid), ibuprofen
DIAGNOSTIC FINDINGS (Motrin), meloxicam (Mobic)
• Blood studies show slightly elevated ESR, • Analgesics: acetaminophen (Tylenol), tra-
positive rheumatoid factor in 25% to 35% of pa- madol (Ultram)
tients, and positive ANA test. • Prostaglandin derivatives: epoprostenol
• Chest X-rays show bilateral basilar pul- (Flolan), treprostinil (Remodulin)
monary fibrosis.
• ECG reveals possible nonspecific abnormal- INTERVENTIONS AND RATIONALES
ities related to myocardial fibrosis. • Evaluate motion restrictions, pain, vital
• GI X-rays show distal esophageal hypomotil- signs, intake and output, respiratory function,
ity and stricture, duodenal loop dilation, and daily weight to monitor disease progression
small-bowel malabsorption pattern, and large and guide the treatment plan.
diverticula. • Teach the patient to monitor blood pressure
• Hand X-rays show terminal phalangeal tuft at home and to report any increases above
resorption, subcutaneous calcification, and baseline. Malignant hypertension is the main
joint space narrowing and erosion. cause of death in patients diagnosed with scle-
• Pulmonary function studies show de- roderma.
creased diffusion and vital capacity. • Warn against fingerstick blood tests because
• Skin biopsy may show changes consistent of compromised circulation.
with the progress of the disease, such as • Help the patient and family adjust to the
marked thickening of the dermis and occlu- patient’s new body image and to the limita-
sive vessel changes. tions and dependence that these changes
• Urinalysis reveals proteinuria, microscopic cause. Patients and their families need time to
hematuria, and casts (with renal involve- adjust to the overwhelming effects of illness.
ment). • Help the patient and family accept the fact
that this condition is incurable. Encourage
NURSING DIAGNOSES them to express their feelings, and help them
• Impaired physical mobility cope with their fears and frustrations by offer- Treatment for
• Chronic pain ing information about the disease, its treat- scleroderma aims to
• Impaired skin integrity ment, and relevant diagnostic tests. Providing preserve normal body
information helps alleviate anxiety and pro- functions and
TREATMENT vides the patient with knowledge necessary for minimize
• Physical therapy to maintain function and informed decision making. complications.
promote muscle strength (currently, no cure • Whenever possible, let the patient partici-
exists for scleroderma) pate in treatment to help the patient gain a
• Exercise to improve overall health sense of control over his condition.
• Involve the patient’s family in treatment to
Drug therapy help the family overcome feelings of help-
• Immunosuppressants: cyclosporine lessness.
(Sandimmune), cyclophosphamide (Cytox-
an), azathioprine (Imuran), mycophenolate Teaching topics
(Cellcept) • Recognizing an impending relapse
• Calcium channel blockers: nifedipine (Pro- • Managing symptoms, such as tension, ner-
cardia), amlodipine (Norvasc), diltiazem vousness, insomnia, decreased ability to con-
(Cardizem) centrate, and apathy
• Angiotensin II receptor antagonists: losar- • Avoiding air conditioning and tobacco use,
tan (Cozaar), valsartan (Diovan) which may aggravate Raynaud’s phenomenon
920105.qxd 8/7/08 3:53 PM Page 158
• Avoiding fatigue by pacing activities and or- Late stage

What a shock!
Septic shock is ganizing schedules to include necessary rest • Altered LOC
caused by bacterial • Complying with the medication regimen • Anuria
infection. Without (follow-up visits for drug dosing if the patient • Apprehension
prompt treatment, it takes a slow-release formulation) and report- • Hyperventilation
may rapidly progress ing any adverse reactions instead of discontin- • Hypotension
to death. uing drugs • Hypothermia
• Contacting the Scleroderma Foundation • Irritability
• Restlessness
• Tachycardia
Septic shock • Tachypnea
• Thirst from decreased cerebral tissue
Septic shock is usually the result of bacterial perfusion
infection. It causes inadequate blood perfu-
sion to organs and circulatory collapse. DIAGNOSTIC FINDINGS
Septic shock occurs most often among hos- • ABG analysis indicates respiratory alkalosis
pitalized patients, especially men older than (low partial pressure of carbon dioxide, low or
age 40 and women ages 25 to 45. It’s second normal bicarbonate level, and high pH) that
only to cardiogenic shock as the leading may progress to metabolic acidosis.
cause of shock-related death. About 25% of pa- • Blood cultures isolate the organism.
tients who develop gram-negative bacteremia • Blood tests show decreased platelet count
go into shock. Unless vigorous treatment be- and leukocytosis (15,000 to 30,000/µl), in-
gins promptly, preferably before symptoms creased BUN and creatinine levels, decreased
fully develop, septic shock rapidly progresses creatinine clearance, and abnormal PT and
to death (commonly within a few hours) in up PTT.
to 80% of these patients. • ECG shows ST-segment depression, in-
verted T waves, and arrhythmias resembling
CAUSES MI.
• Infection from gram-negative bacteria (in
two-thirds of patients): Escherichia coli, Kleb- NURSING DIAGNOSES
Hypotension, siella, Enterobacter, Proteus, Pseudomonas, • Decreased cardiac output
altered LOC, and and Bacteroides • Deficient fluid volume
hyperventilation may
• Infection from gram-positive bacteria: Strep- • Risk for injury
be the only signs of
septic shock among tococcus pneumoniae, S. pyogenes, and Actino-
infants and elderly myces TREATMENT
people. • Removing and replacing any I.V. or urinary
DATA COLLECTION FINDINGS drainage catheter that may be causing the
Indications of septic shock vary according to infection
the stage of the shock, the organism causing • Oxygen therapy (may require ET intubation
it, and the age of the patient. and mechanical ventilation)
• Colloid or crystalloid infusion to increase in-
Early stage travascular volume
• Chills • Diuretics, such as furosemide (Lasix), after
• Diarrhea sufficient fluid volume has been replaced to
• Nausea maintain urine output above 20 ml/hour
• Oliguria • Blood transfusion, if anemia is present
• Prostration • Surgery to drain abscesses, if present
• Sudden fever (over 101° F [38.3° C])
• Vomiting Drug therapy
• Antibiotics: according to sensitivity of
causative organism
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• Human-activated protein C: drotrecogin alfa and in people of African descent, it also oc-
(Xigris) curs in people from Puerto Rico, Turkey, In-
• Vasopressors: dopamine (Intropin), norepi- dia, the Middle East, and the Mediterranean.
nephrine (Levophed), or phenylephrine (Neo- In patients with sickle cell anemia, a change
Synephrine), if fluid resuscitation fails to in- in the gene that encodes the beta chain of Hb
crease blood pressure results in a defect in the hemoglobin S (HbS)
cell. When hypoxia (oxygen deficiency) oc-
INTERVENTIONS AND RATIONALES curs, the HbS in the RBCs becomes insoluble.
• Remove any I.V. or urinary drainage The cells become rigid and rough, forming an
catheters and send them to the laboratory to elongated sickle shape and impairing circula-
culture the causative organism. New catheters tion. Infection, stress, dehydration, and condi-
can be reinserted to provide access for fluid re- tions that provoke hypoxia—strenuous exer-
suscitation and to ensure accurate measure- cise, high altitude, unpressurized aircraft,
ment of urine output. cold, and vasoconstrictive drugs—may all
• Maintain an I.V. infusion with normal saline provoke periodic crises. Crises can occur in
solution or lactated Ringer’s solution, usually different forms, including painful crisis, aplas-
using a large-bore (14G to 18G) catheter, to tic crisis, and acute sequestration crisis.
allow easier infusion.
• If the patient’s systolic blood pressure drops CAUSES
below 80 mm Hg, increase oxygen flow rate • Genetic inheritance: results from homozy-
and call the doctor immediately. A progressive gous inheritance of an autosomal recessive
drop in blood pressure accompanied by a gene that produces a defective Hb molecule
thready pulse generally signifies inadequate (HbS); heterozygous inheritance results in
cardiac output from reduced vascular volume. sickle cell trait (people with this trait are car-
• Keep accurate intake and output records. riers who can then pass the gene to their off-
Maintain adequate urine output (0.5 to 1 ml/ spring)
kg/hour) and systolic pressure to prevent kid-
ney damage and fluid overload. DATA COLLECTION FINDINGS
• Administer antibiotics I.V. to achieve effec- • Aching bones
tive blood levels quickly, and monitor drug lev- • Chronic fatigue
els to prevent toxicity. • Family history of the disease
• Watch closely for complications of septic • History of frequent infections
shock—DIC (abnormal bleeding), renal fail- • Jaundice, pallor
ure (oliguria, increased specific gravity), • Joint pain and swelling
heart failure (dyspnea, edema, tachycardia, • Leg ulcers (especially on ankles)
distended neck veins), GI ulcers (hemateme- • Severe localized and generalized pain
sis, melena), and hepatic abnormalities (jaun- • Tachycardia
dice, hypoprothrombinemia, and hypoalbu- • Unexplained dyspnea or dyspnea on
minemia)—to prevent crisis. exertion
• Unexplained, painful erections (priapism)
Teaching topics
• Disease process and treatment options Sickle cell crisis (general symptoms)
• Potential outcomes of treatment • Hematuria
• Irritability
• Lethargy
Sickle cell anemia • Pale lips, tongue, palms, and nail beds
• Severe pain
Sickle cell anemia is a hereditary hematologic
disease that causes impaired circulation, Painful crisis (vaso-occlusive crisis, which
chronic ill health, and premature death. Al- appears periodically after age 5)
though it’s most common in tropical Africa • Dark urine
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• Low-grade fever • Iron and folic acid supplements to prevent

• Severe abdominal, thoracic, muscle, or anemia
bone pain • I.V. fluid therapy to prevent dehydration and
• Tissue anoxia and necrosis, caused by vessel occlusion
blood vessel obstruction by tangled sickle
cells Drug therapy
• Worsening of jaundice • Analgesics: meperidine (Demerol) or
morphine
Aplastic crisis (generally associated with
viral infection) INTERVENTIONS AND RATIONALES
• Dyspnea • Provide emotional support to allay the
• Lethargy, sleepiness patient’s anxiety.
• Pallor • Refer the patient for genetic counseling to
• Possible coma decrease anxiety and help the patient to under-
stand the chances of passing the disease to off-
Acute sequestration crisis (rare; occurs in spring.
infants ages 8 months to 2 years) • Refer the patient and his family to communi-
• Signs and symptoms of hypovolemic shock ty support groups to help the patient and his
• Lethargy family cope with his illness.
• Liver enlargement
• Pallor During a crisis
• Worsened chronic jaundice • Apply warm compresses to painful areas,
and cover the patient with a blanket. Cold
DIAGNOSTIC FINDINGS compresses and temperature can aggravate the
• Blood tests show low RBC counts, elevated condition.
WBC and platelet counts, decreased ESR, in- • Administer an analgesic-antipyretic, such as
creased serum iron levels, decreased RBC aspirin or acetaminophen, for pain relief. (Ad-
survival, and reticulocytosis. ditional pain relief may be necessary during
• Hb electrophoresis shows HbS. an acute crisis.)
• Hb levels may be low or normal. • Maintain bed rest to reduce workload on the
• Stained blood smear shows sickle cells. heart and reduce pain.
• Monitor the administration of blood compo-
NURSING DIAGNOSES nents (packed RBCs), as ordered, for aplastic
• Impaired gas exchange crisis caused by bone marrow suppression.
• Acute pain • Administer oxygen to enhance oxygenation
• Ineffective tissue perfusion: Peripheral and reduce sickling.
• Encourage fluid intake to prevent dehydra-
In the autosomal TREATMENT tion, which can precipitate a crisis.
recessive inheritance • Application of warm compresses for pain • Maintain prescribed I.V. fluids to ensure flu-
pattern, if two relief id balance and renal perfusion.
carriers have • Blood transfusion therapy if Hb levels drop • Give antibiotics, as ordered, to treat infec-
offspring, each child tions and avoid precipitating a crisis.
has a one-in-four
chance of developing Teaching topics
the disease. • Avoiding circulation restriction
• Receiving normal childhood immunizations
• Obtaining prompt treatment for infections
• Maintaining increased fluid intake to pre-
vent dehydration
• Preventing hypoxia
• Avoiding known triggers
920105.qxd 8/7/08 3:53 PM Page 161
Sodium imbalance • Diabetes insipidus

• Excess adrenocortical hormones, as in
Sodium is the major cation (positively Cushing’s syndrome
charged ion) in ECF. Its functions include • Severe vomiting and diarrhea with water
maintaining tonicity and concentration of loss that exceeds sodium loss
ECF, acid-base balance (reabsorption of sodi-
um ions and excretion of hydrogen ions), DATA COLLECTION FINDINGS
nerve conduction and neuromuscular func- Hyponatremia
tion, glandular secretion, and water balance. • Abdominal cramps
The sodium-potassium pump is constantly • Anxiety
at work in every body cell. Potassium is the • Cold, clammy skin
major cation in intracellular fluid. According • Cyanosis
to the laws of diffusion, a substance moves • Headaches
from an area of high concentration to an area • Hypotension
of lower concentration. Sodium ions, normally • Muscle twitching and weakness
most abundant outside the cells, want to dif- • Nausea and vomiting
fuse inward. Potassium ions, normally abun- • Oliguria or anuria
dant inside the cells, want to diffuse outward. • Seizures
The sodium-potassium pump works to com- • Tachycardia
bat this ionic diffusion and maintain normal
sodium-potassium balance. Hypernatremia
During repolarization, the sodium- • Agitation and restlessness
potassium pump continually shifts sodium • Signs and symptoms of circulatory disor-
into the cells and potassium out of the cells; ders
during depolarization, it does the reverse. • Decreased LOC
The body requires only 2 to 4 g of sodium • Dry, sticky mucous membranes
daily. However, most Americans consume 6 to • Dyspnea
10 g daily (mostly sodium chloride, as table • Excessive weight gain
salt), excreting excess sodium through the • Fever
kidneys and skin. • Flushed skin
A low-sodium diet or excessive use of di- • Hypertension
uretics may induce hyponatremia (decreased • Intense thirst
serum sodium concentration); dehydration • Oliguria
may induce hypernatremia (increased serum • Pitting edema
sodium concentration). • Signs and symptoms of pulmonary edema
• Rough, dry tongue
CAUSES • Seizures
Hyponatremia • Tachycardia
• Diarrhea
• Excessive perspiration or fever DIAGNOSTIC FINDINGS
• Excessive water intake • Serum sodium level less than 135 mEq/L
• Low-sodium diet indicates hyponatremia.
• Malnutrition • Serum sodium level greater than 145 mEq/
• Potent diuretics L indicates hypernatremia.
• Starvation
• Suctioning NURSING DIAGNOSES
• Trauma, wound drainage, or burns Hyponatremia
• Vomiting • Deficient fluid volume
• Risk for injury
Hypernatremia
• Decreased water intake
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Hypernatremia • Obtain a drug history to check for drugs that

• Excess fluid volume promote sodium retention.
• Disturbed thought processes
Teaching topics for hyponatremia
TREATMENT • Maintaining fluid restriction if necessary
Hyponatremia • Increasing dietary intake of sodium
• Antibiotic: demeclocycline (Declomycin) • Following medication regimen and knowing
• I.V. infusion of saline solution possible adverse reactions
• Potassium supplement: potassium chloride
(K-Lor) Teaching topics for hypernatremia
• Following sodium restrictions and planning
Hypernatremia a low-sodium diet
• Diet: sodium restrictions
• Salt-free solution (such as dextrose in wa-
ter), followed by infusion of 0.45% sodium Systemic lupus
chloride to prevent hyponatremia
Don’t overdo it.
During administration
erythematosus
of isosmolar or INTERVENTIONS AND RATIONALES
hyperosmolar saline For hyponatremia SLE is an autoimmune disorder that involves
solution to a patient • Watch for extremely low serum sodium and most organ systems. It’s chronic in nature
with hyponatremia, accompanying serum chloride levels. Monitor and characterized by periods of exacerbation
watch closely for urine specific gravity and other laboratory re- and remission.
signs of hypervolemia.
sults. Record fluid intake and output accurate- In SLE, a depression of T-cell activity and an
ly and weigh the patient daily to guide the increase in the production of antibodies—
treatment plan. specifically antibodies to DNA and ribonucleic
• During administration of isosmolar or hy- acid and anti-erythrocyte, antinuclear, and
perosmolar saline solution, watch closely for antiplatelet antibodies—occur. The immune
signs of hypervolemia (dyspnea, crackles, en- response results in an inflammatory process
gorged neck or hand veins) to prevent respira- involving the veins and arteries (vasculitis),
tory distress. which causes pain, swelling, and tissue dam-
• Note conditions that may cause excessive age in any area of the body.
sodium loss—diaphoresis, prolonged diar-
rhea or vomiting, or severe burns—to prevent CAUSES
hyponatremia. • Autoimmune disease
• Refer the patient receiving a maintenance • Drug-induced: procainamide (Pronestyl),
dosage of diuretics to a dietitian for instruc- hydralazine (Apresoline), and phenytoin
tion about dietary sodium intake to increase (Dilantin)
dietary intake of sodium and decrease the risk • Genetic
of hyponatremia. • Unknown
• Viral
For hypernatremia
• Measure serum sodium levels every DATA COLLECTION FINDINGS
6 hours or at least daily. Monitor vital signs • Alopecia
for changes, especially for rising pulse rate. • Anorexia and weight loss
Watch for signs of hypervolemia, especially in • Anemia, leukopenia, and thrombocytopenia
the patient receiving I.V. fluids, to guide the • Butterfly rash on face (rash may vary in
treatment regimen. severity from malar erythema to discoid
• Record fluid intake and output accurately, lesions)
checking for body fluid loss, to prevent dehy- • Erythema on palms
dration and accompanying hypernatremia. • Fatigue
Weigh the patient daily to monitor fluid vol-
ume status.
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• Signs and symptoms of glomerulonephritis, • Cytotoxic drugs: methotrexate (Trexall) to

renal dysfunction and failure (with renal in- delay or prevent deteriorating renal status
volvement) • Glucocorticoid: prednisone (Deltasone)
• Impaired cognitive function, psychosis, de- • Immunosuppressants: azathioprine (Imu-
pression, seizures, peripheral neuropathies, ran), cyclophosphamide (Cytoxan)
strokes, organic brain syndrome (with CNS • NSAIDs: indomethacin (Indocin), ibuprofen
involvement) (Motrin), sulindac (Clinoril), piroxicam
• Low-grade fever (Feldene), flurbiprofen (Ansaid), diclofenac
• Lymphadenopathy, splenomegaly, and he- sodium (Voltaren), naproxen (Naprosyn), di-
patomegaly flunisal (Dolobid)
• Migratory pain, joint stiffness and swelling
• Oral and nasopharyngeal ulcerations INTERVENTIONS AND RATIONALES
• Photosensitivity • Evaluate musculoskeletal status to deter-
• Signs and symptoms of pleurisy, pericardi- mine the patient’s baseline functional abilities.
tis, myocarditis, noninfectious endocarditis, • Monitor renal status. Decreased urine output
and hypertension (with cardiac involvement) without lowered fluid intake may indicate de-
• Signs and symptoms of Raynaud’s phenom- creased renal perfusion, a possible indication of
enon decreased cardiac output.
• Monitor vital signs to promptly determine
DIAGNOSTIC FINDINGS whether the patient’s condition is deteriorating
• ANA test is positive. and evaluate the effectiveness of treatment.
SLE can affect
• Blood chemistry shows decreased comple- Fever can signal an exacerbation. many different organs,
ment fixation. • Provide prophylactic skin, mouth, and per- but a butterfly rash is
• Hematology shows decreased Hb, HCT, ineal care to prevent skin and oral mucous the signature finding.
WBC, and platelets and an increased ESR. membrane breakdown.
• Lupus erythematosus cell preparation is • Administer medications, as prescribed, to
positive. comply with the treatment regimen.
• Rheumatoid factor is positive. • Maintain seizure precautions to prevent pa-
• Urine chemistry shows proteinuria and tient injury.
hematuria. • Monitor dietary intake to help ensure ade-
quate nutritional intake.
NURSING DIAGNOSES • Minimize environmental stress and provide
• Impaired physical mobility rest periods to help the patient avoid fatigue
• Ineffective breathing pattern and cope with illness.
• Risk for infection • Promote independence in ADLs to help the
patient develop self-esteem.
TREATMENT • Administer antiemetics to alleviate nausea
• Diet high in iron, protein, and vitamins (es- and vomiting.
pecially vitamin C) • Administer antidiarrheals, as prescribed, to
• Hemodialysis or kidney transplant, if renal alleviate diarrhea.
failure occurs • Encourage the patient to express feelings
• Limited exertion and maintenance of ade- about changes in his body image and the
quate rest chronic nature of the disease to help the pa-
• Plasmapheresis tient express doubts and resolve concerns.

• Analgesic: aspirin • Quitting smoking (if appropriate)
• Iron supplements: ferrous sulfate (Feosol), • Reducing stress
ferrous gluconate (Fergon) • Recognizing early signs and symptoms of
• Antirheumatic: hydroxychloroquine renal failure
(Plaquenil) • Avoiding exposure to people with infections
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• Monitoring for infection, fatigue, and joint • signs and symptoms of pulmonary conges-
pain tion
• Performing daily, complete mouth care • weight loss.
• Avoiding OTC medications
• Avoiding exposure to sunlight Temporal arteritis
• Avoiding hair spray or hair coloring This type of vasculitis affects medium- to
• Avoiding hormonal contraceptives large-sized arteries, most commonly branch-
• Using liquid cosmetics to cover rashes es of the carotid artery; involvement may skip
• Contacting groups such as the Lupus Foun- segments. Data collection findings include:
dation of America • fever
• headache (associated with polymyalgia
One name, many
rheumatica syndrome)
disorders. Vasculitis
refers to various Vasculitis • jaw claudication
disorders • myalgia
characterized by Vasculitis is a broad spectrum of disorders • visual changes.
inflammation and characterized by inflammation and necrosis of
necrosis of blood blood vessels. Its clinical effects depend on Takayasu’s arteritis
vessels. the vessels involved and reflect tissue is- Also known as aortic arch syndrome, Takaya-
chemia caused by blood flow obstruction. su’s arteritis affects medium- to large-sized ar-
The prognosis is also variable. For example, teries, particularly the aortic arch and its
hypersensitivity vasculitis is usually a benign branches and, possibly, the pulmonary artery.
disorder limited to the skin, but more exten- Data collection findings include:
sive polyarteritis nodosa can be rapidly fatal. • anorexia
Vasculitis can occur at any age, except for • arthralgias
mucocutaneous lymph node syndrome, which • bruits
occurs only during childhood. Vasculitis may • signs and symptoms of stroke (with disease
be a primary disorder or secondary to other progression)
disorders, such as rheumatoid arthritis or • diplopia and transient blindness, if carotid
SLE. artery is involved
• signs and symptoms of heart failure (with
CAUSES disease progression)
• Excessive levels of an antigen • loss of distal pulses
• High-dose antibiotic therapy • malaise
• Often associated with serious infectious dis- • nausea
ease, such as hepatitis B or bacterial endo- • night sweats
carditis • pain or paresthesia distal to affected area
• pallor
DATA COLLECTION FINDINGS • syncope
A few examples of vasculitis and their specific • weight loss.
data collection findings are listed here.
DIAGNOSTIC FINDINGS
Wegener’s granulomatosis Wegener’s granulomatosis
This form of vasculitis affects medium- to • Tissue biopsy shows necrotizing vasculitis
large-sized vessels of the upper and lower res- with granulomatous inflammation.
piratory tract and kidneys; it may also involve • Blood studies show leukocytosis, elevated
small arteries and veins. Data collection find- ESR, IgA, and IgG; low-titer rheumatoid fac-
ings include: tor; and circulating immune complexes: anti-
• anorexia neutrophil cytoplasmic antibody in more than
• cough 90% of patients.
• fever • Renal biopsy shows focal segmental glomer-
• malaise ulonephritis.
• mild to severe hematuria
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Temporal arteritis • Provide emotional support to help the pa-

• Blood studies show decreased Hb and ele- tient and his family cope with an altered body
vated ESR. image—the result of the disorder or its thera-
• Tissue biopsy shows panarteritis with infil- py. (For example, Wegener’s granulomatosis
tration of mononuclear cells, giant cells within may be associated with saddle nose, steroids
vessel wall (seen in 50%), fragmentation of may cause weight gain, and cyclophospha-
internal elastic lamina, and proliferation of mide may cause alopecia.)
intima.
Teaching topics
Takayasu’s arteritis • Recognizing adverse reactions to medica-
• Blood studies show decreased Hb, leukocy- tion
tosis, positive lupus erythematosus cell prepa- • Increasing fluids during cyclophosphamide
ration, and elevated ESR. therapy
• Arteriography shows calcification and ob-
struction of affected vessels.
• Tissue biopsy shows inflammation of adven-
titia and intima of vessels and thickening of
vessel walls.
NURSING DIAGNOSES
• Ineffective tissue perfusion: Peripheral
• Risk for injury
• Disturbed sensory perception (tactile)
TREATMENT
• Removal of identified environmental antigen
• Diet: elimination of antigenic food, if identi-
fiable Pump up on practice
Drug therapy
questions
• Antineoplastic: cyclophosphamide (Cytox-
an) 1. A client with major abdominal trauma
needs an emergency blood transfusion. The
INTERVENTIONS AND RATIONALES client’s blood type is AB negative. Of the
• Check for dry nasal mucosa in patients with blood types available, the safest type for the
Wegener’s granulomatosis. Instill nose drops nurse to administer is:
to lubricate the mucosa and help diminish 1. AB positive.
crusting. Or, irrigate the nasal passages with 2. A positive.
warm normal saline solution to combat drying. 3. B negative.
• Regulate environmental temperature to pre- 4. O positive.
vent additional vasoconstriction caused by cold. Answer: 3. Individuals with AB negative blood
• Monitor vital signs. Use a Doppler ultrason- (AB type, Rh negative) can receive A nega-
ic flowmeter, if available, to auscultate blood tive, B negative, and AB negative blood. It’s
pressure in patients with Takayasu’s arteritis, unsafe to give Rh-positive blood to an Rh-
whose peripheral pulses are frequently difficult negative person.
to palpate. Client needs category: Physiological
• Monitor intake and output. Check daily for integrity
edema. Keep the patient well hydrated (3 L Client needs subcategory: Pharmaco-
daily) to reduce the risk of hemorrhagic cystitis logical therapies
associated with cyclophosphamide therapy. Cognitive level: Application
920105.qxd 8/7/08 3:53 PM Page 166
2. The nurse is preparing a client with sys- Answer: 4. NSAIDs decrease prostaglandin
temic lupus erythematosus (SLE) for dis- synthesis. Misoprostol, a synthetic analog of
charge. Which instructions should the nurse prostaglandin, is used to treat and prevent
include in the teaching plan? NSAID-induced gastric ulcers. Cyanocobal-
1. Exposure to sunlight will help control amin is used to treat vitamin B12 deficiency.
skin rashes. Ticlopidine is an antiplatelet agent used to re-
2. There are no activity limitations be- duce the risk of stroke. Prednisone is a gluco-
tween flare-ups. corticoid used to treat several inflammatory
3. Monitor body temperature. disorders and may promote gastric ulcer de-
4. Corticosteroids may be stopped when velopment.
symptoms are relieved. Client needs category: Physiological
Answer: 3. The client should monitor his tem- integrity
perature, because fever can signal an exacer- Client needs subcategory: Pharmaco-
bation and should be reported to the physi- logical therapies
cian. Sunlight and other sources of ultraviolet Cognitive level: Comprehension
light may precipitate severe skin reactions
and exacerbate the disease. Fatigue can cause 4. A client with thrombocytopenia secondary
a flare-up of SLE, and clients should be en- to leukemia develops epistaxis. The nurse
couraged to pace activities and plan for rest should instruct the client to:
periods. Corticosteroids must be gradually ta- 1. lie supine with his neck extended.
pered because they can suppress the function 2. sit upright, leaning slightly forward.
of the adrenal gland. Abruptly stopping corti- 3. blow his nose and then put lateral pres-
costeroids can cause adrenal insufficiency, a sure on his nose.
potentially life-threatening situation. 4. hold his nose while bending forward at
Client needs category: Physiological the waist.
integrity Answer: 2. The upright position, leaning
Client needs subcategory: Reduction of slightly forward, avoids increasing the vascu-
risk potential lar pressure in the nose and helps the client
Cognitive level: Application avoid aspirating blood. Lying supine won’t
prevent aspiration of the blood. Nose blowing
can dislodge any clotting that has occurred.
Bending at the waist increases vascular pres-
sure in the nose and promotes bleeding
rather than halting it.
integrity
logical adaptation
5. A nurse is teaching a client diagnosed with

3. A client with rheumatoid arthritis has pernicious anemia. Which point should the
a history of long-term nonsteroidal anti- nurse include?
inflammatory drug (NSAID) use and has de- 1. Importance of receiving monthly vita-
veloped peptic ulcer disease. To prevent or min B12 injections for the rest of the
treat this adverse effect, the nurse would ad- client’s life
minister: 2. Establishing a low-protein diet
1. cyanocobalamin (vitamin B12). 3. Discontinuing his vegetarian diet
2. ticlopidine (Ticlid). 4. Using heating pads or electric blankets
3. prednisone (Deltasone). to warm his feet
4. misoprostol (Cytotec).
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Answer: 1. The nurse should teach the client 7. A nurse is reviewing findings data for a
with pernicious anemia the importance of re- client diagnosed with stage III lymphoma.
ceiving lifelong monthly injections of vitamin This diagnosis is most strongly supported by
B12. The client should also be taught to con- lymphatic involvement in both sides of the:
sume a diet high in iron and protein. The 1. blood-brain barrier.
client doesn’t have to stop his vegetarian diet 2. diaphragm.
as long as he includes foods that are high in 3. descending aorta.
these nutrients. The use of heating pads or 4. spinal column.
electric blankets should be avoided because Answer: 2. In stage III lymphoma, malignant
sensation in the foot may be reduced. cells are widely disseminated to lymph nodes
Client needs category: Physiological on both sides of the diaphragm.
integrity Client needs category: Physiological
Client needs subcategory: Reduction of integrity
risk potential Client needs subcategory: Physio-
Cognitive level: Application logical adaptation
Cognitive level: Comprehension
8. A nurse is providing care for a client with

acquired immunodeficiency syndrome and
Pneumocystis carinii pneumonia. The client is
receiving aerosolized pentamidine isethionate
(NebuPent). What’s the best evidence that
the therapy is succeeding?
1. A sudden weight gain
2. Whitening of lung fields on the chest
X-ray
3. Improving client vitality and activity
6. A nurse is reviewing the laboratory report tolerance
of a client who underwent a bone marrow 4. Afebrile body temperature and develop-
biopsy. The finding that would most strongly ment of leukocytosis
support a diagnosis of acute leukemia is the Answer: 3. P. carinii pneumonia is a protozoal
existence of a large number of immature: infection of the lungs. Pentamidine isethio-
1. lymphocytes. nate is one of the agents used to treat this in-
2. thrombocytes. fection. Because a common manifestation of
3. reticulocytes. the infection is activity intolerance and loss of
4. leukocytes. vitality, improvements in these areas would
Answer: 4. Leukemia is manifested by an ab- suggest success of the therapy. Sudden
normal overproduction of immature leuko- weight gain, whitening of the lung fields on
cytes in the bone marrow. The other cells list- chest X-ray, and development of leukocytosis
ed aren’t diagnostic for leukemia. aren’t evidence of therapeutic success.
Client needs category: Physiological Client needs category: Physiological
integrity integrity
Client needs subcategory: Reduction of Client needs subcategory: Pharmaco-
risk potential logical therapies
Cognitive level: Comprehension Cognitive level: Application
920105.qxd 8/7/08 3:53 PM Page 168
9. A nurse is documenting her care for a 10. A nurse is administering cyanocobalamin

client with iron deficiency anemia. Which (vitamin B12) to a client with pernicious ane-
nursing diagnosis is most appropriate? mia secondary to gastrectomy. Which route
1. Impaired gas exchange should the nurse use to administer the vita-
2. Deficient fluid volume min most effectively?
3. Ineffective airway clearance 1. Topical route
4. Ineffective breathing pattern 2. Transdermal route
Answer: 1. Iron is necessary for hemoglobin 3. Enteral route
(Hb) synthesis. Hb is responsible for oxygen 4. Parenteral route
transport in the body. Iron deficiency anemia Answer: 4. Following a gastrectomy, the client
causes subnormal Hb levels, which leads to no longer has the intrinsic factor available to
impaired tissue oxygenation and calls for a promote vitamin B12 absorption in his GI
nursing diagnosis of impaired gas exchange. tract. Therefore, vitamin B12 is administered
Iron deficiency anemia doesn’t cause deficient parenterally (I.M. or deep subQ). Topical and
fluid volume and is less directly related to in- transdermal forms aren’t available, and the
effective airway clearance and breathing pat- enteral route is inappropriate after a gastrec-
tern than it is to ineffective gas exchange. tomy.
integrity integrity
Client needs subcategory: Physio- Client needs subcategory: Pharmaco-
logical adaptation logical therapies
Cognitive level: Comprehension Cognitive level: Application
Now it’s time to

reward yourself.
Remember, it’s an
important part of an
effective study
program.
920106.qxd 8/7/08 2:59 PM Page 169
6 Neurosensory
system
The cerebrum, the largest part of the
In this chapter,
you’ll review:
Brush up on key brain, houses the nerve center that controls
motor and sensory functions and intelligence.
✐ components of the concepts It’s divided into hemispheres. Because motor
impulses descending from the brain cross in
neurosensory system
and their functions The neurosensory system serves as the the medulla, the right hemisphere controls
body’s communication network. It processes the left side of the body and the left hemi-
information from the outside world (through sphere controls the right side of the body.
nose neurosensory
the sensory portion) and coordinates and or- Several fissures divide the cerebrum into four
disorders ganizes the functions of all other body sys- lobes:
✐ common neuro- tems. Major parts of the neurosensory sys- • frontal lobe—the site of personality, memo-
sensory disorders. tem include the brain, spinal cord, peripheral ry, reasoning, concentration, and motor con-
nerves, eyes, and ears. trol of speech
At any time, you can review the major points • parietal lobe—the site of sensation, integra-
of this chapter by consulting the Cheat sheet tion of sensory information, and spatial rela-
on pages 170 to 176. tionships
• temporal lobe—the site of hearing, speech,
The little conductor that could memory, and emotion
The neuron, or nerve cell, is the basic func- • occipital lobe—the site of vision and invol-
tional unit of the neurosensory system. This untary eye movements.
highly specialized conductor cell receives and
transmits electrochemical nerve impulses. Brain networking
From its cell body, delicate, threadlike nerve The thalamus is a structure located deep
fibers called axons and dendrites extend and within the brain that consists of two oval-
transmit signals. Axons carry impulses away shaped parts, one located in each hemi-
from the cell body; dendrites carry impulses sphere. The thalamus is referred to as the re-
toward the cell body. lay station of the brain because it receives in-
A covering called a myelin sheath protects put from all of the senses except olfaction
the entire neuron. Substances known as neu- (smell), analyzes that input, and then trans-
rotransmitters (acetylcholine, serotonin, do- mits that information to other parts of the
pamine, endorphins, gamma-aminobutyric brain.
acid, and norepinephrine) help conduct im- The hypothalamus, located beneath the
pulses across a synapse and into the next thalamus, controls sleep and wakefulness,
neuron. temperature, respiration, blood pressure, sex-
ual arousal, fluid balance, and emotional re-
House of intelligence sponse.
The central ner vous system (CNS) in-
cludes the brain and spinal cord. These frag- Movement, balance, and posture
ile structures are protected by the skull and The cerebellum, at the base of the brain, co-
vertebrae, cerebrospinal fluid (CSF), and ordinates muscle movements, maintains bal-
three membranes: the dura mater, the pia ance, and controls posture.
mater, and the arachnoid membrane.
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170 Neurosensory system
et
heat she
C
Neurosensory refresher
ACUTE HEAD INJURY AMYOTROPHIC LATERAL SCLEROSIS
• Altered mental status • Awkwardness of fine finger movements
• Unequal pupil size, loss of pupillary reaction • Dysphagia
(late sign) • Fatigue
Key test results • Muscle weakness of hands and feet
• Computed tomography (CT) scan shows hemor- Key test results
rhage, cerebral edema, or shift of midline struc- • Creatine kinase level is elevated.
tures. • Electromyography (EMG) shows impaired im-
• Magnetic resonance imaging (MRI) shows pulse conduction in the muscles.
hemorrhage, cerebral edema, or shift of midline Key treatments
structures. • Symptomatic relief
Key treatments • Neuroprotective agent: riluzole (Rilutek)
• Cervical collar (until neck injury is ruled out) Key interventions
• Anticonvulsant: phenytoin (Dilantin) • Monitor neurologic and respiratory status.
• Barbiturate: pentobarbital (Nembutal) if unable • Evaluate swallow and gag reflexes.
to control intracranial pressure (ICP) with diure- • Monitor and record vital signs and intake and
sis output.
• Diuretics: mannitol (Osmitrol), furosemide • Devise an alternate method of communication
(Lasix) to combat cerebral edema when necessary.
• Vasopressors: dopamine (Intropin) or phenyl- • Suction the oropharynx as necessary.
ephrine (Neo-Synephrine) to maintain cerebral
perfusion pressure above 60 mm Hg (if blood BELL’S PALSY
pressure is low and ICP is elevated) Key signs and symptoms
• Glucocorticoid: dexamethasone (Decadron) to • Inability to close eye completely on the affected
reduce cerebral edema side
• Histamine-2 (H2)-receptor antagonists: cimeti- • Pain around the jaw or ear
dine (Tagamet), ranitidine (Zantac), famotidine • Unilateral facial weakness
(Pepcid), nizatidine (Axid) Key test results
• Mucosal barrier fortifier: sucralfate (Carafate) • EMG helps predict the level of expected recov-
When I’m on • Posterior pituitary hormone: vasopressin ery by distinguishing temporary conduction de-
overload, I skip directly (Pitressin), if patient develops diabetes insipidus fects from a pathologic interruption of nerve
to the Cheat sheet.
Key interventions fibers.
• Monitor neurologic and respiratory status. Key treatments
• Keep the patient free from stimuli. • Moist heat
• Monitor and record vital signs, intake and out- • Corticosteroid: prednisone (Deltasone) to re-
put, urine specific gravity, laboratory studies, and duce facial nerve edema and improve nerve con-
pulse oximetry values. duction and blood flow
• Check for signs of diabetes insipidus (low urine • Artificial tears to protect the cornea from injury
specific gravity, high urine output).
Key interventions
• Allow a rest period between nursing activities.
• During treatment with prednisone, watch for
adverse reactions, especially GI distress and flu-
id retention.
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Neurosensory refresher (continued)

BELL’S PALSY (continued) Key treatments
• Apply moist heat to the affected side of the face, taking care • Craniotomy
not to burn the skin. • Anticonvulsant: phenytoin (Dilantin)
• Massage the patient’s face with a gentle upward motion two • Glucocorticoid: dexamethasone (Decadron)
or three times daily for 5 to 10 minutes, or have him massage his • H2-receptor antagonists: cimetidine (Tagamet), ranitidine (Zan-
face himself. When he’s ready for active facial exercises, teach tac), famotidine (Pepcid), nizatidine (Axid)
him to grimace in front of a mirror. • Mucosal barrier fortifier: sucralfate (Carafate)
• Arrange for privacy at mealtimes. Key interventions
• Offer psychological support. Give reassurance that recovery is • Monitor neurologic and respiratory status.
likely within 1 to 8 weeks. • Evaluate pain.
BRAIN ABSCESS • Observe for signs and symptoms of increased ICP.
• Monitor for signs and symptoms of syndrome of inappropriate
antidiuretic hormone (edema, weight gain, positive fluid balance,
• Headache
high urine specific gravity).
• Chills
• Encourage the patient to express feelings about changes in
• Fever
body image and a fear of dying.
• Confusion
• Drowsiness CATARACT
• Physical examination shows increased ICP. • Dimmed or blurred vision
• Enhanced CT scan reveals the abscess site. • Poor night vision
• A CT-guided stereotactic biopsy may be performed to drain • Yellow, gray, or white pupil
and culture the abscess. Key test result
Key treatments • Ophthalmoscopy or slit-lamp examination confirms the diagno-
• Penicillinase-resistant antibiotics: nafcillin, methicillin sis by revealing a dark area in the normally homogeneous red
• Surgical aspiration or drainage of the abscess reflex.
Key interventions Key treatment
• Frequently monitor neurologic status. • Extracapsular cataract extraction and intracapsular lens im-
• Monitor and record vital signs at least once every hour. plant
• Monitor fluid intake and output carefully. Key interventions
• After surgery, monitor neurologic status. Monitor vital signs • Provide a safe environment for the patient.
and intake and output. • Modify the environment to help the patient meet his self-care
• Watch for signs of meningitis (nuchal rigidity, headaches, needs (for example, by placing items on the unaffected side).
chills, sweats).
• Change the dressing when damp. Never allow bandages to re- CEREBRAL ANEURYSM
main damp. Key sign or symptom
• Position the patient on the operative side. • Sudden headache (commonly described by the patient as the
• Measure drainage from a Jackson-Pratt drain or other type of worst he’s ever had)
drain as instructed by the surgeon. Key test results
BRAIN TUMOR • Cerebral angiogram identifies the aneurysm.
Key sign or symptom • CT scan may show a shift of intracranial midline structures and
blood in the subarachnoid space.
• Vary, depending on location of tumor
Key treatments
Key test results
• Aneurysm clipping
• CT scan shows location and size of tumor.
• Anticonvulsant: phenytoin (Dilantin)
• MRI shows location and size of tumor.
• Calcium channel blocker: nimodipine (Nimotop) preferred to
prevent cerebral vasospasm
(continued)
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CEREBRAL ANEURYSM (continued) Key test result
• Glucocorticoid: dexamethasone (Decadron) • Staining the cornea with fluorescein stain confirms the diagno-
• H2-receptor antagonists: cimetidine (Tagamet), ranitidine (Zan- sis: The injured area appears green when examined with a
tac), famotidine (Pepcid), nizatidine (Axid) flashlight.
• Stool softener: docusate sodium (Colace) Key treatments
Key interventions • Cycloplegic agent: tropicamide (Tropicacyl)
• Monitor neurologic status. • Irrigation with saline solution
• Maintain crystalloid solutions after aneurysm clipping. • Pressure patch (a tightly applied eye patch)
• Take vital signs every 1 to 2 hours initially and then every 4 • Removal of a deeply embedded foreign body with a foreign
hours when the patient becomes stable. body spud, using a topical anesthetic
• Allow a rest period between nursing activities. Key interventions
CONJUNCTIVITIS • Assist with examination of the eye. Check visual acuity before
beginning treatment.
• If a foreign body is visible, carefully irrigate the eye with nor-
• Excessive tearing
mal saline solution.
• Itching, burning
• Tell the patient with an eye patch to leave the patch in place
• Mucopurulent discharge
for 6 to 8 hours.
Key test result • Stress the importance of instilling prescribed antibiotic eye-
• Culture and sensitivity tests identify the causative bacterial or- drops.
ganism and indicate appropriate antibiotic therapy.
ENCEPHALITIS
Key treatments
• Antiviral agents: vidarabine ointment (Vira-A) or oral acyclovir Key signs and symptoms
(Zovirax), if herpes simplex is the cause • Meningeal irritation (stiff neck and back) and neuronal dam-
• Corticosteroids: dexamethasone (Maxidex), fluorometholone age (drowsiness, coma, paralysis, seizures, ataxia, and organic
(Fluor-Op Ophthalmic), if the cause is nonviral psychoses)
• Mast cell stabilizer: cromolyn (Opticrom) for allergic conjunc- • Sudden onset of fever
tivitis • Headache
• Topical antibiotics: according to the sensitivity of the infective • Vomiting
organism (if bacterial) Key test results
Key interventions • Blood studies identify the virus and confirm the diagnosis.
• Teach proper hand-washing technique. • Cerebrospinal fluid (CSF) analysis identifies the virus.
• Stress the risk of spreading infection to family members by Key treatments
sharing washcloths, towels, and pillows. Warn against rubbing • Endotracheal (ET) intubation and mechanical ventilation
the infected eye, which can spread the infection to the other eye • Nasogastric (NG) tube feedings or total parenteral nutrition (if
and to other persons. unable to use the GI tract)
• Apply warm compresses and therapeutic ointment or drops. • Anticonvulsants: phenytoin (Dilantin), phenobarbital (Luminal)
Don’t irrigate the eye. • Analgesics and antipyretics: aspirin, acetaminophen (Tylenol)
• Have the patient wash his hands before he uses the medica- to relieve headache and reduce fever
tion, and tell him to use clean washcloths or towels frequently. • Diuretics: furosemide (Lasix), mannitol (Osmitrol) to reduce
• Teach the patient to instill eyedrops and ointments correctly— cerebral swelling
without touching the bottle tip to his eye or lashes. • Corticosteroid: dexamethasone (Decadron) to reduce cerebral
inflammation and edema
CORNEAL ABRASION
Key interventions
• Monitor neurologic function often. Observe the patient’s men-
• Burning
tal status and cognitive abilities.
• Increased tearing
• Avoid fluid overload. Measure and record intake and output
• Redness
accurately.
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ENCEPHALITIS (continued) • NG tube feedings or parenteral nutrition (if unable to use the GI
• Carefully position the patient and turn him often. tract)
• Assist with range-of-motion exercises. • Plasmapheresis
• Maintain a quiet environment. Darken the room. Key interventions
GLAUCOMA • Watch for ascending sensory loss, which precedes motor loss.
Also, monitor vital signs and level of consciousness.
• Monitor and treat respiratory dysfunction.
Chronic open-angle glaucoma • Maintain respiratory support, if needed.
• Initially asymptomatic • Reposition the patient every 2 hours.
Acute angle-closure glaucoma • If aspiration can’t be minimized by diet and position modifica-
• Acute ocular pain tion, expect to provide NG tube feeding.
• Blurred vision • Inspect the patient’s legs regularly for signs of thrombophle-
• Dilated pupil bitis. Apply antiembolism stockings and sequential compression
• Halo vision devices, and give prophylactic anticoagulants as needed.
Key test results • Encourage adequate fluid intake (2,000 ml/day), unless con-
• Ophthalmoscopy shows atrophy and cupping of optic nerve traindicated.
head.
• Tonometry shows increased intraocular pressure. HUNTINGTON’S DISEASE
Chronic open-angle glaucoma • Dementia (can be mild at first but eventually disrupts the pa-
• Alpha-adrenergic agonist: brimonidine (Alphagan) tient’s personality)
• Beta-adrenergic antagonist: timolol (Timoptic) • Gradual loss of musculoskeletal control, eventually leading to
Acute angle-closure glaucoma total dependence
• Cholinergic: pilocarpine (Pilopine HS) Key test results
• Laser iridectomy or surgical iridectomy, if pressure doesn’t • Positron emission tomography detects the disease.
decrease with drug therapy • Deoxyribonucleic acid analysis detects the disease.
Key interventions Key treatments
• Monitor eye pain, and administer medication as prescribed. • Antidepressant: imipramine (Tofranil) to alleviate depression
• Modify the environment. • Antipsychotics: chlorpromazine (Thorazine), haloperidol (Hal-
dol) to help control choreic movements
GUILLAIN-BARRÉ SYNDROME • Supportive, protective treatment aimed at relieving symptoms
Key sign or symptom (because Huntington’s disease has no known cure)
• Symmetrical muscle weakness (ascending from the legs to the Key interventions
arms) • Provide physical support by attending to the patient’s basic
Key test results needs, such as hygiene, skin care, bowel and bladder care, and
• A history of preceding febrile illness (usually a respiratory tract nutrition. Increase this support as mental and physical deterio-
infection) and typical clinical features suggest Guillain-Barré ration makes him increasingly immobile.
syndrome. • Stay alert for possible suicide attempts. Control the patient’s
• CSF protein level begins to rise, peaking in 4 to 6 weeks. The environment to protect him from suicide or other self-inflicted in-
CSF white blood cell count remains normal but, in severe dis- jury.
ease, CSF pressure may rise above normal. • Pad the side rails of the bed but avoid restraints.
Key treatments
MÉNIÈRE’S DISEASE
• Anticoagulants: heparin, warfarin (Coumadin)
• ET intubation or tracheotomy, possibly mechanical ventilation • Sensorineural hearing loss
• I.V. fluid therapy • Severe vertigo
• Tinnitus
(continued)
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MÉNIÈRE’S DISEASE (continued) • Oxygen therapy, possibly with ET intubation and mechanical
Key test result ventilation
• Audiometric studies indicate a sensorineural hearing loss and • Antibiotics: penicillin G (Pfizerpen), ampicillin (Omnipen), or
loss of discrimination and recruitment. nafcillin; tetracycline (Achromycin V) or chloramphenicol
(Chloromycetin), if allergic to penicillin
Key treatments
• Diuretic: mannitol (Osmitrol)
• Restriction of sodium intake to less than 2 g/day
• Anticonvulsants: phenytoin (Dilantin), phenobarbital (Luminal)
• Anticholinergic: atropine (may stop an attack in 20 to 30 min-
• Analgesics or antipyretics: acetaminophen (Tylenol), aspirin
utes)
• Antihistamine: diphenhydramine (Benadryl) for severe attack Key interventions
• Monitor neurologic function often.
Key interventions
• Watch for deterioration in the patient’s condition.
• Advise the patient against reading and exposure to glaring
• Monitor fluid balance. Maintain adequate fluid intake
lights during an attack.
• Suction the patient only if necessary. Limit suctioning to 10 to
• Stress safety measures. Tell the patient not to get out of bed or
15 seconds per pass of the catheter.
walk without assistance during an attack.
• Hyperoxygenate the lungs with 100% oxygen for 1 minute be-
• Instruct the patient to avoid sudden position changes and
fore and after suctioning.
tasks that vertigo makes hazardous.
• Position the patient carefully.
Before surgery
• Darken the room.
• If the patient is vomiting, record fluid intake and output and
• Relieve headache with a nonopioid analgesic, such as aspirin
characteristics of vomitus. Administer antiemetics as necessary,
or acetaminophen, as needed.
and give small amounts of fluid frequently.
After surgery MULTIPLE SCLEROSIS
• Tell the patient to expect dizziness and nausea for 1 or 2 days Key signs and symptoms
after surgery. • Nystagmus, diplopia, blurred vision, optic neuritis
MENINGITIS • Weakness, paresthesia, impaired sensation, paralysis
• Chills • CT scan eliminates other diagnoses such as brain or spinal
• Fever cord tumors.
• Headache • MRI may reveal plaques associated with multiple sclerosis.
• Malaise Key treatments
• Photophobia • Plasmapheresis (for antibody removal)
• Positive Brudzinski’s sign (patient flexes hips or knees when • Cholinergic: bethanechol (Urecholine)
the nurse places her hands behind his neck and flexes it for- • Glucocorticoids: prednisone (Deltasone), dexamethasone
ward)—a sign of meningeal inflammation and irritation (Decadron), corticotropin (ACTH)
• Positive Kernig’s sign (pain or resistance when the patient’s leg • Immunosuppressants: interferon beta-1b (Betaseron), cy-
is flexed at the hip or knee while he’s in a supine position) clophosphamide (Cytoxan), methotrexate (Trexall), glatiramer
• Stiff neck and back (Copaxone)
• Vomiting • Skeletal muscle relaxants: dantrolene (Dantrium), baclofen
Key test result (Lioresal)
• A lumbar puncture shows elevated CSF pressure, cloudy or Key interventions
milky white CSF, high protein level, positive Gram stain and cul- • Monitor for changes in motor coordination, paralysis, or mus-
ture that usually identifies the infecting organism (unless it’s a cle weakness.
virus) and depressed CSF glucose concentration. • Encourage the patient to express feelings about changes in
Key treatments body image.
• Bed rest • Establish a bowel and bladder program.
• Hypothermia • Maintain activity as tolerated (alternating rest and activity).
• I.V. fluid administration
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MYASTHENIA GRAVIS Key treatments
Key signs and symptoms • Antidepressant: amitriptyline (Elavil)
• Dysphagia, drooling • Antiparkinsonian agents: levodopa (Larodopa), carbidopa-
• Muscle weakness and fatigue (typically, muscles are strongest levodopa (Sinemet), benztropine (Cogentin)
in the morning but weaken throughout the day, especially after Key interventions
exercise) • Monitor neurologic and respiratory status.
• Profuse sweating • Reinforce gait training.
Key test results • Reinforce independence in care.
• EMG shows impaired impulse conduction in the muscles. RETINAL DETACHMENT
• Neostigmine (Prostigmin) or edrophonium (Tensilon) test re-
lieves symptoms after medication administration—a positive in-
dication of the disease. • Painless change in vision (floaters and flashes of light)
• With progression of detachment, painless vision loss may be
Key treatments
described as a “veil,” “curtain,” or “cobweb” that eliminates
• Anticholinesterase inhibitors: neostigmine (Prostigmin), pyri- part of visual field
dostigmine (Mestinon)
Key test results
• Glucocorticoids: prednisone (Deltasone), dexamethasone
(Decadron), corticotropin (ACTH) • Indirect ophthalmoscopy shows retinal tear or detachment.
• Immunosuppressants: azathioprine (Imuran), cyclophos- • Slit-lamp examination shows retinal tear or detachment.
phamide (Cytoxan) Key treatment
• Thymectomy • Scleral buckling to reattach the retina
• Monitor neurologic and respiratory status. • Postoperatively, instruct the patient to lie on his back or on his
• Evaluate swallow and gag reflexes. unoperated side.
• Watch the patient for choking while eating. • Discourage straining during defecation, bending down, and
hard coughing, sneezing, or vomiting.
OTOSCLEROSIS
Key signs and symptoms SPINAL CORD INJURY
• Progressive hearing loss Key signs and symptoms
• Tinnitus • Loss of bowel and bladder control
Key test result • Paralysis below the level of the injury
• Audiometric testing confirms hearing loss. • Paresthesia below the level of the injury
Key treatment Key test results
• Stapedectomy and insertion of a prosthesis to restore partial • CT scan shows spinal cord edema, vertebral fracture, and
or total hearing spinal cord compression.
• MRI shows spinal cord edema, vertebral fracture, and spinal
Key intervention
cord compression.
• Develop alternative means of communication.
Key treatments
PARKINSON’S DISEASE • Flat position, with neck immobilized in a cervical collar
Key signs and symptoms • Maintenance of vertebral alignment through Crutchfield tongs
• “Pill-rolling” tremors, tremors at rest or Halo vest
• Masklike facial expression • Surgery for stabilization of the upper spine, such as insertion
• Shuffling gait, stiff joints, dyskinesia, “cogwheel” rigidity, of Harrington rods
stooped posture • Antianxiety agent: lorazepam (Ativan)
Key test result • Glucocorticoid: methylprednisolone (Solu-Medrol) given as in-
fusion immediately following injury (may improve neurologic re-
• EEG reveals minimal slowing of brain activity.
covery when administered within 8 hours of injury)
(continued)
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SPINAL CORD INJURY (continued) TRIGEMINAL NEURALGIA
• H2-receptor antagonists: cimetidine (Tagamet), ranitidine (Zan- Key sign or symptom
tac), famotidine (Pepcid), nizatidine (Axid) • Searing pain in the facial area
• Laxative: bisacodyl (Dulcolax) Key test result
• Mucosal barrier fortifier: sucralfate (Carafate)
• Observation during the examination shows the patient favoring
• Muscle relaxant: dantrolene (Dantrium)
(splinting) the affected area. To ward off a painful attack, the pa-
Key interventions tient often holds his face immobile when talking. He may also
• Monitor neurologic and respiratory status. leave the affected side of his face unwashed and unshaven.
• Observe for signs and symptoms of spinal shock. Key treatments
• Check for autonomic dysreflexia (sudden extreme rise in blood
• Anticonvulsants: carbamazepine (Tegretol) or phenytoin (Di-
pressure).
lantin)
• Provide skin care.
• Microsurgery for vascular decompression
STROKE Key interventions
Key signs and symptoms • Observe and record the characteristics of each attack, includ-
• Garbled or impaired speech ing the patient’s protective mechanisms.
• Inability to move, or difficulty moving, limbs or one side of the • Provide adequate nutrition in small, frequent meals at room
body temperature.
• Vision disturbances • Advise the patient to place food in the unaffected side of his
• Headache mouth when chewing, to brush his teeth and rinse his mouth of-
• Mental impairment ten, and to see a dentist twice per year to detect cavities.
• Seizures • After surgical decompression of the root or partial nerve dis-
• Coma section, check neurologic and vital signs often.
• Vomiting • Watch for adverse reactions to prescribed medications.
Key test results WEST NILE ENCEPHALITIS
• CT scan reveals intracranial bleeding, infarct (shows up 24 Key signs and symptoms
hours after the initial symptoms), or shift of midline structures.
• Fever
• Digital subtraction angiography reveals occlusion or narrow-
• Headache
ing of vessels.
• Disorientation
• MRI shows intracranial bleeding, infarct, or shift of midline
structures. Key test result
• Patient history reveals recent mosquito bites.
Key treatments
• Anticoagulants: heparin, warfarin (Coumadin) Key treatments
• Anticonvulsant: phenytoin (Dilantin) • Symptom control, such as I.V. fluids and respiratory support
• Glucocorticoid: dexamethasone (Decadron) • Antipyretic: acetaminophen (Tylenol)
• Thrombolytic therapy: tissue plasminogen activator given with- Key interventions
in the first 3 hours of an ischemic stroke to restore circulation to • Monitor respiratory status.
the affected brain tissue and limit the extent of brain injury • Administer supplemental oxygen as prescribed.
• Antiplatelet aggregation agent: ticlopidine (Ticlid) • Monitor neurologic status.
Key interventions • Administer medications, as prescribed.
• Take vital signs every 1 to 2 hours initially and then every 4 • Monitor pulse oximetry values
hours when the patient becomes stable.
• Elevate the head of the bed 30 degrees.
• Conduct a neurologic assessment every 1 to 2 hours initially
and then every 4 hours when the patient becomes stable.
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Conjunction junction thetic nervous system conserves and restores

The brain stem provides the connection be- energy stores.
tween the spinal cord and the brain. It con-
tains three sections: Blink and you’ll miss it
• the midbrain—mediates pupillary reflexes The eyes have external and internal struc-
and eye movements; it’s also the reflex center tures. External structures include the eyelids,
for the third and fourth cranial nerves conjunctivae (thin, transparent mucous mem-
• the pons—helps regulate respiration; it’s branes that line the lids), lacrimal apparatuses
also the reflex center for the fifth through (which lubricate and protect the cornea and
eighth cranial nerves and mediates chewing, conjunctivae by producing and absorbing
tasting, saliva secretion, and equilibrium tears), extraocular muscles (which hold the
• the medulla oblongata—contains the vomit- eyes parallel to create binocular vision), and
ing, vasomotor, respiratory, and cardiac the eyeballs themselves.
centers.
An inside view
Information superhighway Some of the eye’s most important internal
The spinal cord functions as a two-way con- structures include:
ductor pathway between the brain stem and • the iris—a thin, circular, pigmented muscu-
the peripheral nervous system. It consists of lar structure that gives color to the eye and di-
gray matter and white matter. The gray mat- vides the space between the cornea and lens Memory
ter is made up of cell bodies, dendrites, and into anterior and posterior chambers jogger
axons. The white matter contains ascending • the cornea—a smooth, transparent tissue
(sensory) and descending (motor) tracts, that works with the sclera to give the eye its To help you
which send signals up to the brain and motor shape remember
signals out to the muscles. • the pupil—the circular aperture in the iris
the cranial nerves
(and their order),
that changes size as the iris adapts to the think of the
Messenger service amount of light entering the eye mnemonic “On Old
The peripheral ner vous system delivers • the lens—a biconvex, avascular, colorless, Olympus’s Towering
messages from the spinal cord to outlying ar- and transparent structure suspended behind Tops, A Finn And
eas of the body. The main nerves of this sys- the iris by the ciliary zonulae German Viewed
tem are grouped into: • the anterior chamber—the space between Some Hops.”
• 31 pairs of spinal nerves, which carry the iris and cornea that’s filled with aqueous Olfactory (CN I)
mixed (motor and sensory) impulses to and humor, a watery, clear fluid that moistens and
from the spinal cord nourishes the lens and cornea Optic (CN II)
• 12 pairs of cranial nerves—olfactory, optic, • the posterior chamber—the space behind Oculomotor (CN III)
oculomotor, trochlear, trigeminal, abducens, the lens containing vitreous humor, a clear, Trochlear (CN IV)
facial, acoustic, glossopharyngeal, vagus, gelatinous fluid
spinal accessory, and hypoglossal. • the retina—a thin, semitransparent layer of Trigeminal (CN V)
nerve tissue that lines the eye wall Abducens (CN VI)
Involuntary actions • retinal cones—visual cell segments respon-
Facial (CN VII)
The autonomic ner vous system, a subdivi- sible for visual acuity and color discrimination
sion of the peripheral nervous system, con- • retinal rods—visual cell segments responsi- Acoustic (CN VIII)
trols involuntary body functions, such as di- ble for peripheral vision under decreased Glossopharyngeal
gestion, respiration, and cardiovascular func- light conditions (CN IX)
tion. • the optic nerve—a nerve located at the pos-
Vagus (CN X)
It’s divided into two cooperating systems to terior portion of the eye that transmits visual
maintain homeostasis: the sympathetic ner- impulses from the retina to the brain. Spinal accessory
vous system and the parasympathetic ner- (CN XI)
vous system. The sympathetic nervous sys- External, middle, and inner Hypoglossal
tem coordinates activities that handle stress The ears are composed of three sections: ex- (CN XII)
(the fight-or-flight response). The parasympa- ternal, middle, and inner. The external ear in-
920106.qxd 8/7/08 2:59 PM Page 178
cludes the pinna (auricle) and external audito- Nursing actions

ry canal. It’s separated from the middle ear by • Note the patient’s allergies to iodine, sea-
the tympanic membrane. food, and radiopaque dyes, if dye will be used.
The middle ear, known as the tympanum, is • Make sure that written, informed consent
an air-filled cavity in the temporal bone. It has been obtained, if appropriate.
contains three small bones (malleus, incus, • Inform the patient about possible throat irri-
and stapes). tation and facial flushing, if contrast dye is to
The inner ear, known as the labyrinth, is the be injected.
portion of the ear that consists of the cochlea,
vestibule, and semicircular canals. Magnetic snapshot
Magnetic resonance imaging (MRI) uses
magnetic and radio waves to create a detailed
visualization of the brain and its structures.
diagnostic tests • Make sure that written, informed consent
has been obtained if appropriate.
Here are some important tests used to diag- • Be aware that patients with pacemakers,
nose neurosensory disorders, along with surgical and orthopedic hardware, or shrap-
common nursing actions associated with each nel can’t undergo MRI scanning.
test. • Remove jewelry and metal objects from the
patient.
Electrical graph • Determine the patient’s ability to lie still for
An electroencephalogram (EEG) records 45 to 60 minutes.
the electrical activity of the brain. Using elec- • Administer sedatives as prescribed.
trodes, this noninvasive test gives a graphic
representation of brain activity. Upstairs artery exam
A cerebral angiogram uses a radiopaque
Nursing actions dye, in conjunction with X-rays, to examine
• Determine the patient’s ability to lie still. the cerebral arteries.
• Reassure the patient that electrical shock
won’t occur. Nursing actions
• Explain that the patient will be subjected to Before the procedure
stimuli, such as lights and sounds. • Note the patient’s allergies to iodine, sea-
Hmmm… • Withhold medications that may interfere food, or radiopaque dyes.
Contraindications with the results (such as anticonvulsants, • Make sure that written, informed consent
count. The presence of antianxiety agents, sedatives, and antidepres- has been obtained.
a pacemaker rules out
sants) and caffeine for 24 to 48 hours before • Inform the patient about possible throat irri-
an MRI.
the procedure. tation and facial flushing from the dye.
After the procedure
Brain images • Monitor vital signs.
A computed tomography (CT) scan, used • Check the insertion site for bleeding, and
to identify brain abnormalities, produces a se- assess pulses distal to the site.
ries of tomograms translated by a computer • Monitor neurologic status.
and displayed on a monitor, which represent • Force fluids, if the patient’s condition al-
cross-sectional images of various layers of the lows.
brain. It can be used to identify intracranial tu-
mors, bleeding, and other brain lesions. It Puncture reveals pressure
may be performed with or without the injec- With a lumbar puncture (LP), a doctor in-
tion of contrast dye. serts a needle into the lumbar subarachnoid
space. This procedure allows measurement of
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CSF pressure, collection of CSF fluid for test- See the spine
ing, and the injection of radiopaque dye for a With myelography, an injection of radi-
myelogram. opaque dye by LP, followed by fluoroscopy,
allows visualization of the subarachnoid Memory
Nursing actions space, spinal cord, and vertebrae. jogger
• Determine the patient’s ability to lie still in a Nursing actions To remem-
flexed, lateral, recumbent position. Before the procedure ber that
• Explain the procedure to the patient. • Note the patient’s allergies to iodine, sea-
increased intracra-
nial pressure con-
• Make sure that written, informed consent food, or radiopaque dyes. traindicates a lum-
has been obtained. • Make sure that written, informed consent bar puncture, think:
• Be aware that a substantial increase in in- has been obtained.
tracranial pressure (ICP) is a contraindication • Inform the patient about possible throat irri- Increased ICP—No
for having the test. tation and facial flushing from dye injection.
LP.
After the procedure After the procedure
• Monitor neurologic status. • Monitor neurologic status.
• Keep the patient flat in bed as directed • Keep the patient flat in bed as directed.
(from 20 minutes to a few hours). • Check the puncture site for bleeding or
• Administer analgesics as prescribed. CSF leakage.
• Check the puncture site for bleeding or • Encourage fluids, if the patient’s condition
CSF leakage. allows.
• Force fluids, if the patient’s condition al-
lows. Snooping on the skull
Skull X-rays provide a radiographic picture
Fluid to the lab of the head and neck bones.
Cerebrospinal fluid analysis is a laboratory
test of CSF obtained by LP or ventriculosto- Nursing actions
my. It allows microscopic examination of CSF • Determine the patient’s ability to lie still
for blood, white blood cells (WBCs), immuno- during the procedure.
globulins, bacteria, protein, glucose, and elec- • Explain the events that will occur during
trolytes. the procedure.
Nursing actions Marking blood flow in the brain

• Label specimens properly, and send them to Positron emission tomography (PET) in-
the laboratory immediately. volves injection of a radioisotope, allowing vi-
• Adhere to nursing interventions that follow sualization of the brain’s oxygen uptake,
an LP. blood flow, and glucose metabolism.
Electric flex Nursing actions

Electromyography (EMG) uses electrodes • Determine the patient’s ability to lie still
to graphically record the electrical activity of during the procedure.
a muscle at rest and during contraction. • Make sure that written, informed consent
has been obtained.
Nursing actions • Withhold alcohol, tobacco, and caffeine for
• Explain that the patient must flex and relax 24 hours before the procedure.
the muscles during the procedure. • Withhold medications, as directed, before
• Explain that the patient will feel some dis- the procedure.
comfort but not pain. • Check the injection site for bleeding after
• Administer analgesics, as prescribed, after the procedure.
the procedure.
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Studying blood once… All lined up?

A blood chemistr y test analyzes a blood Extraocular eye muscle testing checks for
sample for potassium, sodium, calcium, phos- parallel alignment of the eyes, muscle
phorus, protein, osmolality, glucose, bicar- strength, and cranial nerve function.
bonate, blood urea nitrogen, and creatinine.
Nursing actions
Nursing actions • Explain the testing procedure to the patient.
• Explain the reason for testing to the patient. • Advise the examiner if the patient has diffi-
• Monitor the venipuncture site for bleeding culty hearing or following directions.
after the procedure.
Seeing on the side
…Studying blood twice… A visual field examination tests the degree
A hematologic study analyzes a blood sam- of peripheral vision of each eye.
ple for WBCs, red blood cells, erythrocyte
sedimentation rate, platelets, hemoglobin, and Nursing actions
hematocrit. • Explain the testing procedure to the patient.
• Advise the examiner if the patient has diffi-
Nursing actions culty hearing or following directions.
• Note current drug therapy before the pro-
cedure. Puff to measure pressure
• Check the venipuncture site for bleeding af- A tonometr y test measures intraocular fluid
ter the procedure. pressure using an applanation tonometer or
an air-puff tonometer.
…Studying blood three times
A coagulation study analyzes a blood sample Nursing actions
for prothrombin time, International Normal- • Ask the patient to remain still.
ized Ratio, and partial thromboplastin time. • Depending on the method of examination,
advise the patient that a puff of air or the in-
Nursing actions strument may be felt touching the eye.
• Note current drug therapy before the pro-
cedure. Tick-tock test
• Check the venipuncture site for bleeding af- An auditor y acuity test gives a general esti-
ter the procedure. mation of a patient’s hearing. It evaluates the
patient’s ability to hear a whispered phrase or
Ye olde eye chart ticking watch.
A visual acuity test measures clarity of vi-
sion using a letter chart (Snellen’s) placed 20⬘ Nursing actions
(6 m) from the patient. Acuity is expressed in • Explain the testing procedure to the patient.
a ratio that relates what a person with normal • Advise the examiner if the patient has diffi-
vision sees at 20⬘ to what the patient can see culty following directions.
at 20⬘.
Scope inside the ear
Nursing actions An otoscopic examination uses an otoscope
• Explain the testing procedure to the patient. to visualize the tympanic membrane.
• Remind the patient to bring eyeglasses or
contact lenses, if presently prescribed. Nursing actions
• Advise the examiner if the patient is unable • Advise the patient to hold still during the
to read alphabet letters. examination.
• Advise the examiner if the patient has diffi- • Explain that a gentle pull will be felt on the
culty hearing or following directions. auricle and that slight pressure will be felt in
the ear.
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Determining degree of deafness DATA COLLECTION FINDINGS

Audiometr y measures the patient’s degree • Decreased level of consciousness (LOC)
of deafness using pure-tone or speech meth- • Altered mental status
ods. • Complaint of pain or headache
• Elevated systolic blood pressure
Nursing actions • Bradycardia
• Explain that the patient will need to wear • Respiratory depression
earphones for the procedure. • Otorrhea, rhinorrhea, frequent swallowing
• Explain that the patient will be asked to sig- (if a CSF leak occurs)
nal when a tone is heard while sitting in a • Paresthesia
soundproof room. • Unequal pupil size, loss of pupillary reac-
tion (late sign)
DIAGNOSTIC FINDINGS
Polish up on patient • CT scan shows hemorrhage, cerebral ede-
ma, or shift of midline structures.
care • EEG may reveal seizure activity.
• ICP monitoring shows increased ICP.
Major neurosensory disorders include acute • MRI shows hemorrhage, cerebral edema,
head injury, amyotrophic lateral sclerosis, or shift of midline structures.
Bell’s palsy, brain abscess, brain tumor, • Skull X-ray may show skull fracture.
cataract, cerebral aneurysm, conjunctivitis,
corneal abrasion, encephalitis, glaucoma, NURSING DIAGNOSES
Guillain-Barré syndrome, Huntington’s dis- • Ineffective tissue perfusion: Cerebral
ease, Ménière’s disease, meningitis, multiple • Decreased intracranial adaptive capacity
sclerosis, myasthenia gravis, otosclerosis, • Risk for injury
Parkinson’s disease, retinal detachment,
spinal cord injury, stroke, trigeminal neural- TREATMENT
gia, and West Nile encephalitis. • Cervical collar (until neck injury is ruled
out)
• Craniotomy: surgical incision into the crani-
Acute head injury um (may be necessary to evacuate a
hematoma or evacuate contents to make
Acute head injury results from a trauma to room for swelling to prevent herniation) Terrible news!
the head, leading to brain injury or bleeding • Oxygen therapy: intubation and mechanical Acute head injury
within the brain. Effects of injury may include ventilation, if necessary results from trauma
edema and hypoxia. Manifestations of the in- • Restricted oral intake for 24 to 48 hours to the head, leading to
jury can vary greatly from a mild cognitive ef- • Ventriculostomy: insertion of a drain into brain injury or bleeding
fect to severe functional deficits. the ventricles (to drain CSF in the presence of within the brain.
A head injury is classified by brain injury hydrocephalus, which may occur as a result
type: fracture, hemorrhage, or trauma. Frac- of head injury; can also be used to monitor
tures can be depressed, comminuted, or lin- ICP)
ear. Hemorrhages are classified as epidural,
subdural, intracerebral, or subarachnoid. Drug therapy
• Analgesic: codeine phosphate
CAUSES • Anticonvulsant: phenytoin (Dilantin)
• Assault • Barbiturate: pentobarbital (Nembutal),
• Automobile accident if unable to control ICP with diuresis
• Blunt trauma • Diuretics: mannitol (Osmitrol),
• Fall furosemide (Lasix) to combat cerebral
• Penetrating trauma edema
• Sports injury
920106.qxd 8/7/08 2:59 PM Page 182
• Vasopressors: dopamine (Intropin) or • Maintain seizure precautions to maintain

In patients with
head injuries, allow a phenylephrine (Neo-Synephrine) to maintain patient safety. (See Implementing seizure pre-
rest period between cerebral perfusion pressure above 60 mm Hg cautions.)
procedures to avoid (if blood pressure is low and ICP is elevated) • Administer medications as prescribed to de-
increasing ICP. • Glucocorticoid: dexamethasone (Decadron) crease ICP and pain.
to reduce cerebral edema • Allow a rest period between nursing activi-
• Histamine-2 (H2)–receptor antagonists: ties to avoid an increase in ICP.
cimetidine (Tagamet), ranitidine (Zantac), • Encourage the patient to express feelings
famotidine (Pepcid), nizatidine (Axid) to pre- about changes in body image to allay anxiety.
vent gastritis • Provide appropriate sensory input and stim-
• Mucosal barrier fortifier: sucralfate uli with frequent reorientation to foster aware-
(Carafate) ness of the environment.
• Posterior pituitary hormone: vasopressin • Provide a means of communication, such as
(Pitressin), if patient develops diabetes in- a communication board, to prevent anxiety.
sipidus • Provide eye, skin, and mouth care to prevent
tissue damage.
INTERVENTIONS AND RATIONALES • Turn the patient every 2 hours or maintain
• Monitor neurologic and respiratory status him in a rotating bed, if his condition allows,
to monitor for signs of increased ICP and respi- to prevent skin breakdown.
ratory distress. • Apply antiembolism stockings and a se-
• Elevate the head of the bed as ordered and quential compression device to prevent throm-
keep the patient’s neck aligned to promote ve- boembolism formation.
nous return and decrease ICP.
• Keep the patient free from excessive stimuli Teaching topics
to prevent increased ICP. • Recognizing the signs and symptoms of de-
• Monitor and record vital signs, intake and creased LOC
output, urine, specific gravity, laboratory stud- • Recognizing the signs of seizures
ies, and pulse oximetry to detect early signs of • Adhering to fluid restrictions
compromise. • Contacting the National Head Injury Foun-
• Observe for CSF leak as evidenced by otor- dation
rhea or rhinorrhea. CSF leak could leave the
patient at risk for infection.
• Evalaute pain. Pain may cause anxiety and Amyotrophic lateral sclerosis
increase ICP.
• Check cough and gag reflex to prevent aspi- Amyotrophic lateral sclerosis (ALS), com-
ration. monly known as Lou Gehrig’s disease, is a
• Check for signs of diabetes insipidus (low progressive, degenerative disorder that leads
urine specific gravity, high urine output) to to decreased motor function in the upper and
maintain hydration. lower motor neuron systems. With ALS, cer-
• Maintain I.V. fluids to prevent dehydration. tain nerve cells degenerate, resulting in dis-
• Administer oxygen and maintain position torted or blocked nerve impulses. Nerve cells
and patency of the endotracheal (ET) tube, if die and muscle fibers undergo atrophic
present, to maintain airway and hyperventi- changes, resulting in progressive motor dys-
late the patient to lower ICP. function. The disease affects males three
• Provide suctioning; if the patient is able, as- times more often than females.
sist with turning, coughing, and deep breath-
ing to prevent pooling of secretions. CAUSES
• Maintain position, patency, and low suction • Exact cause unknown
of the nasogastric (NG) tube to prevent vomit- Possible causes
ing. • Nutritional deficiency related to a distur-
bance in enzyme metabolism
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Stepping up
Implementing seizure precautions

WHY YOU DO IT • To protect the patient’s limbs, head, and feet
By taking appropriate precautions, you can help from injury if he has a seizure while in bed, cov-
protect a patient from injury, aspiration, and air- er the side rails, headboard, and footboard with
way obstruction in the event that he has a side rail pads or bath blankets. If you use blan-
seizure. Plan your precautions using information kets, keep them in place with adhesive tape.
obtained from the patient’s history. What kind of • Keep the side rails raised while the patient is
seizure has the patient previously had? Is he in bed to prevent falls. Keep the bed in a low po-
aware of exacerbating factors? Sleep depriva- sition to minimize injuries that may occur if the
tion, missed doses of anticonvulsants, and even patient climbs over the rails.
upper respiratory infections can increase • Place an airway at the patient’s bedside or
seizure frequency in some people who have had tape it to the wall above the bed according to
seizures. Was his previous seizure an acute your facility’s protocol. Keep suction equipment
episode, or did it result from a chronic condi- nearby in case you need to establish a patent
tion? airway. Explain to the patient how the airway
Remember that a patient with preexisting will be used.
seizures who’s being admitted for a change in • If the patient has frequent or prolonged
medication, treatment of an infection, or detoxi- seizures, insert a heparin lock to facilitate ad-
fication may be at greater risk for seizures. ministration of emergency medications.
• Document that seizure precautions have been
HOW YOU DO IT
implemented.
• Explain the reasons for the precautions to the
patient.
• Genetic predisposition NURSING DIAGNOSES

• Slow-acting virus • Ineffective health maintenance
• Impaired physical mobility
DATA COLLECTION FINDINGS • Ineffective airway clearance
• Atrophy of tongue
• Awkwardness of fine finger movements TREATMENT Teach family
• Dysphagia • Management of symptoms members of a patient
• Dyspnea • Stem cell therapy (currently being studied) with ALS about
• Fasciculations of face options for long-term
• Fatigue Drug therapy care.
• Muscle weakness of hands and feet • Anticholinergic: dicyclomine (Bentyl)
• Nasal quality of speech • Neuroprotective agent: riluzole (Rilutek)
• Spasticity
• Muscle cramps INTERVENTIONS AND
RATIONALES
DIAGNOSTIC FINDINGS • Monitor neurologic and
• Creatine kinase level is elevated. respiratory status to detect
• EMG shows impaired impulse conduction decreases in neurologic
in the muscles. functioning.
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• Evaluate swallow and gag reflexes to delayed in older adults. If recovery is partial,
crease the risk of aspiration. contractures may develop on the paralyzed
• Monitor and record vital signs and intake side of the face. Bell’s palsy may recur on the
and output to determine baseline values and same or opposite side of the face.
detect changes from baseline assessment.
• Administer medications, as prescribed, to CAUSES
help the patient achieve maximum potential. • Blockage of the seventh cranial nerve, re-
• Devise an alternate method of communica- sulting from infection, hemorrhage, tumor,
tion, when necessary, to help the patient com- meningitis, or local trauma
municate and to decrease the patient’s anxiety
and frustration. DATA COLLECTION FINDINGS
• Encourage the patient to verbalize his feel- • Upward rolling and excessive tearing of the
ings and maintain his independence for as eye when the patient attempts to close it
long as possible to decrease anxiety and pro- • Inability to close eye completely on the af-
mote self-esteem. fected side
• Suction the oropharynx as necessary to • Pain around the jaw or ear
stimulate cough and clear the airways. • Ringing in the ears
• Maintain the patient’s diet to improve nutri- • Taste distortion on the anterior portion of
tional status. the tongue on the affected side
• Apply antiembolism stockings and a se- • Unilateral facial weakness
quential compression device to prevent throm-
boembolism formation. DIAGNOSTIC FINDINGS
• EMG helps predict the level of expected re-
Teaching topics covery by distinguishing temporary conduc-
• Maintaining a tucked-chin position while tion defects from a pathologic interruption of
eating or drinking nerve fibers.
• Using a tonsillar suction tip to clear the
oropharynx NURSING DIAGNOSES
• Using prosthetic devices to assist with activ- • Acute pain
ities of daily living (ADLs) • Disturbed sensory perception (gustatory)
• For the patient’s family, providing informa- • Disturbed body image
tion about the disease, required treatment,
and possible need for long-term care TREATMENT
There are two • Contacting the Amyotrophic Lateral Sclero- • With mild cases, no treatment because
facial nerves, one on sis Association, which may supply the patient symptoms typically subside on their own
each side. Bell’s palsy with some of the needed equipment, such as a • Physical therapy to stimulate the facial
occurs when one of wheelchair and communication board, as well nerve and help maintain muscle tone
those nerves becomes as provide the patient with information about • Relaxation techniques
swollen and pinched. local support groups • Biofeedback
• Electrical stimulation therapy
• Moist heat
Bell’s palsy
Drug therapy
This neurologic disorder affects the seventh • Corticosteroid: prednisone (Deltasone) to
cranial (facial) nerve and produces unilateral reduce facial nerve edema and improve nerve
facial weakness or paralysis. Onset is rapid. conduction and blood flow
Although Bell’s palsy affects all age-groups, it • Artificial tears to protect the cornea from
occurs most commonly in persons younger injury
than age 60. In 80% to 90% of patients, it sub- • Antiviral: acyclovir (Zovirax), if cause is
sides spontaneously, with complete recovery thought to be viral
in 1 to 8 weeks; however, recovery may be de-
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• If the patient has diabetes, prednisone must • Infection, especially otitis media, sinusitis,
be used with caution and necessitates fre- dental abscess, and mastoiditis
quent monitoring of serum glucose levels. Hy- • Subdural empyema
perglycemia is an adverse effect of prednisone • Physical trauma
therapy.
• During treatment with prednisone, watch DATA COLLECTION FINDINGS
for adverse reactions, especially GI distress • Headache
and fluid retention, to ensure prompt inter- • Chills
vention. • Fever
• Apply moist heat to the affected side of the • Malaise
face, taking care not to burn the skin, to re- • Confusion
duce pain. • Drowsiness
• Massage the patient’s face with a gentle up- • Behavior changes
ward motion two or three times daily for 5 to
10 minutes, or have him massage his face Temporal lobe abscess
himself. When he’s ready for active facial ex- • Auditory-receptive dysphasia
ercises, teach him to exercise by grimacing in • Central facial weakness
front of a mirror to help maintain muscle tone. • Hemiparesis
• Arrange for privacy at mealtimes to reduce
embarrassment. Cerebellar abscess
• Give the patient frequent and complete • Dizziness
mouth care, being careful to remove residual • Coarse nystagmus
food that collects between the cheeks and • Gaze weakness on lesion side
gums to prevent breakdown of oral mucosa. • Tremor
• Offer psychological support. Give reassur- • Ataxia
ance that recovery is likely within 1 to 8
weeks to allay the patient’s anxiety. Frontal lobe abscess
• Expressive dysphasia
Teaching topics • Hemiparesis with unilateral motor seizure
• Protecting the eye by covering it with an • Drowsiness
eye patch, especially when outdoors and at • Inattention
night • Mental function impairment
• Keeping warm, avoiding exposure to dust • Seizures
and wind, and covering face when exposure is Location, location,
unavoidable DIAGNOSTIC FINDINGS location. Effects of a
• Performing facial exercises • Physical examination shows signs of in- brain abscess depend
on which part of the
creased ICP.
brain is affected.
• Enhanced CT scan reveals the abscess site.
Brain abscess • Arteriography highlights the abscess by a
halo appearance.
A brain abscess is a free or encapsulated col- • A CT-guided stereotactic biopsy may be per-
lection of pus that usually occurs in the tem- formed to drain and culture the abscess.
poral lobe, cerebellum, or frontal lobes. A • Culture and sensitivity of drainage identifies
brain abscess is rare. Although it can occur at the causative organism.
any age, it’s most common in people ages 10
to 35 and is rare in older adults. NURSING DIAGNOSES
An untreated brain abscess is usually fatal; • Decreased intracranial adaptive capacity
with treatment, the prognosis is only fair. • Disturbed thought processes
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Early increases in
ICP can be detected Using the Glasgow Coma Scale
by using the Glasgow
Coma Scale. The Glasgow Coma Scale is used to assess a alert, can follow simple commands, and is com-
patient’s level of consciousness. It was de- pletely oriented to person, place, and time, his
signed to help predict a patient’s survival and re- score will total 15 points. If the patient is co-
covery after a head injury. The scale scores matose, his score will total 7 or less. A score of
three observations: eye opening response, best 3, the lowest possible score, indicates brain
motor response, and best verbal response. Each death.
response receives a point value. If the patient is
Observation Response Score
Eye response Opens spontaneously 4

Opens to verbal command 3
Opens to pain 2
No response 1
Best motor response Follows commands 6

Localizes pain 5
Flexion withdrawal 4
Abnormal flexion 3
Abnormal extension 2
No response 1
Best verbal response Is oriented and converses 5

Is disoriented but converses 4
Uses inappropriate words 3
Makes incomprehensible sounds 2
No response 1
Total score Ranges between 3 and 15
TREATMENT • Anticonvulsants: phenytoin (Dilantin), phe-

• ET intubation and mechanical ventilation nobarbital (Luminal)
• I.V. therapy • Analgesics: codeine phosphate, codeine sul-
• Surgical aspiration or drainage of the fate
abscess
Drug therapy • Provide intensive care and monitoring to
• Antipyretics: acetaminophen (Tylenol), closely monitor ICP and provide necessary life
aspirin support.
• Diuretics: urea (Ureaphil), mannitol • Frequently monitor neurologic status to de-
(Osmitrol) tect early signs of increased ICP. (See Using the
• Corticosteroids: dexamethasone Glasgow Coma Scale.)
(Decadron) • Monitor and record vital signs at least once
• Penicillinase-resistant antibiotics: nafcillin, every hour to detect trends that may signify in-
methicillin creasing ICP, such as increasing blood pressure
and slowing heart rate.
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• Monitor fluid intake and output carefully be- blood vessels, producing ischemia, edema,
cause fluid overload could contribute to cere- and increased ICP.
bral edema. Signs and symptoms vary, depending on the
• If surgery is necessary, explain the proce- location and size of the tumor in the brain.
A brain tumor is
dure to the patient and answer his questions The tumor can be primary (originating in the an abnormal mass
to allay anxiety. brain tissue) or secondary (metastasizing found in the brain
• After surgery, monitor neurologic status to from another area of the body). Tumors are resulting from
detect rises in ICP and deteriorating neurologic classified according to the tissue of origin, unregulated cell
status. Monitor vital signs and intake and out- such as gliomas (composed of neuroglial growth and division.
put. cells), meningiomas (originating in the
• Watch for signs of meningitis (nuchal rigidi- meninges), and astrocytomas (composed of
ty, headaches, chills, sweating) to avoid treat- astrocytes).
ment delay.
• Change the dressing when damp to decrease CAUSES
the chances of infection. • Environmental
• Position the patient on the operative side to • Genetic
promote drainage and prevent reaccumulation
of the abscess. DATA COLLECTION FINDINGS
• Measure drainage from a Jackson-Pratt • Deficits in cerebral function
drain or another type of drain as instructed by • Headache
the surgeon, to determine effectiveness of the
drains and detect signs of hemorrhage (blood Frontal lobe
accumulating in the drain). • Aphasia
• Provide meticulous skin care to prevent • Memory loss
pressure ulcers and position the patient to pre- • Personality changes
serve joint function and prevent muscle con-
tractures. Temporal lobe
• Apply antiembolism stockings and a se- • Aphasia
quential compression device to prevent throm- • Seizures
boembolism formation.
• Ambulate the patient as soon as possible to Parietal lobe
prevent immobility and encourage indepen- • Motor seizures
dence. • Sensory impairment
• Give prophylactic antibiotics as ordered af-
ter a compound skull fracture or penetrating Occipital lobe
head wound to prevent brain abscess. • Homonymous hemianopia (defective vision
or blindness affecting the right or left half of
Teaching topics the visual field of both eyes)
• Stressing the need for treatment of otitis • Visual hallucinations
media, mastoiditis, dental abscess, and other • Vision impairment
infections to prevent brain abscess
Cerebellum
• Impaired coordination
Brain tumor • Impaired equilibrium
A brain tumor is an abnormal mass found in DIAGNOSTIC FINDINGS

the brain resulting from unregulated cell • CT scan shows location and size of tumor.
growth and division. These tumors can either • MRI shows location and size of tumor.
infiltrate and destroy surrounding tissue or be
encapsulated and displace brain tissue. The NURSING DIAGNOSES
presence of the lesion causes compression of • Anxiety
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• Risk for injury • Administer oxygen to prevent cerebral

• Disturbed sensory perception (kinesthetic) hypoxia.
• Administer enteral nutrition or monitor total
TREATMENT parenteral nutrition (TPN), as indicated, to
• Craniotomy meet nutritional needs.
• High-calorie diet • Limit environmental noise. Auditory stimuli
• Radiation therapy can contribute to increased ICP.
• Encourage the patient to express feelings
Drug therapy about changes in body image and a fear of dy-
• Analgesics: codeine, acetaminophen ing to decrease anxiety.
(Tylenol) • Maintain normothermia and control shiver-
• Anticonvulsant: phenytoin (Dilantin) ing. Shivering causes isometric muscle contrac-
• Antineoplastics: vincristine (Oncovin), lotion, which can increase ICP.
mustine (CeeNu), carmustine (BiCNU) • Provide rest periods. Cerebral blood flow in-
• Diuretics: mannitol (Osmitrol), furosemide creases during rapid-eye-movement sleep.
(Lasix), if increased ICP • Maintain seizure precautions and adminis-
• Antiemetic: dolasetron (Anzemet), trimeth- ter an anticonvulsant, as ordered. Seizures in-
obenzamide (Tigan), metoclopramide crease intrathoracic pressure, decrease cerebral
(Reglan) venous outflow, and increase cerebral blood vol-
• Glucocorticoid: dexamethasone (Decadron) ume, thereby increasing ICP.
• H2-receptor antagonists: cimetidine (Taga- • Apply antiembolism stockings and a se-
met), ranitidine (Zantac), famotidine (Pepcid), quential compression device to prevent throm-
nizatidine (Axid) to prevent gastritis bophlebitis.
• Mucosal barrier fortifier: sucralfate
(Carafate) Teaching topics
• Recognizing decreased LOC
INTERVENTIONS AND RATIONALES • Maintaining a safe, quiet environment
• Monitor neurologic and respiratory status • Discussing quality-of-life decisions
to determine baseline and to detect deviations • Arranging for hospice care, if appropriate
from baseline assessment.
• Evaluate pain to correlate the patient’s subjec-
tive complaints and behavior with organic Cataract
pathology.
• Observe for signs and symptoms of in- A cataract occurs when the normally clear,
creased ICP to facilitate early intervention and transparent crystalline lens in the eye be-
Does your
brain need a prevent neurologic complications. comes opaque. With age, lens fibers become
break from all • Monitor and record vital signs, intake and more densely packed, making the lens less
of this review? output, and laboratory studies to determine transparent and giving the lens a yellowish
Take five! baseline and to detect early deviations from hue. These changes result in vision loss.
baseline assessment. A cataract usually develops first in one eye
• Monitor for signs and symptoms of syn- and then, in many cases, in the other eye.
drome of inappropriate antidiuretic hormone
(edema, weight gain, positive fluid balance, CAUSES
high urine specific gravity) to facilitate early • Aging
intervention and prevent increased ICP. • Anterior uveitis
• Turn and reposition the patient every 2 • Blunt or penetrating trauma
hours to maintain skin integrity. • Diabetes mellitus
• Encourage the patient to drink fluids or • Hypoparathyroidism
maintain I.V. fluids to maintain hydration if • Long-term steroid treatment
the patient is unable to drink adequate • Radiation exposure
amounts. • Ultraviolet light exposure
920106.qxd 8/7/08 2:59 PM Page 189
DATA COLLECTION FINDINGS Cerebral aneurysm

• Dimmed or blurred vision
• Disabling glare A cerebral aneurysm is an outpouching of a
• Distorted images cerebral artery that results from weakness of
• Poor night vision the artery’s middle layer. It usually results
On the
• Yellow, gray, or white pupil from a congenital weakness in the structure lookout for
of the artery and remains asymptomatic until subarachnoid
DIAGNOSTIC FINDINGS it ruptures.
• Ophthalmoscopy or slit-lamp examination Cerebral aneurysms are classified by size or hemorrhage
confirms the diagnosis by revealing a dark shape, such as saccular, berry, and dissecting. complications
area in the normally homogeneous red reflex. Saccular aneurysms, the most common type,
Because the mortality
occur at the base of the brain at the juncture
rate is high for patients
NURSING DIAGNOSES where the large arteries bifurcate.
who experience sub-
• Disturbed sensory perception (visual)
arachnoid hemorrhage
• Impaired physical mobility CAUSES
as a result of cerebral
• Risk for injury • Atherosclerosis
aneurysm rupture,
• Congenital weakness
prompt recognition of
TREATMENT • Head trauma
changes and rapid
• Extracapsular cataract extraction and intra-
treatment are essen-
capsular lens implant DATA COLLECTION FINDINGS
tial. When caring for a
• Asymptomatic until aneurysm ruptures
patient at risk for sub-
INTERVENTIONS AND RATIONALES • Decreased LOC
arachnoid hemor-
• Provide a safe environment for the patient. • Diplopia, ptosis, blurred vision
rhage, follow these
Orienting the patient to his surroundings re- • Nausea
guidelines:
duces the risk of injury. • Vomiting
• Perform neurologic
• Modify the environment to help the patient • Photophobia
assessment frequently.
meet his self-care needs by placing items on • Fever
Monitor for subtle
the unaffected side to discourage movement or • Sudden headache (commonly described by
changes in level of
positions that would apply pressure to the oper- the patient as the worst he’s ever had)
consciousness or
ative site or cause increased intraocular • Hemiparesis
worsening headache,
pressure. • Nuchal rigidity
which may indicate
• Provide sensory stimulation (such as large • Seizure activity
further bleeding. If
print or tapes) to help compensate for vision
changes occur, notify
loss. DIAGNOSTIC FINDINGS
the doctor immedi-
• Cerebral angiogram identifies the
ately.
Teaching topics aneurysm.
• Maintain the patient
• Returning for a checkup the day after • CT scan shows a shift of intracranial mid-
on bed rest with the
surgery line structures and blood in the subarachnoid
head of the bed elevat-
• Protecting the eye from injury by wearing space.
ed per doctor’s order.
an eye shield • LP (contraindicated with increased ICP)
• Avoid engaging the
• Correctly instilling eyedrops shows increased CSF pressure, protein level,
patient in any activities
• Notifying the doctor immediately if sharp and WBCs and grossly bloody and xantho-
that can increase in-
eye pain occurs chromic CSF.
tracranial pressure.
• Maintaining activity restrictions, which in- • MRI may show a shift of intracranial mid-
• Keep the lights dim
clude avoiding sleeping on the affected side, line structures and blood in the subarachnoid
and minimize other
lifting more than 5 lb, straining with bowel space. (See On the lookout for subarachnoid
stimuli.
movements, and bending the head lower than hemorrhage complications.)
• Space nursing care
waist level.
to avoid overstimu-
NURSING DIAGNOSES
lation.
• Anxiety
• Ineffective tissue perfusion: Cerebral
• Decreased intracranial adaptive capacity
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TREATMENT • Administer oxygen (which may require in-

• Aneurysm and seizure precautions tubation and mechanical ventilation) to meet
• Aneurysm clipping cerebral oxygen demands.
• Bed rest • Keep the head of the bed elevated, per doc-
• Elevating the head of bed per doctor’s order tor’s order, to reduce increased ICP.
• I.V. therapy • Monitor for Cushing’s triad (bradycardia,
• Oxygen therapy (intubation and mechanical systolic hypertension, and wide pulse pres-
ventilation, if decreased LOC sure), a sign of increased ICP.
• Balloon embolization or microcoil thrombo- • Take vital signs every 1 or 2 hours initially
sis (before rupture occurs, if clipping is too and then every 4 hours when the patient be-
risky) comes stable to detect early signs of decreased
cerebral perfusion pressure or increased ICP.
Drug therapy • Allow a rest period between nursing activi-
• Analgesic: codeine ties to reduce increased ICP.
• Anticonvulsant: phenytoin (Dilantin) • Maintain seizure precautions and adminis-
• Antihypertensives: hydralazine (Apreso- ter anticonvulsants, as ordered. Seizures in-
line), nitroprusside (Nitropress), labetalol crease intrathoracic pressure, decrease cerebral
(Trandate), esmolol (Brevibloc) venous outflow, and increase cerebral blood vol-
• Calcium channel blocker: nimodipine ume, thereby increasing ICP.
(Nimotop) preferred to prevent cerebral va- • Provide skin care and turn the patient every
sospasm 2 hours to prevent pressure ulcers.
• Diuretics: furosemide (Lasix), mannitol • Maintain adequate nutrition to facilitate tis-
(Osmitrol) sue healing and meet metabolic needs.
• Glucocorticoid: dexamethasone (Decadron) • Prevent constipation and straining at defeca-
• H2-receptor antagonists: cimetidine (Taga- tion to prevent increased ICP.
met), ranitidine (Zantac), famotidine (Pepcid), • Use an antiemetic or NG tube attached to
nizatidine (Axid) suction to prevent nausea and vomiting, which
• Antiemetics: dolasetron (Anzemet), trimeth- may increase ICP.
obenzamide (Tigan), metoclopramide • Apply antiembolism stockings and a se-
(Reglan) quential compression device to prevent throm-
• Vasopressors: dopamine (Intropin), phenyl- boembolism.
ephrine (Neo-Synephrine) to maintain systolic
blood pressure between 140 and 160 mm Hg Teaching topics
• Mucosal barrier fortifier: sucralfate • Recognizing decreasing LOC
(Carafate) • Minimizing environmental stress
• Stool softener: docusate sodium (Colace) • Altering ADLs to compensate for neurologic
deficits
INTERVENTIONS AND RATIONALES • Preventing constipation
• Monitor neurologic status to screen for
changes in the patient’s condition.
• Keep the environment and patient quiet, us- Conjunctivitis
ing sedatives and pain medication, to reduce
increased ICP. Conjunctivitis is characterized by inflamma-
• Administer a diuretic to prevent or treat in- tion of the conjunctiva, the delicate mem-
creased ICP. brane that lines the eyelids and covers the ex-
• Maintain crystalloid solutions after aneu- posed surface of the eyeball. It may result
rysm clipping to induce hypervolemia and in- from infection, allergy, or chemical reactions.
crease cerebral perfusion, thus decreasing the Conjunctivitis is common. Bacterial and vi-
risk of vasospasm. ral conjunctivitis are highly contagious but
are also self-limiting after a couple of weeks’
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duration. Chronic conjunctivitis may result in Drug therapy

degenerative changes to the eyelids. • Antiviral agents: vidarabine ointment (Vira-
A) or oral acyclovir (Zovirax), if herpes sim- Encourage a
patient with
CAUSES plex is the cause
conjunctivitis to
The most common causative organisms are: • Corticosteroids: dexamethasone (Maxi- practice meticulous
• bacterial: Staphylococcus aureus, Streptococ- dex), fluorometholone (Fluor-Op Ophthal- hygiene. The disorder
cus pneumoniae, Neisseria gonorrhoeae, mic), if the cause is nonviral can be highly
N. meningitidis • Mast cell stabilizer: cromolyn (Opticrom) contagious.
• chlamydial: Chlamydia trachomatis (inclu- for allergic conjunctivitis
sion conjunctivitis) • Topical antibiotics according to sensitivity
• viral: adenovirus types 3, 7, and 8; herpes of infective organism (if bacterial)
simplex virus type 1.
Other causes • Teach proper hand-washing tech-
• Allergic reactions to pollen, grass, topical nique because certain forms of conjunc-
medications, air pollutants, and smoke tivitis are highly contagious.
• Fungal infections (rare) • Stress the risk of spreading infection
• Occupational irritants (acids and alkalies) to family members by sharing wash-
• Parasitic diseases caused by Phthirus pubis cloths, towels, and pillows. Warn
or Schistosoma haematobium against rubbing the infected eye, which can
• Rickettsial diseases (Rocky Mountain spot- spread the infection to the other eye and to
ted fever) other persons. These measures prevent the
spread of infection.
DATA COLLECTION FINDINGS • Apply warm compresses and therapeutic
• Excessive tearing ointment or drops. Don’t irrigate the eye; do-
• Hyperemia (engorgement) of the conjuncti- ing so will only spread infection.
va, sometimes accompanied by discharge and • Have the patient wash his hands before he
tearing uses the medication, and tell him to use clean
• Itching, burning washcloths or towels frequently so he doesn’t
• Mucopurulent discharge infect his other eye.
• Teach the patient to instill eyedrops and
DIAGNOSTIC FINDINGS ointments correctly—without touching the
• Culture and sensitivity tests identify the bottle tip to his eye or lashes—to prevent the
causative bacterial organism and indicate ap- spread of infection.
propriate antibiotic therapy. • Stress the importance of safety glasses for
the patient who works near chemical irritants
NURSING DIAGNOSES to prevent further episodes of conjunctivitis.
• Risk for infection • Notify public health authorities if cultures
• Disturbed sensory perception (visual) show N. gonorrhoeae. Public health authorities
• Disturbed body image track sexually transmitted diseases.

• Cold compresses to relieve itching for aller- • Knowing disease process and treatment op-
gic conjunctivitis tions
• Warm compresses to treat bacterial or viral • Using proper hand-washing technique
conjunctivitis • Preventing the spread of infection
• Instilling eyedrops
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Corneal abrasion • Tell the patient with an eye patch to leave

the patch in place for 6 to 8 hours to protect
A corneal abrasion is a scratch on the surface the eye from further corneal irritation when the
epithelium of the cornea, the dome-shaped patient blinks.
transparent structure in front of the eye. • Warn the patient with an eye patch that
wearing a patch alters depth perception, so
CAUSES advise caution in everyday activities, such as
• Improper use of contact lenses climbing stairs or stepping off a curb, to pre-
• Trauma caused by a foreign body (such as a vent injury.
cinder or a piece of dust, dirt, or grit) • Reassure the patient that the corneal epithe-
lium usually heals in 24 to 48 hours to allay
DATA COLLECTION FINDINGS anxiety.
• Burning • Stress the importance of instilling pre-
• Change in visual acuity (depending on the scribed antibiotic eyedrops because an un-
size and location of injury) treated corneal infection can lead to ulceration
• Increased tearing and permanent loss of vision.
• Pain disproportionate to size of injury • Emphasize the importance of safety glasses
• Redness to protect a worker’s eyes from flying fragments.
• Sensation of foreign substance in the eye
Teaching topics
DIAGNOSTIC FINDINGS • Instilling eyedrops
• Staining the cornea with fluorescein stain • Using contacts properly
confirms the diagnosis: The injured area ap-
pears green when examined with a flashlight.
• Slit-lamp examination discloses the depth of Encephalitis
the abrasion.
Encephalitis is a severe inflammation and
NURSING DIAGNOSES swelling of the brain, usually caused by a
• Acute pain mosquito-borne or, in some areas, a tick-
• Risk for infection borne virus. Viruses that may cause the infec-
• Disturbed sensory perception (visual) tion include the arboviruses, enteroviruses,
herpes virus, mumps virus, human immuno-
TREATMENT deficiency virus (HIV), and adenoviruses.
A pressure patch • Irrigation with saline solution Transmission also may occur through inges-
may be applied in • Pressure patch (a tightly applied eye patch) tion of infected goat’s milk and accidental in-
corneal abrasion to • Removal of a deeply embedded foreign jection or inhalation of the virus. Eastern
prevent further body with a foreign body spud, using a topical equine encephalitis may produce permanent
corneal irritation when anesthetic neurologic damage and is commonly fatal.
the patient blinks. With encephalitis, intense lymphocytic infil-
Drug therapy tration of brain tissues and the leptomeninges
• Antibiotic: sulfisoxazole (Gantrisin) causes cerebral edema, degeneration of the
• Cycloplegic agent: tropicamide (Tropicacyl) brain’s ganglion cells, and diffuse nerve cell
destruction.
• Assist with examination of the eye. Check CAUSES
visual acuity before beginning treatment to as- • Exposure to virus or toxic substances such
sess visual loss from injury. as infected goat’s milk
• If a foreign body is visible, carefully irrigate
the eye with normal saline solution to wash DATA COLLECTION FINDINGS
away the foreign body without damaging the • Agitation
eye. • Headache
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• Signs and symptoms of meningeal irritation INTERVENTIONS AND RATIONALES Encephalitis may
(stiff neck and back) and neuronal damage • Monitor neurologic function often. Observe produce only mild
(drowsiness, coma, paralysis, seizures, ataxia, the patient’s mental status and cognitive abili- effects, or it may
organic psychoses) ties. If the tissue within the brain becomes ede- cause permanent
• Sensory alterations matous, changes will occur in the patient’s neurologic damage
• Sudden onset of fever mental status and cognitive abilities. and death.
• Vomiting • Maintain adequate fluid intake to prevent de-
• Restlessness hydration, but avoid fluid overload, which may
increase cerebral edema. Measure and record
DIAGNOSTIC FINDINGS intake and output accurately to assess fluid sta-
• Blood studies identify the virus and confirm tus.
the diagnosis. • Give acyclovir by slow I.V. infusion only.
• CSF analysis identifies the virus. The patient must be well-hydrated and the in-
• LP discloses that CSF pressure is elevated fusion given over 1 hour to avoid kidney dam-
and, despite inflammation, the fluid is com- age. Watch for adverse effects, such as nau-
monly clear. WBC and protein levels in CSF sea, diarrhea, pruritus, and rash, and adverse
are slightly elevated, but the glucose level re- effects of other drugs to prevent complica-
mains normal. tions. Check the infusion site often to avoid in-
• EEG reveals abnormalities such as general- filtration and phlebitis.
ized slowing of waveforms. • Carefully position the patient to prevent joint
• CT scan may be ordered to rule out cere- stiffness and neck pain, and turn him often to
bral hematoma. prevent skin breakdown.
• Assist with range-of-motion (ROM) exer-
NURSING DIAGNOSES cises to maintain joint mobility.
• Disturbed thought processes • Maintain adequate nutrition to keep up with
• Hyperthermia increased metabolic needs and promote
• Impaired physical mobility healing. It may be necessary to give the pa-
tient small, frequent meals or to supplement
TREATMENT these meals with NG tube or parenteral feed-
• ET intubation and mechanical ventilation ings to meet nutritional needs.
• I.V. fluids • Give a stool softener or mild laxative to pre-
• NG tube feedings or TPN (if unable to use vent constipation and minimize the risk of in-
the GI tract) creased ICP from straining during defecation.
• Provide good mouth care to prevent break-
Drug therapy down of oral mucous membrane.
• Anticonvulsants: phenytoin (Dilantin), phe- • Maintain a quiet environment to promote Infuse I.V. acyclovir
over 1 hour to avoid
nobarbital (Luminal) comfort and decrease stimulation that can
damaging me.
• Antiviral: acyclovir (Zovirax) (effective only cause ICP to rise. Darkening the room may de-
against herpes encephalitis and only if admin- crease photophobia and headache.
istered before the onset of coma) • If the patient naps during the day and is
• Analgesics and antipyretics: aspirin, aceta- restless at night, plan daytime activities to
minophen (Tylenol) to relieve headache and minimize napping and promote sleep at night.
reduce fever • Provide emotional support and reassurance
• Diuretics: furosemide (Lasix), mannitol because the patient is apt to be frightened by the
(Osmitrol) to reduce cerebral swelling illness and frequent diagnostic tests.
• Corticosteroid: dexamethasone (Decadron) • Reassure the patient and his family that be-
to reduce cerebral inflammation and edema havioral changes caused by encephalitis usu-
• Laxative: bisacodyl (Dulcolax) ally disappear, to decrease anxiety.
• Sedative: lorazepam (Ativan) for restless- • Apply antiembolism stockings and a se-
ness quential compression device to prevent throm-
• Stool softener: docusate (Colace) boembolism.
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• Understanding the disease and its effects • Gonioscopy reveals whether angle is open
• Understanding treatment and rehabilitation or closed.
options • Ophthalmoscopy shows atrophy and cup-
ping of optic nerve head.
• Perimetry shows decreased field of vision.
Glaucoma • Tonometry shows increased intraocular
pressure.
With glaucoma, the patient experiences visual
field loss due to damage to the optic nerve re- NURSING DIAGNOSES
sulting from increased intraocular pressure. • Anxiety
If left untreated, glaucoma can lead to blind- • Risk for injury
ness. • Disturbed sensory perception (visual)
Glaucoma is either open-angle or angle-
closure. With open-angle glaucoma, increased TREATMENT
intraocular pressure is caused by overproduc- Chronic open-angle glaucoma
tion or obstructed outflow of aqueous humor • Drug therapy (treatment of choice). If this
(a fluid in the front of the eye). With angle- fails, argon laser trabeculoplasty (argon laser
closure glaucoma, an obstructed outflow of beam is focused on the trabecular meshwork
aqueous humor is due to anatomically narrow of an open angle, producing a thermal burn
angles. This ocular emergency requires im- that changes the meshwork surface and in-
Angle-closure
glaucoma is an mediate treatment to lower intraocular pres- creases aqueous humor outflow) or trabecu-
emergency, requiring sure. If drugs don’t lower intraocular pressure lectomy.
immediate treatment. sufficiently, surgery follows.
If drugs don’t lower Acute angle-closure glaucoma
intraocular pressure CAUSES • Laser iridectomy or surgical iridectomy, if
sufficiently, surgery • Diabetes mellitus intraocular pressure doesn’t decrease with
follows. • Family history of glaucoma drug therapy
• Long-term steroid treatment
• Previous eye trauma or surgery Drug therapy
• Race (blacks have higher incidence) Chronic open-angle glaucoma
• Uveitis • Alpha-adrenergic agonist: brimonidine
(Alphagan)
DATA COLLECTION FINDINGS • Beta-adrenergic antagonist: timolol
Chronic open-angle glaucoma (Timoptic)
• Initially asymptomatic Acute angle-closure glaucoma
• Signs and symptoms of increased intraocu- • Cholinergic: pilocarpine(Pilopine HS)
lar pressure
• Narrowed field of vision INTERVENTIONS AND RATIONALES
• Monitor eye pain, and administer medica-
Acute angle-closure glaucoma tion as prescribed. Medication reduces pain
• Acute ocular pain and may control disease process.
• Blurred vision • Provide a safe environment. Orienting the
• Dilated pupil patient to surroundings reduces the risk of
• Halo vision injury.
• Signs and symptoms of increased intraocu- • Modify the environment to meet patient’s
lar pressure self-care needs.
• Nausea and vomiting • For an acute episode, limit activities that
raise intraocular pressure. Avoiding activities
that increase intraocular pressure helps reduce
complications.
920106.qxd 8/7/08 2:59 PM Page 195
• Encourage the patient to express feelings which affect shoulder movement and head ro-
Time is on my side.
about changes in body image to aid accep- tation (a less common finding) The nerve damage of
tance of visual loss. Guillain-Barré is
DIAGNOSTIC FINDINGS usually temporary.
Teaching topics • A history of preceding febrile illness (usual-
• Meticulous compliance with prescribed ly a respiratory tract infection) and typical
drug therapy to prevent an increase in in- clinical features suggest Guillain-Barré syn-
traocular pressure drome.
• Monitoring eye for discharge, watering, • CSF protein level begins to rise, peaking in
blurred or cloudy vision, halos, flashes of 4 to 6 weeks. The WBC count in CSF remains
light, and floaters normal, but in severe disease, CSF pressure
may rise.
• Blood studies reveal a complete blood count
Guillain-Barré syndrome that shows leukocytosis with the presence of
immature forms early in the illness, but blood
Guillain-Barré syndrome is an acute, rapidly study results soon return to normal.
progressive, and potentially fatal form of • EMG may show repeated firing of the same
polyneuritis (inflammation of several periph- motor unit, instead of widespread sectional
eral nerves at once) that causes muscle weak- stimulation.
ness and mild distal sensory loss. • Nerve conduction velocities are slowed
Recovery is spontaneous and complete in soon after paralysis develops. Diagnosis must
about 95% of patients, although mild motor or rule out similar diseases such as acute po-
reflex deficits in the feet and legs may persist. liomyelitis.
The prognosis is best when symptoms clear
between 15 and 20 days after onset. NURSING DIAGNOSES
This disorder is also known as infectious • Impaired physical mobility
polyneuritis, Landry-Guillain-Barré syn- • Ineffective breathing pattern
drome, and acute idiopathic polyneuritis. • Risk for injury
CAUSES AND CONTRIBUTING FACTORS TREATMENT

• Autoimmune attack on peripheral nerves in • ET intubation or tracheotomy, if the patient
response to a viral infection or live vaccine has difficulty clearing secretions; possible me-
• Demyelination of the peripheral nerves chanical ventilation
• NG tube feedings or parenteral nutrition (if
DATA COLLECTION FINDINGS unable to use the GI tract)
• Dysphagia (difficulty swallowing) or • I.V. fluid therapy
dysarthria (poor speech caused by impaired • Specialty bed or support surfaces
muscular control) • Plasmapheresis
• Facial diplegia (paralysis affecting like parts • Physical therapy
on both sides of the face; possibly accompa-
nied by ophthalmoplegia [ocular paralysis]) Drug therapy
• Hypertonia (excessive muscle tone) and • Corticosteroid: prednisone (Deltasone)
areflexia (absence of reflexes) • Immunoglobulin therapy
• Symmetrical muscle weakness (ascending • Anticoagulants: heparin, warfarin
from the legs to the arms) (Coumadin)
• Paresthesia
• Stiffness and pain in the form of a severe INTERVENTIONS AND RATIONALES
“charley horse” • Watch for ascending sensory loss, which
• Weakness of the muscles supplied by cra- precedes motor loss. Also, monitor vital signs
nial nerve XI, the spinal accessory nerve, and LOC to detect disease progression.
920106.qxd 8/7/08 2:59 PM Page 196
• Monitor and treat respiratory dysfunction to sure and pulse rate during tilting periods to
Potential
complications of prevent respiratory arrest. detect postural hypotension.
Guillain-Barré • Auscultate for breath sounds to detect early • Inspect the patient’s legs regularly for signs
syndrome include changes in respiratory function, and encourage of thrombophlebitis. Thrombophlebitis is a
respiratory failure, coughing and deep breathing to mobilize se- common complication of Guillain-Barré syn-
aspiration cretions and prevent atelectasis. drome.
pneumonia, sepsis, • Maintain respiratory support, if necessary. • Apply antiembolism stockings and sequen-
joint contractures, • Give meticulous skin care to prevent skin tial compression devices, and give prophylac-
and deep vein breakdown and contractures. tic anticoagulants, as needed, to prevent
thrombosis. • Establish a strict turning schedule; inspect thrombophlebitis.
the skin (especially the sacrum, heels, and an- • If the patient has facial paralysis, give eye
kles) for breakdown, and reposition the pa- and mouth care every 4 hours to prevent
tient every 2 hours. These measures prevent corneal damage and breakdown of oral
skin breakdown and pressure ulcer develop- mucosa.
ment. • Protect the corneas with isotonic eyedrops
• After each position change, stimulate circu- and eye shields to prevent corneal injury.
lation by carefully massaging pressure points. • Encourage adequate fluid intake (2,000 ml/
Also, use foam, gel, or alternating-pressure day), unless contraindicated, to prevent dehy-
pads at points of contact to prevent skin break- dration, constipation, and renal calculi for-
down. mation.
• Perform passive ROM exercises within the • Measure and record intake and output
patient’s pain limits. Remember that the proxi- every 8 hours and offer the bedpan every 3 or
mal muscle groups of the thighs, shoulders, 4 hours to monitor for urine retention.
and trunk will be the most tender and cause • Begin intermittent catheterization, as need-
the most pain on passive movement and turned, to relieve urine retention. The patient may
ing. Passive ROM exercises maintain joint need manual pressure on the bladder
function. (Credé’s maneuver) before he can urinate be-
• When the patient’s condition stabilizes, cause the abdominal muscles are weak. (See
change to gentle stretching and active assis- Performing Credé’s maneuver.)
tance exercises to strengthen muscles and • Offer prune juice and a high-fiber diet to
maintain joint function. prevent and relieve constipation. If necessary,
• Evaluate the patient for signs of dysphagia, give daily or alternate-day suppositories (glyc-
such as coughing, choking, “wet”-sounding erin or bisacodyl) or Fleet enemas to relieve
voice, rhonchi after feeding, drooling, delayed constipation.
swallowing, and regurgitation of food. These • Refer the patient for physical therapy, oc-
measures help prevent aspiration. cupational therapy, and speech therapy, as
• Elevate the head of the bed, position the pa- needed.
tient upright and leaning forward when eat-
ing, provide semisolid food, and check the Teaching topics
mouth for food pockets to minimize the risk of • Transferring from bed to wheelchair and
aspiration. from wheelchair to toilet or tub and how to
• Encourage the patient to eat slowly and re- walk short distances with a walker or cane
main upright for 15 to 20 minutes after eating • Caregiving strategies for the family, such as
to prevent aspiration. how to help the patient eat, compensate for fa-
• If aspiration can’t be minimized by diet and cial weakness, and help avoid skin breakdown
position modification, expect to provide NG as well as the need for a regular bowel and
feeding to prevent aspiration and ensure that bladder routine
nutritional needs are met.
• As the patient regains strength and can tol-
erate a vertical position, monitor blood pres-
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Stepping up
Performing Credé’s maneuver

WHY YOU DO IT tion of residual urine. Credé’s
When lower motor neuron maneuver can’t be performed
damage impairs the voiding re- after abdominal surgery if the
flex, the bladder may become incision isn’t completely
flaccid or areflexic. Because healed.
the bladder fails to contract
HOW YOU DO IT
properly, urine collects inside
• Explain the procedure to the
it, causing distention. Credé’s
patient.
maneuver—application of
• Wash your hands.
manual pressure over the low-
• If the patient’s condition per-
er abdomen—promotes com-
mits, assist her onto the bed-
plete emptying of the bladder.
side commode. If not, place
Even when performed proper-
the patient in Fowler’s position
ly, however, Credé’s maneuver
and position the bedpan or ward to compress the bladder
isn’t always successful and
urinal. and to expel residual urine.
doesn’t always eliminate the
• Place your hands flat on the • Some facilities require a
need for catheterization.
patient’s abdomen just below doctor’s order for performing
After appropriate instruction,
the umbilicus. (Ask the female Credé’s maneuver. This proce-
the patient can perform the
patient to bend forward from dure shouldn’t be performed
maneuver, unless she can’t
the hips.) Firmly stroke down- on patients with normal blad-
reach her lower abdomen or
ward toward the bladder about der tone or bladder spasms.
lacks sufficient strength and
six times to stimulate the void- • Record the date and time of
dexterity. When a patient per-
ing reflex. the procedure, the amount of
forms Credé’s maneuver, close
• Place one hand on top of the urine expelled, and the
monitoring of urine output is
other above the pubic arch. patient’s tolerance of the
necessary to help detect pos-
Press firmly inward and down- procedure.
sible infection from accumula-
Huntington’s disease chorea, hereditary chorea, chronic progres-

sive chorea, and adult chorea.
Huntington’s disease is a hereditary disease
in which degeneration in the cerebral cortex CAUSES
and basal ganglia causes chronic progressive • Genetic transmission: autosomal dominant
chorea (involuntary and irregular move- trait. (Either sex can transmit and inherit the
ments) and cognitive deterioration, ending in disease.) Each child of a parent with this dis-
dementia. ease has a 50% chance of inheriting it; howev-
Huntington’s disease usually strikes people er, a child who doesn’t inherit it can’t pass it
between ages 25 and 55 (the average age is on to his own children.
35). Death usually results 10 to 15 years after
onset from suicide, heart failure, or pneumo- DATA COLLECTION FINDINGS
nia. The disorder is also called Huntington’s • Choreic movements; rapid, often violent
and purposeless; become progressively se-
920106.qxd 8/7/08 2:59 PM Page 198
vere; may include mild fidgeting, tongue • Assist in designing a behavioral plan that
smacking, dysarthria (indistinct speech), deals with the disruptive and aggressive be-
athetoid movements (slow, sinuous, writhing havior and impulse control problems. Rein-
movements, especially of the hands), and tor- force positive behaviors, and maintain consis-
ticollis (twisting of the neck) tency with all caregiving. These interventions
• Dementia (can be mild at first but eventual- consistently limit the patient’s negative be-
ly disrupts the patient’s personality) haviors.
Slow down. Allow
• Gradual loss of musculoskeletal control, • Offer emotional support to the patient and
the patient with
Huntington’s disease eventually leading to total dependence his family to relieve anxiety and enhance cop-
extra time to express • Personality changes, such as obstinacy, ing. Keep in mind the patient’s dysarthria, and
himself. carelessness, untidiness, moodiness, apathy, allow him extra time to express himself, there-
loss of memory and, possibly, paranoia (in lat- by decreasing frustration.
er stages of dementia) • Stay alert for possible suicide attempts.
Control the patient’s environment to protect
DIAGNOSTIC FINDINGS him from suicide or other self-inflicted injury.
• PET scan detects the disease. The patient may be unable to cope with the dev-
• Deoxyribonucleic acid analysis detects the astating nature of the disease.
disease. • Pad the side rails of the bed but avoid re-
• CT scan reveals brain atrophy. straints, which may cause the patient to injure
• MRI demonstrates brain atrophy. himself with violent, uncontrolled movements.
• Molecular genetics may detect the gene for • If the patient has difficulty walking, provide
Huntington’s disease in people at risk while a walker to help him maintain his balance.
they’re still asymptomatic. • Refer the patient and his family to appropri-
ate community organizations, which may pro-
NURSING DIAGNOSES vide information and support.
• Impaired physical mobility • Apply antiembolism stockings and a se-
• Ineffective health maintenance quential compression device while the patient
• Risk for injury is on bedrest to prevent thromboembolism.

• Because Huntington’s disease has no • Understanding the disease process
known cure, treatment is supportive, protec- • Encouraging family participation in the pa-
tive, and aimed at relieving symptoms. tient’s care
• Knowing the importance of genetic counsel-
Drug therapy ing (each child of a parent with this disease
• Antipsychotics: chlorpromazine (Tho- has a 50% chance of inheriting it)
razine), haloperidol (Haldol) to help control • Contacting the Huntington’s Disease Asso-
choreic movements ciation
• Antidepressant: imipramine (Tofranil) to al-
leviate depression
Ménière’s disease
• Provide physical support by attending to Ménière’s disease is a dysfunction in the
the patient’s basic needs, such as hygiene, labyrinth (the part of the ear that produces
skin care, bowel and bladder care, and nutri- balance) that produces severe vertigo, sen-
tion. Increase this support as mental and sorineural hearing loss, and tinnitus. It usual-
physical deterioration makes him increasingly ly affects adults, men slightly more often than
immobile. These measures help prevent compli- women, between the ages of 30 and 60. After
cations of immobility. multiple attacks over several years, this disor-
der leads to residual tinnitus and hearing loss.
920106.qxd 8/7/08 2:59 PM Page 199
This disorder may also be called endolym- sue in the ear) when conservative measures
phatic hydrops. fail
CAUSES Drug therapy

• Autonomic nervous system dysfunction that • Anticholinergic: atropine (may stop an at-
produces a temporary constriction of blood tack in 20 to 30 minutes)
vessels supplying the inner ear • Diuretic: furosemide (Lasix)
• Overproduction or decreased absorption of • Antihistamines: diphenhydramine (Bena-
endolymph, which causes endolymphatic hy- dryl) (may be necessary in a severe attack),
drops or endolymphatic hypertension, with meclizine (Antivert), dimenhydrinate (Dra-
consequent degeneration of the vestibular mamine) (for milder attacks; may also be ad-
and cochlear hair cells ministered as part of prophylactic therapy)
• Antiemetics: dolasetron (Anzemet), tri-
DATA COLLECTION FINDINGS methobenzamide (Tigan), metoclopramide
• Sensorineural hearing loss (Reglan)
• Severe vertigo
• Tinnitus INTERVENTIONS AND RATIONALES
• Feeling of fullness or blockage in the ear • Advise the patient against reading and expo-
• Severe nausea sure to glaring lights during an attack to re-
• Vomiting duce dizziness.
• Sweating • Stress safety measures. Tell the patient not
• Giddiness to get out of bed or walk during an attack
• Nystagmus without assistance to prevent injury.
• Instruct the patient to avoid sudden position
DIAGNOSTIC FINDINGS changes and tasks that vertigo makes haz-
• Electronystagmography, electrocochleogra- ardous because an attack can begin quite
phy, a CT scan, MRI, and X-rays of the inter- rapidly.
nal meatus may be necessary for differential
diagnosis. Before surgery
• Audiometric studies indicate a sensorineu- • If the patient is vomiting, record fluid intake With Ménière’s
ral hearing loss and loss of discrimination and and output and characteristics of the vomitus disease, an increase in
recruitment. to prevent dehydration. Administer an anti- the amount of fluid in
emetic as necessary and give small amounts the labyrinth
NURSING DIAGNOSES of fluid frequently to prevent vomiting. increases pressure in
the inner ear,
disrupting the sense
• Risk for injury After surgery of balance.
• Disturbed sensory perception (auditory) • Record intake and output carefully to moni-
tor fluid status and direct the treat-
TREATMENT ment plan.
• Restriction of sodium intake to less than • Tell the patient to expect dizzi-
2 g/day ness and nausea for 1 or 2 days
• Vestibular rehabilitation therapy after surgery to relieve
• Surgery to destroy the affected labyrinth anxiety.
(only if medical treatment fails; destruction of
the labyrinth permanently relieves symptoms Teaching topics
but at the expense of irreversible hearing • Knowing disease process and
loss) treatment options
• Chemical labyrinthectomy (injection of an • Performing measures to com-
aminoglycoside antibiotic, such as gentam- bat dizziness, such as rising slow-
icin, into the ear to destroy the vestibular tis- ly from a sitting or lying position
920106.qxd 8/7/08 2:59 PM Page 200
Meningitis • Positive Kernig’s sign (pain or resistance

when the patient’s leg is flexed at the hip or
With meningitis, the brain and the spinal cord knee while he’s in a supine position)
meninges become inflamed, usually as a re- • Seizures
Blame it on sult of bacterial infection. Such inflammation • Signs and symptoms of increased ICP
bacteria. In meningitis, may involve all three meningeal membranes: • Stiff neck and back
the brain and the the dura mater, arachnoid, and pia mater. • Twitching
spinal cord meninges
The prognosis is good and complications • Visual alterations such as diplopia (two im-
become inflamed,
usually as a result of are rare, especially if the disease is recog- ages of a single object)
bacterial infection. nized early and the infecting organism re- • Vomiting
sponds to antibiotics. The prognosis is poorer
for neonates and elderly people. Mortality is DIAGNOSTIC FINDINGS
high in untreated meningitis. • An LP shows elevated CSF pressure, cloudy
or milky white CSF, high protein level, posi-
CAUSES tive Gram stain and culture that usually identi-
• Bacterial infection (may occur secondary to fies the infecting organism (unless it’s a
bacteremia [especially from pneumonia, virus), and depressed CSF glucose concentra-
empyema, osteomyelitis, and endocarditis], tion.
sinusitis, otitis media, encephalitis, myelitis, • Chest X-ray may reveal pneumonitis or lung
or brain abscess) abscess, tubercular lesions, or granulomas
• Head trauma (may follow a skull fracture, a secondary to fungal infection.
penetrating head wound, LP, or ventricular • Sinus and skull X-rays may help identify the
shunting procedure) presence of cranial osteomyelitis, paranasal si-
• Virus (usually mild and self-limiting) nusitis, or skull fracture.
• Fungal or protozoal infection (less • WBC count reveals leukocytosis.
common) • CT scan can rule out cerebral hematoma,
hemorrhage, or tumor.
• Chills NURSING DIAGNOSES
• Coma • Hyperthermia
• Confusion • Risk for injury
• Deep stupor • Decreased intracranial adaptive capacity
• Delirium
• Exaggerated deep tendon reflexes TREATMENT
• Fever • Bed rest
• Headache • Hypothermia
• Irritability • I.V. fluid administration
• Malaise • Oxygen therapy, possibly with ET intuba-
• Opisthotonos (a spasm in which the back tion and mechanical ventilation
and extremities arch backward so that the
body rests on the head and heels) Drug therapy
• Petechial, purpuric, or ecchymotic rash on • Antibiotics: penicillin G (Pfizerpen), ampi-
the lower part of the body (meningococcal cillin (Omnipen), or nafcillin; tetracycline
meningitis) (Achromycin V) or chloramphenicol
• Photophobia (Chloromycetin), if allergic to penicillin
• Positive Brudzinski’s sign, in which the pa- • Diuretic: mannitol (Osmitrol)
tient flexes his hips or knees when the nurse • Anticonvulsants: phenytoin (Dilantin), phe-
places her hands behind his neck and flexes it nobarbital (Luminal)
forward (a sign of meningeal inflammation • Analgesics or antipyretics: acetaminophen
and irritation) (Tylenol), aspirin
• Laxative: bisacodyl (Dulcolax)
• Stool softener: docusate (Colace)
920106.qxd 8/7/08 2:59 PM Page 201
INTERVENTIONS AND RATIONALES • Darken the room to decrease photophobia.

• Monitor neurologic function often to detect • Relieve headache with a nonopioid anal-
early signs of increased intracranial pressure gesic, such as aspirin or acetaminophen, as Shhh. Auditory
(ICP) and ensure prompt treatment. needed. Opioids interfere with accurate neuro- stimuli can increase
• Watch for deterioration in the patient’s con- logic assessment. ICP. Plus, as you can
dition, which may signal an impending crisis. • Provide reassurance and support. The pa- see, I’m studying.
• Monitor fluid balance. Maintain adequate tient may be frightened by his illness and fre-
fluid intake to avoid dehydration without caus- quent LPs. These measures decrease anxiety;
ing fluid overload, which may lead to cerebral emotional upsets may increase ICP.
edema. • Reassure the family that the delirium and
• Suction the patient only if necessary. Limit behavior changes caused by meningitis usual-
suctioning to 10 to 15 seconds per pass of the ly disappear. Doing so allays anxiety.
catheter. Suctioning stimulates coughing and • Follow strict aseptic technique when treat-
Valsalva’s maneuver; Valsalva’s maneuvers in- ing patients with head wounds or skull frac-
crease intrathoracic pressure, decrease cerebral tures to prevent meningitis.
venous drainage, and increase cerebral blood
volume, resulting in increased ICP. Teaching topics
• Hyperoxygenate the lungs with 100% oxy- • Preventing meningitis (for example, teach-
gen for 1 minute before and after suctioning. ing patients with chronic sinusitis or other
Hypercapnia results in cerebral vasodilation, chronic infections the importance of proper
increased blood volume, and increased ICP. medical treatment)
Preoxygenation helps avoid hypoxemia and tis- • Recognizing signs of meningitis
sue ischemia. • Identifying contagion risks; notifying
• Watch for adverse reactions to I.V. antibi- anyone who came in close contact with the
otics and other drugs to prevent complications patient
such as anaphylaxis.
• Position the patient carefully to prevent joint
stiffness and neck pain. Multiple sclerosis
• Turn the patient often, according to a
planned positioning schedule, to prevent skin Multiple sclerosis (MS) is a progressive dis-
breakdown. ease that destroys myelin in the neurons of
• Apply antiembolism stockings and a se- the brain and spinal cord. Degeneration of the
quential compression device to prevent throm- myelin sheath results in patches of sclerotic
boembolism. tissue that impair the ability of the nervous
• Assist with ROM exercises to prevent con- system to conduct motor nerve impulses.
tractures.
• Provide small, frequent meals or supple- CAUSES
ment meals with NG tube or parenteral feed- • Exact cause unknown
ings, as necessary, to maintain adequate nu- Possible causes
trition and elimination. • Autoimmune response
• Give the patient a mild laxative or stool soft- • Environmental or genetic factors
ener to prevent constipation and minimize the • Slow-acting or latent viral infection
risk of increased ICP resulting from straining
during defecation. DATA COLLECTION FINDINGS
• Ensure the patient’s comfort to prevent in- • Ataxia (incoordination and irregularity of
creased ICP. voluntary, purposeful movements)
• Provide mouth care regularly to prevent • Feelings of euphoria
breakdown of oral mucosa and promote patient • Heat intolerance
comfort. • Inability to sense or gauge body position
• Maintain a quiet environment. Auditory • Intention tremor
stimuli can increase ICP.
920106.qxd 8/7/08 2:59 PM Page 202
• Nystagmus, diplopia, blurred vision, optic • Encourage fluids to decrease risk of urinary
neuritis tract infection.
• Scanning speech • Administer medications, as prescribed, to
Patients with
multiple sclerosis • Urinary incontinence or retention improve or maintain the patient’s condition
should increase their • Weakness, paresthesia, impaired sensation, and functional status.
fluid intake. paralysis • Encourage the patient to express feelings
about changes in body image to promote
DIAGNOSTIC FINDINGS acceptance of muscular impairment.
• CSF analysis shows increased immunoglob- • Provide active and passive ROM exercises
ulin G, protein, and WBCs, or it may be nor- to maintain mobility and prevent musculoskele-
mal. tal degeneration.
• CT scan eliminates other diagnoses such as • Establish a bowel and bladder program to
brain or spinal cord tumors. decrease risk of constipation and urinary reten-
• MRI may reveal plaques associated with tion.
multiple sclerosis. • Maintain activity, as tolerated (alternating
rest and activity), to improve muscle tone and
NURSING DIAGNOSES enhance self-esteem.
• Ineffective airway clearance • Protect the patient from falls to prevent
• Impaired physical mobility injury.
• Imbalanced nutrition: Less than body re- • Monitor patient’s neuromuscular status and
quirements voiding pattern to facilitate early interventions
for urinary retention.
TREATMENT
• High-calorie, high-vitamin, gluten-free, and Teaching topics
low-fat diet • Reducing stress
• Increased intake of fluids • Recognizing the signs and symptoms of ex-
• Physical therapy acerbation
• Plasmapheresis (for antibody removal) • Avoiding exposure to people with infections
• Speech therapy • Alternating rest and activity
• Maintaining a safe, quiet environment
Drug therapy • Using devices to assist with ADLs
• Analgesic: carbamazepine (Tegretol) • Maintaining a sense of independence
• Cholinergic: bethanechol (Urecholine) • Avoiding temperature extremes, especially
• Glucocorticoids: prednisone (Deltasone), heat
dexamethasone (Decadron), corticotropin • Contacting the National Multiple Sclerosis
(ACTH) Society
• Immunosuppressants: interferon beta-1b
(Betaseron), cyclophosphamide (Cytoxan),
methotrexate (Folex), glatiramer (Copaxone) Myasthenia gravis
• Skeletal muscle relaxants: dantrolene
(Dantrium), baclofen (Lioresal) Myasthenia gravis, a neuromuscular disorder,
is marked by weakness of voluntary muscles.
INTERVENTIONS AND RATIONALES The patient experiences sporadic, progressive
• Monitor for changes in motor coordination, weakness and abnormal fatigue of voluntary
paralysis, or muscle weakness to facilitate ear- skeletal muscles.
ly intervention. Myasthenia gravis is characterized by a dis-
• Evaluate respiratory status at least every 4 turbance in transmission of nerve impulses at
hours to detect early signs of compromise. neuromuscular junctions. This transmission
• Maintain the patient’s diet to decrease risk of defect results from a deficiency in release of
constipation. acetylcholine or a deficient number of acetyl-
choline receptor sites.
920106.qxd 8/7/08 2:59 PM Page 203
CAUSES • Evaluate swallow and gag reflexes to pre-

• Autoimmune disease vent aspiration and determine extent of neuro-
• Excessive cholinesterase logic deficit.
• Insufficient acetylcholine • Watch the patient for choking while eating
to prevent aspiration of food particles.
DATA COLLECTION FINDINGS • Monitor and record vital signs and intake
• Diplopia, ptosis, strabismus and output to prevent fluid overload or deficit
• Dysarthria and facilitate early intervention for deteriora-
• Dysphagia, drooling tion of respiratory status.
• Impaired speech • Administer medications, as prescribed, to
• Masklike expression relieve symptoms.
• Muscle weakness and fatigue (typically, • Maintain the patient’s diet; encourage small,
muscles are strongest in the morning but frequent meals to conserve energy and meet
weaken throughout the day, especially after nutritional needs.
exercise) • Encourage the patient to express feelings
• Profuse sweating about changes in body image and about diffi-
• Respiratory distress culty in communicating verbally to reduce the
patient’s tendency to suppress or repress feelings
DIAGNOSTIC FINDINGS about neuromuscular loss.
• EMG shows impaired impulse conduction • Determine the patient’s activity tolerance
in the muscles. and assist in ADLs to conserve energy and
• Neostigmine (Prostigmin) or edrophonium avoid fatigue.
(Tensilon) test relieves symptoms after med- • Provide rest periods to reduce the body’s oxy-
ication administration (which is a positive in- gen demands and prevent fatigue.
dication of the disease). • Provide oral hygiene to promote comfort and
• Thymus scan reveals hyperplasia or thy- enhance appetite.
moma. • Improve environmental safety to protect the
patient from falls.
NURSING DIAGNOSES • Apply antiembolism stockings and a se-
• Impaired gas exchange quential compression device when the patient
• Impaired physical mobility is on bed rest to prevent thromboembolism.
• Impaired verbal communication • Monitor for signs and symptoms of acute in-
fection to detect complications.
TREATMENT
• High-calorie diet with soft foods Teaching topics
• Plasmapheresis (in severe exacerbations) • Reducing stress
• Thymectomy • Recognizing the signs and symptoms of res-
piratory distress
Drug therapy • Recognizing the signs and symptoms of
• Anticholinesterase inhibitors: neostigmine myasthenic crisis
(Prostigmin), pyridostigmine (Mestinon) • Adhering to activity limitations
• Glucocorticoids: prednisone (Deltasone), • Contacting the Myasthenia Gravis Founda-
dexamethasone (Decadron), corticotropin tion of America
(ACTH)
• Immunosuppressants: azathioprine (Imu-
ran), cyclophosphamide (Cytoxan) Otosclerosis
INTERVENTIONS AND RATIONALES Otosclerosis is an overgrowth of the ear’s
• Monitor neurologic and respiratory status. spongy bone around the oval window and
Respiratory muscle weakness may be severe stapes footplate. This overgrowth curtails
enough in myasthenic crisis to require an emer- movement of the stapes in the oval window,
gency airway and mechanical ventilation. preventing sound from being transmitted to
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the cochlea and resulting in conductive hear- CAUSES

ing loss. • Exact cause unknown
Possible causes
CAUSES • Cerebral vascular disease
• Familial tendency • Dopamine deficiency
• Certain drugs
DATA COLLECTION FINDINGS • Imbalance of dopamine and acetylcholine in
• Progressive hearing loss basal ganglia
• Tinnitus • Repeated head trauma
• Unknown
DIAGNOSTIC FINDINGS
• Audiometric testing confirms hearing loss. DATA COLLECTION FINDINGS
• Difficulty in initiating voluntary activity
NURSING DIAGNOSES • Dysphagia, drooling
• Anxiety • Fatigue
• Impaired verbal communication • Masklike facial expression
• Disturbed sensory perception (auditory) • “Pill-rolling” tremors, tremors at rest
• Shuffling gait, stiff joints, dyskinesia, “cog-
TREATMENT wheel” rigidity, stooped posture
• Hearing aid • Small handwriting
• Stapedectomy and insertion of a prosthesis
to restore partial or total hearing DIAGNOSTIC FINDINGS
• CT scan is normal.
INTERVENTIONS AND RATIONALES • EEG reveals minimal slowing of brain
• Monitor vital signs and dressing postopera- activity.
tively to detect complications and bleeding.
• Develop alternative means of communica- NURSING DIAGNOSES
tion to decrease anxiety and communicate effec- • Activity intolerance
tively with the patient. • Impaired physical mobility
• Imbalanced nutrition: Less than body re-
Teaching topics quirements
• Using a hearing aid
• Avoiding loud noises and sudden pressure TREATMENT
changes until healing is complete • A high-residue, high-calorie, high-protein
Loud noises are • Avoiding (for at least 1 week) blowing the diet composed primarily of soft foods
bad for otosclerosis nose to prevent contaminated air and bacteria • Physical therapy
patients—and for from entering the eustachian tube • Stereotactic neurosurgery: thalamotomy or
NCLEX review. Find a • Protecting the ears against cold pallidotomy
quiet, calm place to • Avoiding activities that provoke dizziness
study.
• Changing external ear dressings Drug therapy
• Anticholinergic: trihexyphenidyl (Artane)
• Antidepressant: amitriptyline (Elavil)
Parkinson’s disease • Antiparkinsonian agents: levodopa (Laro-
dopa), carbidopa-levodopa (Sinemet), benz-
Parkinson’s disease is a progressive, degener- tropine (Cogentin)
ative disorder of the CNS associated with • Antispasmodic: procyclidine (Kemadrin)
dopamine deficiency. This lack of dopamine • Antiviral: amantadine (Symmetrel) (used
impairs the area of the brain responsible for early on to reduce tremors and rigidity)
control of voluntary movement. As a result, • Dopamine receptor agonists: pergolide
most symptoms relate to problems with pos- (Permax), bromocriptine (Parlodel)
ture and movement. • Enzyme inhibiting agent: selegiline
(Eldepryl)
920106.qxd 8/7/08 2:59 PM Page 205

• Monitor neurologic and respiratory status • Aging
to detect change in status and possible need for • Diabetic neovascularization
change in treatment. • Familial tendency
• Monitor and record vital signs and intake • Hemorrhage
and output to detect complications. • Inflammatory process
• Monitor the patient at mealtimes to decrease • Myopia
risk of aspiration. • Trauma
• Position the patient to prevent contractures • Tumor
and maintain skin integrity.
• Administer medications, as prescribed, to DATA COLLECTION FINDINGS
improve functioning. • Painless change in vision (floaters and
• Encourage the patient to express feelings flashes of light)
about changes in body image to reduce anxiety • Photopsia (recurrent flashes of light)
and depression. • With progression of detachment, painless
• Encourage daily ambulation to promote in- vision loss possibly described as a “veil,” “cur-
dependence. tain,” or “cobweb” that eliminates part of visu-
• Provide active and passive ROM exercises al field
to maintain mobility.
• Maintain the patient’s diet to meet nutrition- DIAGNOSTIC FINDINGS
al demands. • Indirect ophthalmoscopy shows retinal tear
• Provide skin care daily to maintain skin in- or detachment.
tegrity. • Slit-lamp examination shows retinal tear or
• Provide oral hygiene to promote self-care detachment.
and improve nutritional intake. • Ultrasound shows retinal tear or detach-
• Reinforce gait training to improve mobility. ment in presence of a cataract.
• Reinforce independence in care to maintain
self-esteem. NURSING DIAGNOSES
• Anxiety
Teaching topics • Risk for injury
• Recognizing early signs and symptoms of • Disturbed sensory perception (visual)
respiratory distress
• Alternating rest periods with activity TREATMENT
• Promoting a safe environment • Complete bed rest and restriction of eye Speaking of
• Preventing choking movement to prevent further detachment seeing, make sure
• Eating soft foods cut into small pieces • Cryopexy, if there’s a hole in the peripheral that you have good
• Increasing intake of fiber and fluids to pre- retina lighting. It’ll help you
study longer and
vent constipation • Laser therapy, if there’s a hole in the poste-
more comfortably.
rior portion of the retina
• Scleral buckling to reattach the retina
Retinal detachment
Retinal detachment is the separation of the • Evaluate visual status and functional vision
retina (a thin, semitransparent layer of nerve in the unaffected eye to determine self-care
tissue that lines the eye wall) from the needs.
choroid (the middle vascular coat of the eye • Postoperatively, instruct the patient to lie on
between the retina and the sclera). It occurs his back or on his unoperated side to reduce
when the retina develops a hole or tear and intraocular pressure on the affected side.
the vitreous humor seeps between the retina • Discourage straining during defecation,
and choroid. If left untreated, retinal detach- bending down, and hard coughing, sneezing,
ment can lead to vision loss.
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or vomiting to avoid activities that can in- DIAGNOSTIC FINDINGS

crease intraocular pressure. • CT scan shows spinal cord edema, vertebral
• Provide assistance with ADLs to minimize fracture, and spinal cord compression.
frustration and strain. • MRI shows spinal cord edema, vertebral
• Assist with ambulation, as needed, to help fracture, and spinal cord compression.
the patient remain independent. • Spinal X-rays reveal vertebral fracture.
• Approach the patient from the unaffected
side to avoid startling the patient. NURSING DIAGNOSES
• Orient the patient to his environment to re- • Impaired physical mobility
duce the risk of injury. • Posttrauma syndrome
• Powerlessness
Teaching topics
• Resting eyes frequently TREATMENT
• Keeping walkways free of clutter to prevent • Patient in flat position, with neck immobi-
falls lized in a cervical collar
• Maintenance of vertebral alignment
through Crutchfield tongs, Halo vest
Spinal cord injury • Specialized rotation bed
• Surgery for stabilization of the upper spine,
Spinal cord injuries usually result from trau- such as insertion of Harrington rods
matic force on the vertebral column, which, in
turn, injures the spinal cord. Necrosis and Drug therapy
scar tissue form in the area of the traumatized • Antianxiety agent: lorazepam (Ativan)
cord. Damage to the spinal cord results in • Glucocorticoid: methylprednisolone (Solu-
sensory and motor deficits. The patient may Medrol) infusion immediately following in-
experience partial or full loss of function of jury (may improve neurologic recovery when
any or all extremities and bodily functions. administered within 8 hours of injury)
• H2-receptor antagonists: cimetidine (Taga-
CAUSES met), ranitidine (Zantac), famotidine (Pepcid),
• Car accidents nizatidine (Axid)
• Congenital anomalies • Laxative: bisacodyl (Dulcolax)
• Diving into shallow water • Mucosal barrier fortifier: sucralfate
• Falls (Carafate)
• Gunshot wounds • Muscle relaxant: dantrolene (Dantrium)
• Infections
• Sports injury INTERVENTIONS AND RATIONALES
• Stab wounds • Monitor neurologic and respiratory status
• Tumors to determine baseline and to detect early com-
plications.
DATA COLLECTION FINDINGS • Observe for signs and symptoms of spinal
• Absence of reflexes below the level of the shock to detect early changes in the patient’s
injury condition.
• Flaccid muscles • Monitor and record vital signs, intake and
• Loss of bowel and bladder control output, laboratory studies, and pulse oxime-
• Neck pain try values to detect early changes in the pa-
• Numbness and tingling tient’s condition.
• Paralysis below the level of the injury • Check for autonomic dysreflexia (sudden
• Paresthesia below the level of the injury extreme rise in blood pressure) to prevent life-
• Respiratory distress threatening complications.
• Administer fluids to maintain hydration.
• Administer oxygen, as needed, to maintain
oxygenation to cells.
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• Provide suctioning, if necessary, and en- • Maintaining a sense of independence

courage coughing and deep breathing to • Contacting the National Spinal Cord Injury
maintain a patent airway. Association
maintain or improve the patient’s condition.
• Encourage the patient to express feelings Stroke
about changes in body image, sexual expres-
sion and function, and mobility to reduce anxi- A stroke, also known as a cerebrovascular ac-
ety and depression. cident, results from a sudden impairment of
• Turn the patient every 2 hours using the cerebral circulation in one or more of the
logrolling technique (only if the patient is sta- blood vessels supplying the brain. A stroke in-
bilized and not in a specialty bed) to prevent terrupts or diminishes oxygen supply and
pressure ulcers. commonly causes serious damage or necrosis
• Keep a tool available to open the Halo vest in brain tissues.
in case of cardiac arrest to maintain patient The sooner circulation returns to normal af-
safety. ter the stroke, the better the patient’s chances
• Maintain body alignment to maintain joint for a complete recovery. However, about half
function and prevent musculoskeletal degene- of those who survive a stroke remain perma-
ration. nently disabled and experience a recurrence
• Initiate bowel and bladder retraining to within weeks, months, or years.
avoid stimuli that could trigger autonomic
dysreflexia. CAUSES
• Provide passive ROM exercises to maintain • Arrhythmia
ROM and joint mobility. • Cerebral arteriosclerosis
• Provide skin care to avoid discomfort and • Embolism
loss of skin integrity, which can become a per- • Hemorrhage
manent impairment. Maintaining skin integri- • Hypertension
ty becomes a priority after the patient is stabi- • Thrombosis
lized. • Vasospasm
• Apply antiembolism stockings and a se-
quential compression device to maintain ve- DATA COLLECTION FINDINGS
nous circulation and prevent thromboem- Stroke symptoms depend on the artery
bolism. affected. (See Location, location, location, A stroke results
• Provide sexual counseling to encourage page 208.) from a sudden
questions and avoid misunderstandings about Symptoms are sudden and may include: impairment of cerebral
sexual activity. • garbled or impaired speech circulation in one or
• inability to move, or difficulty moving, limbs more of the blood
Teaching topics or one side of the body vessels supplying the
• Exercising regularly to strengthen muscles • vision disturbances brain. Not cool.
• Recognizing the signs and symptoms of au- • headache
tonomic dysreflexia, urinary tract infection, • mental impairment
and upper respiratory infection • seizures
• Continuing a bowel and bladder program • coma
• Maintaining acidic urine with cranberry • vomiting.
juice
• Consuming adequate fluids: 3,000 ml/day DIAGNOSTIC FINDINGS
• Using assistive devices with proper body • CT scan reveals intracranial bleeding, in-
mechanics for ADLs farct (shows up 24 hours after the initial
• Maintaining skin integrity symptoms), or shift of midline structures.
• Using a wheelchair and proper transfer • Digital subtraction angiography reveals
techniques, such as moving the strong part of occlusion or narrowing of vessels.
the patient’s body to the chair first
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Location, location, location

Clinical features of stroke vary with the artery affected (and, VERTEBROBASILAR ARTERY
consequently, the portion of the brain the artery supplies), the A stroke affecting this artery may lead to weakness on the af-
severity of damage, and the extent of collateral circulation that fected side, numbness around the lips and mouth, visual field
develops to help the brain compensate for decreased blood cuts, diplopia, poor coordination, dysphagia, slurred speech,
supply. dizziness, amnesia, and ataxia.
Typical arteries affected and their associated signs and symp-
ANTERIOR CEREBRAL ARTERY
toms are described here.
If this artery becomes affected, the patient may develop confu-
MIDDLE CEREBRAL ARTERY sion, weakness, and numbness (especially in the leg) on the af-
Injury to this artery causes aphasia, dysphagia, visual field cuts, fected side as well as incontinence, loss of coordination, im-
and hemiparesis on the affected side (more severe in the face paired motor and sensory functions, and personality changes.
and arm than in the leg).
POSTERIOR CEREBRAL ARTERIES
CAROTID ARTERY If these arteries are affected, the patient may develop visual
If the carotid artery is affected, the patient may develop weak- field cuts, sensory impairment, dyslexia, coma, and cortical
ness, paralysis, numbness, sensory changes, and visual distur- blindness. Usually, paralysis is absent.
bances on the affected side as well as altered level of con-
sciousness, bruits, headaches, aphasia, and ptosis.
• EEG shows focal slowing in area of lesion. • H2-receptor antagonists: cimetidine (Taga-
• MRI shows intracranial bleeding, infarct, or met), ranitidine (Zantac), famotidine (Pepcid),
shift of midline structures. nizatidine (Axid)
• Thrombolytic therapy: tissue plasminogen
NURSING DIAGNOSES activator given within the first 3 hours of an is-
• Ineffective tissue perfusion: Cerebral chemic stroke to restore circulation to the af-
• Risk for aspiration fected brain tissue and limit the extent of
• Risk for injury brain injury
• Antiplatelet aggregation agent: ticlodipine
Thrombolytic TREATMENT (Ticlid)
therapy can help limit
• Active and passive ROM and isometric exer-
the extent of brain
injury after an cises (see Performing passive ROM exercises) INTERVENTIONS AND RATIONALES
ischemic stroke. • Bed rest until blood pressure stabilizes • Take vital signs every 1 to 2 hours initially,
• Low-sodium diet then every 4 hours when the patient becomes
• Physical therapy stable, to detect early signs of decreased cere-
bral perfusion pressure or increased ICP.
Drug therapy • Elevate the head of the bed 30 degrees to fa-
• Analgesics: codeine sulfate or codeine phos- cilitate venous drainage and reduce cellular
phate (if nothing-by-mouth status) to reduce edema.
headache • Maintain the patient’s diet to promote nutri-
• Anticoagulants: heparin, warfarin tional status and healing.
(Coumadin) • Maintain I.V. fluids and monitor intake and
• Anticonvulsant: phenytoin (Dilantin) output to prevent volume overload or deficit.
• Diuretics: mannitol (Osmitrol), furosemide • Conduct a neurologic assessment every 1 to
(Lasix) 2 hours initially, then every 4 hours when the
• Glucocorticoid: dexamethasone (Decadron) patient becomes stable, to screen for changes
in LOC and neurologic status.
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Stepping up
Performing passive ROM exercises

WHY YOU DO IT forearm and flex it back. Abduct the arm • Spread two adjoining fingers apart (ab-
Passive range-of-motion (ROM) exercis- outward from the side of the body, and duction), and then bring them together
es improve or maintain joint mobility and adduct it back to the side. (adduction).
help prevent contractures. Performed by • Rotate the shoulder so that the arm • Oppose each fingertip to the thumb,
a nurse, a physical therapist, or a care- crosses the midline, and bend the elbow and rotate the thumb and each finger in
giver, these exercises are indicated for so that the hand touches the opposite a circle.
the patient with temporary or permanent shoulder and then touches the mattress Exercising the hip and knee
loss of mobility, sensation, or conscious- of the bed for complete internal rotation. • Fully extend the patient’s leg, and then
ness. Passive ROM exercises require • Return the shoulder to a neutral posi- bend the hip and knee toward the chest,
recognition of the patient’s limits of motion and, with elbow bent, push the arm allowing full joint flexion.
tion and support of all joints during backward so that the back of the hand • Next, move the straight leg sideways,
movement. touches the mattress for complete exter- out and away from the other leg (abduc-
nal rotation. tion), and then back, over, and across it
HOW YOU DO IT
• Determine the joints that need passive Exercising the elbow (adduction).
ROM exercises, and consult the doctor • Place the patient’s arm at his side with • Rotate the straight leg internally to-
or physical therapist about limitations or his palm facing up. ward the midline and then externally
precautions for specific exercises. • Flex and extend the arm at the elbow. away from the midline.
• Perform passive ROM at least once Exercising the forearm Exercising the ankle
each shift, possibly while bathing or • Stabilize the patient’s elbow; then twist • Bend the patient’s foot so that the toes
turning the patient or when the patient is the hand to bring the palm up (supina- push upward (dorsiflexion); then bend
in a convenient position. Repeat each tion). the foot so that the toes push downward
exercise at least three times. • Twist it back again to bring the palm (plantar flexion).
• Record which joints were exercised, down (pronation). • Rotate the ankle in a circular motion.
the presence of edema or pressure ar- Exercising the wrist • Invert the ankle so that the sole of the
eas, any pain resulting from the exercis- • Stabilize the forearm, and flex and ex- foot faces the midline, and evert the an-
es, any limitation of ROM, and the pa- tend the wrist. kle so that the sole faces away from the
tient’s tolerance of the exercises. • Rock the hand sideways for lateral midline.
Exercising the neck flexion, and rotate the hand in a circular Exercising the toes
• Support the patient’s head with your motion. • Flex the patient’s toes toward the sole,
hands and extend the neck, flex the chin Exercising the fingers and thumb and then extend them back toward the
to the chest, and tilt the head laterally to- • Extend the patient’s fingers, and then top of the foot.
ward each shoulder. flex the hand into a fist. • Spread two adjoining toes apart (ab-
• Rotate the head from right to left. • Repeat extension and flexion of each duction), and then bring them back to-
Exercising the shoulders joint of each finger and thumb gether (adduction).
• Support the patient’s arm in an extend- separately.
ed, neutral position; then extend the
• Take the patient’s temperature at least • Monitor hemoglobin and hematocrit and re-
every 4 hours. Hyperthermia causes increased port anomalies to prevent tissue ischemia.
ICP; hypothermia causes reduced cerebral per- • Evaluate respiratory status at least every 4
fusion pressure. hours for signs of aspiration or respiratory de-
pression.
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• Make sure that suction equipment is avail- • Initiating lifestyle changes

able and suction as needed to keep airway • Contacting the American Heart Association
clear. and the National Stroke Association
• Administer oxygen to promote cerebral tis-
sue oxygenation.
• Assist the patient with coughing and deep Trigeminal neuralgia
breathing to mobilize secretions.
• Maintain position, patency, and low suction Trigeminal neuralgia is a painful disorder of
of the NG tube. Delayed gastric emptying and one or more branches of the fifth cranial
elevated intragastric pressure may cause regur- (trigeminal) nerve that produces paroxysmal
gitation of stomach contents. attacks of excruciating facial pain. Attacks are
• Administer enteral nutrition or monitor precipitated by stimulation of a trigger zone, a
TPN, depending on the patient’s condition, to hypersensitive area of the face.
facilitate tissue healing and meet metabolic It occurs mostly in people over age 40, in
needs. women more often than men, and on the right
• Apply antiembolism stockings and a se- side of the face more often than the left. Tri-
quential compression device to promote ve- geminal neuralgia can subside spontaneously,
nous return and prevent thromboembolism for- with remissions lasting from several months
mation. to years. The disorder is also called tic
• Maintain seizure precautions and adminis- douloureux.
ter an anticonvulsant, as ordered. Seizures in-
crease intrathoracic pressure, decrease cerebral CAUSES
venous outflow, and increase cerebral blood vol- Although the cause remains undetermined,
ume, thereby increasing ICP. trigeminal neuralgia may:
• Provide passive ROM exercises to prevent • reflect an afferent reflex phenomenon locat-
venous thrombosis and contractures. ed centrally in the brain stem or more periph-
• Turn and position the patient every 2 hours erally in the sensory root of the trigeminal
to prevent pressure ulcers. nerve
• Provide means of communication to pro- • be related to compression of the nerve root
mote understanding and decrease anxiety. by posterior fossa tumors, middle fossa tu-
Who says I’m • Maintain routine bowel and bladder func- mors, or vascular lesions (subclinical aneu-
not sensitive? In tion and administer diuretics, as ordered, to rysm), although such lesions usually produce
trigeminal promote fluid mobilization. simultaneous loss of sensation
neuralgia, pain • Encourage the patient to express feelings • occasionally be a manifestation of multiple
may be triggered about changes in body image and about diffi- sclerosis or herpes zoster.
by touching a
culty in communicating verbally to promote re-
sensitive area on
the face or even by duced anxiety and expression of feelings. DATA COLLECTION FINDINGS
temperature • Maintain a quiet environment to prevent in- • Searing pain in the facial area
changes. creases in ICP.
• Protect the patient from falls and injury, and Triggers
provide a safe environment to reduce the risk • Light touch to a sensitive area of the face
of injury. (trigger zone)
• Exposure to hot or cold
Teaching topics • Eating, smiling, talking, or shaving
• Monitoring blood pressure • Drinking hot or cold beverages
• Recognizing signs and symptoms of stroke
• Minimizing environmental stress DIAGNOSTIC FINDINGS
• Communicating effectively (for an aphasic • Observation during the examination shows
patient) the patient favoring (splinting) the affected
• Using devices to assist in ADLs area. To ward off a painful attack, the patient
920106.qxd 8/7/08 2:59 PM Page 211
often holds his face immobile when talking. and vital signs often to detect early signs of
He may also leave the affected side of his face postoperative complications.
unwashed and unshaven. • Reinforce natural avoidance of stimulation Offer the patient
• Skull X-rays, tomography, and CT scan rule (air, heat, cold) of trigger zones (lips, cheeks, with trigeminal
out sinus or tooth infections and tumors. gums) to prevent further episodes. neuralgia small,
frequent meals at
NURSING DIAGNOSES Teaching topics room temperature.
• Acute pain • Knowing disease process and treatment Extremes of
• Powerlessness options temperature may
• Anxiety • Avoiding things that can trigger an attack, cause an attack.
such as temperature extremes
TREATMENT
• Percutaneous radiofrequency procedure,
which causes partial root destruction and re- West Nile encephalitis
lieves pain
• Microsurgery for vascular decompression West Nile encephalitis is an infectious disease
• Percutaneous electrocoagulation of nerve that primarily causes an inflammation of the
rootlets, under local anesthesia brain. The etiology stems from the West Nile
virus, a flavivirus commonly found in hu-
Drug therapy mans, birds, and other vertebrates in Africa,
• Anticonvulsants: carbamazepine (Tegretol), west Asia, and the Middle East. This disease
phenytoin (Dilantin) is part of a family of vector-borne diseases
• Muscle relaxant: baclofen (Lioresol) that also includes malaria, yellow fever, and
Lyme disease.
• Observe and record the characteristics of CAUSES
each attack, including the patient’s protective • Transferred to humans by the bite of a mos-
mechanisms, to gain information for develop- quito infected with the virus
ing the treatment plan.
• Provide adequate nutrition in small, fre- DATA COLLECTION FINDINGS
quent meals at room temperature to ensure Mild infections
that nutritional needs are met. Extremes of tem- • Fever
perature may cause an attack. • Headache
• Watch for adverse reactions to prescribed • Body aches
medication to detect complications. • Skin rash
• After resection of the first division of the • Swollen lymph glands
trigeminal nerve, tell the patient to avoid rub-
bing his eyes and using aerosol spray. Advise Severe infections
him to wear glasses or goggles outdoors and • Headache
to blink often to prevent injury. • High fever
• After surgery to sever the second or third • Neck stiffness
division, tell the patient to avoid hot foods and • Stupor
drinks, which could burn his mouth, and to • Disorientation
chew carefully to avoid biting his mouth. • Coma
• Advise the patient to place food in the unaf- • Tremors
fected side of his mouth when chewing, to • Seizures
brush his teeth often, and to see a dentist • Death
twice per year to detect cavities. Cavities in
the area of the severed nerve won’t cause pain. DIAGNOSTIC FINDINGS
• After surgical decompression of the root or • Patient history reveals recent mosquito
partial nerve dissection, check neurologic bites.
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• Enzyme-linked immunosorbent assay re-

veals West Nile virus.
NURSING DIAGNOSES
• Anxiety
• Hyperthermia
TREATMENT
• Symptom control, such as I.V. fluids and
respiratory support
Drug therapy
• Analgesics: codeine sulfate, ibuprofen
(Motrin)
Pump up on practice
• Antipyretic: acetaminophen (Tylenol)
• Corticosteroid: dexamethasone (Decadron)
questions
INTERVENTIONS AND RATIONALES 1. A nurse is caring for a client with a cere-
•Monitor respiratory status to detect respira- bral injury that impaired his speech and hear-
tory complications. ing. Most likely, the client has experienced
• Administer supplemental oxygen, as pre- damage to the:
scribed, to prevent hypoxemia. 1. frontal lobe.
• Monitor pulse oximetry values, to detect hy- 2. parietal lobe.
poxia. 3. occipital lobe.
• Monitor neurologic status to detect subtle 4. temporal lobe.
changes and ensure prompt treatment interven- Answer: 4. The portion of the cerebrum that
tion. controls speech and hearing is the temporal
• Administer medications, as prescribed, to lobe. Injury to the frontal lobe causes person-
alleviate symptoms. ality changes, difficulty speaking, and distur-
• Monitor and record vital signs to detect signs bances in memory, reasoning, and concentra-
of compromise. tion. Injury to the parietal lobe causes senso-
• Provide frequent oral hygiene to promote ry alterations and problems with spatial
comfort. relationships. Damage to the occipital lobe
• Monitor and record intake and output to causes vision disturbances.
prevent dehydration. Client needs category: Physiological
integrity
Teaching topics Client needs subcategory: Physio-
• Staying indoors at dawn and dusk and in the logical adaptation
early evening Cognitive level: Comprehension
• Wearing long-sleeved shirts and long pants
whenever the patient is outdoors 2. Stimulation of the autonomic nervous sys-
• Applying insect repellent sparingly when tem that produces a parasympathetic re-
going outdoors sponse would most likely cause:
1. increased heart rate.
2. increased metabolism.
3. increased gastric motility.
4. increased systemic vascular resistance.
920106.qxd 8/7/08 2:59 PM Page 213
Answer: 3. A parasympathetic response in- Client needs category: Physiological

creases gastric motility but decreases heart integrity
rate, metabolism, and systemic vascular resis- Client needs subcategory: Reduction of
tance. risk potential
Client needs category: Health pro- Cognitive level: Analysis
motion and maintenance
Client needs subcategory: None 5. In some clients with MS, plasmapheresis
Cognitive level: Comprehension diminishes symptoms. Plasmapheresis
achieves this effect by removing:
3. A client with a massive cerebral hemor- 1. catecholamines.
rhage and loss of consciousness is scheduled 2. antibodies.
for an EEG. A nurse is discussing the purpose 3. plasma proteins.
of the test with the family. It would be most 4. lymphocytes.
accurate for the nurse to tell family members Answer: 2. In plasmapheresis, antibodies are
that the test will measure: removed from the client’s plasma. Antibodies
1. extent of intracranial bleeding. attack the myelin sheath of the neuron, caus-
2. sites of brain injury. ing the manifestations of MS. Plasmapheresis
3. electrical activity of the brain. for MS isn’t intended to remove catechola-
4. percentage of functional brain tissue. mines, plasma proteins, or lymphocytes.
Answer: 3. An EEG measures the electrical ac- Client needs category: Physiological
tivity of the brain. The extent of intracranial integrity
bleeding and the injury site would be deter- Client needs subcategory: Physio-
mined by CT scan or MRI. Percent of func- logical adaptation
tional brain tissue would be determined by a Cognitive level: Comprehension
series of tests.
Client needs category: Physiological 6. A client undergoes a surgical clipping of a
integrity cerebral aneurysm. To prevent vasospasm,
Client needs subcategory: Physio- postsurgical care focuses on maintaining an
logical adaptation optimal cerebral perfusion pressure. This is
Cognitive level: Comprehension best accomplished by administering:
1. a diuretic such as furosemide (Lasix).
4. A nurse is teaching a client and his family 2. blood products such as cryoprecipitate.
about dietary practices related to Parkinson’s 3. a calcium channel blocker such as
disease. A priority for the nurse to address is nifedipine (Procardia).
risk of: 4. volume expanders such as crystalloids.
1. fluid overload and drooling. Answer: 4. To prevent vasospasm following
2. aspiration and anorexia. repair of a cerebral aneurysm, treatment fo-
3. choking and diarrhea. cuses on increasing cerebral perfusion. This
4. dysphagia and constipation. can be accomplished by giving volume ex-
Answer: 4. The problems associated with panders such as crystalloids. Diuretics would
Parkinson’s disease that affect eating include decrease cerebral perfusion by reducing vol-
dysphagia, aspiration, constipation, and risk ume. Cryoprecipitate isn’t used as a volume
of choking. Fluid overload, anorexia, and diar- expander. Nimodipine (Nimotop), not nifedi-
rhea aren’t problems specifically related to pine (Procardia), is the calcium channel
Parkinson’s disease. Drooling occurs with blocker indicated for use in cerebral vaso-
Parkinson’s disease but doesn’t take priority. spasm treatment and prevention.
920106.qxd 8/7/08 2:59 PM Page 214

integrity integrity
Client needs subcategory: Reduction of Client needs subcategory: Basic care
risk potential and comfort
Cognitive level: Application Cognitive level: Application
7. A client is diagnosed with a brain tumor. 9. A client who recently underwent cranial
Palliative care is all that can be offered to the surgery develops syndrome of inappropriate
client. In addressing the client and family, it antidiuretic hormone (SIADH). A nurse
would be most therapeutic for the nurse to should anticipate that the client will:
say: 1. experience edema and weight gain.
1. “I’m sorry. I wish there were more we 2. produce excessive amounts of urine.
could do.” 3. need vigorous fluid replacement
2. “Be optimistic. Others have survived therapy.
equally as grave situations.” 4. have a low urine specific gravity.
3. “I understand how this may be affecting Answer: 1. SIADH is an abnormally high re-
you, and I want to help.” lease of antidiuretic hormone causing water
4. “Be thankful you and your family have retention, which leads to edema and weight
each other for support during this time.” gain. Urine output is low, fluid is restricted
Answer: 3. Initially, the client and family may rather than replaced, and the urine specific
be in shock and disbelief. They need the gravity is high.
nurse’s understanding, support, and offer of Client needs category: Physiological
help. The other responses communicate pity, integrity
false hope, and detachment. Client needs subcategory: Reduction of
Client needs category: Psychosocial risk potential
integrity Cognitive level: Application
Client needs subcategory: None
Cognitive level: Application 10. A nurse is providing care for a client fol-
lowing right cataract removal surgery. In
8. A nurse is teaching a client with a T4 which position should the nurse place the
spinal cord injury and paralysis of the lower client?
extremities how to transfer from bed to a 1. Right side-lying
wheelchair independently. In transferring, it 2. Prone
is important for the client to move: 3. Supine
1. his upper and lower body simultaneous- 4. Trendelenburg’s
ly into the wheelchair. Answer: 3. Positioning the client on his back
2. his upper body to the wheelchair first. (supine) or unoperative side prevents pres-
3. his feet to the wheelchair pedals and sure on the operative eye. A right side-lying
then his hands to the wheelchair arms. or prone position may put external pressure
4. his feet to the floor and then his but- on the affected eye. Trendelenburg’s position
tocks to the wheelchair seat. may increase intraocular pressure.
Answer: 2. The proper technique in transfer- Client needs category: Physiological
ring from a bed to a wheelchair when there’s integrity
paralysis of the lower extremities is to move Client needs subcategory: Physio-
the strong part of the body to the chair first. logical adaptation
The client should move his upper body to the Cognitive level: Application
wheelchair first and then move his legs from
the bed to the wheelchair. Other techniques
are less safe and can endanger the client.
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7 Musculoskeletal
system
bones and encircle joints to add strength and
In this chapter,
you’ll review:
Brush up on key stability. Tendons connect muscles to bones.
✐ components of the concepts Where bones meet

A joint is the articulation of two bone sur-
musculoskeletal
system and their The musculoskeletal system has two main faces. Joints provide stabilization and permit
functions: to provide support and to produce locomotion. The degree of joint movement is
functions
movement. In addition, the musculoskeletal called range of motion (ROM).
system protects internal tissues and organs,
nose musculoskeletal produces red blood cells (RBCs) in the bone Friction reduction
disorders marrow, and stores mineral salts such as The synovium is the membrane that lines a
✐ common musculo- calcium. joint’s inner surfaces. In conjunction with car-
skeletal disorders. At any time, you can review the major points tilage, the synovium reduces friction in joints
of this chapter by consulting the Cheat sheet through its production of synovial fluid.
on pages 216 to 218.
Shock absorber
Mr. Bones Cartilage is a specialized tissue that serves
The skeleton consists of 206 bones, which as a smooth surface for articulating bones. It
work with the muscles to support and protect absorbs shock to joints and serves as padding
internal organs. to reduce friction. Cartilage atrophies with
The skeleton also stores calcium, magne- limited ROM or in the absence of weight-
sium, and phosphorus. The bone marrow is bearing bursae (small sacs of synovial fluid).
the soft material found in the center of bones
that’s responsible for RBC production.
Body movin’
The skeletal muscles, which are attached to
Keep abreast of
the bones by tendons, provide body move-
ment and posture by tightening and shorten-
diagnostic tests
ing. The muscles begin contracting when Here are some important tests used to diag-
stimulated by a motor neuron. They derive nose musculoskeletal disorders, along with
energy for contraction from hydrolysis of common nursing interventions associated
adenosine triphosphate to adenosine diphos- with each test.
phate and phosphate.
The skeletal muscles relax with the break- Muscle picture
down of acetylcholine by cholinesterase. Even Electromyography (EMG) uses electrodes
then, however, they retain some contraction to create a graphic recording of the muscle at
to maintain muscle tone. rest and during contraction.
Bones to bones and bones to Nursing actions

muscles • Explain that the patient will be asked to flex
Ligaments and tendons are tough bands of and relax his muscles during the procedure.
collagen fibers. Ligaments connect bones to (Text continues on page 219.)
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216 Musculoskeletal system
et
heat she
C
Musculoskeletal refresher
ARM AND LEG FRACTURES CARPAL TUNNEL SYNDROME
• Loss of limb function • Numbness, burning, or tingling in arms
• Pain • Pain in arms and hands
• Deformity • Weakness in arms and hands
Key test result Key test results
• Anteroposterior and lateral X-rays of the sus- • A blood pressure cuff on the forearm inflated
pected fracture as well as X-rays of the joints above systolic pressure for 1 to 2 minutes pro-
above and below it confirm the diagnosis. vokes pain and paresthesia along the distribution
Key treatments of the median nerve.
• Closed reduction (restoring displaced bone • Electromyography detects a median nerve mo-
segments to their normal position) tor conduction delay of more than 5 milliseconds.
• Immobilization with a splint, a cast, or traction Key treatments
• Open reduction during surgery to reduce and • Resting the hands by splinting the wrist in neu-
immobilize the fracture with rods, plates, or tral extension for 1 to 2 weeks
screws when closed reduction is impossible, • Possibly changing occupations (if a definite link
usually followed by application of a plaster cast has been established between the patient’s oc-
• Analgesics: morphine, acetaminophen cupation and the development of carpal tunnel
(Tylenol), oxycodone (Percocet), hydrocodone syndrome)
(Vicodin) • Corticosteroid injections: betamethasone (Cele-
Key interventions stone), hydrocortisone (Hydrocortone)
You can quickly • Nonsteroidal anti-inflammatory drugs
• Monitor vital signs and be especially alert for a
bone up on (NSAIDs): indomethacin (Indocin), ibuprofen
musculoskeletal rapid pulse, decreased blood pressure, pallor,
and cool, clammy skin. (Motrin), naproxen (Naprosyn)
system disorders
by studying this • Maintain I.V. fluids as ordered. Key interventions
Cheat sheet. • Ease pain with analgesics as ordered. • Administer NSAIDs as needed.
• Reposition the immobilized patient often. Assist • Assist with eating and bathing if the patient’s
with active range-of-motion (ROM) exercises to dominant hand has been impaired.
the unaffected extremities. Encourage deep • Monitor vital signs and regularly check the col-
breathing and coughing. or, sensation, and motion of the affected hand, if
• Make sure that the immobilized patient re- surgery is performed.
ceives adequate fluid intake. Watch for signs of
COMPARTMENT SYNDROME
renal calculi, such as flank pain, nausea, and
vomiting. Key signs and symptoms
• Provide cast care. • Severe or increased pain that occurs when the
• Encourage the patient to start moving around affected muscle is stretched or elevated and that
as soon as possible. Assist with walking. (Re- is unrelieved by opioid analgesics
member, the patient who has been bedridden for • Loss of distal pulse
some time may be dizzy at first.) Demonstrate • Tense, swollen muscle
how to use crutches properly. Key test result
• Intracompartment pressure is elevated, as indi-
cated by a blood pressure sphygmomanometer.
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Musculoskeletal refresher (continued)

COMPARTMENT SYNDROME (continued) In cervical area
Key treatments • Neck pain that radiates down the arm to the hand
• Fasciotomy • Neck stiffness
• Positioning the affected extremity lower than the heart • Weakness of the affected upper extremities
• Removal of dressings or constrictive coverings of the area • Weakness, numbness, and tingling of the hand
Key interventions Key test results
• Monitor the affected extremity, and perform frequent neu- • Myelogram shows compression of the spinal cord.
rovascular checks. • X-ray shows narrowing of disk space.
• Perform dressing changes after fasciotomy, and reinforce • Magnetic resonance imaging identifies the herniated disk.
dressings frequently. (Expect a large amount of bloody Key treatments
drainage.) • Corticosteroid: cortisone (Cortone)
• NSAIDs: indomethacin (Indocin), ibuprofen (Motrin), sulindac
GOUT
(Clinoril), piroxicam (Feldene), flurbiprofen (Ansaid), diclofenac
Key sign or symptom sodium (Voltaren), naproxen (Naprosyn), diflunisal (Dolobid)
• Inflamed, painful joints
Key interventions
Key test result • Monitor neurovascular status.
• Blood studies show a serum uric acid level that’s above nor- • Turn the patient every 2 hours using the logrolling technique.
mal. The urine uric acid level is usually higher in secondary gout
than in primary gout. HIP FRACTURE
• Antigout drugs: colchicine (Colgout), allopurinol (Zyloprim) • Shorter appearance and outward rotation of affected leg
• Uricosuric drugs: probenecid (Probalan), sulfinpyrazone resulting in limited or abnormal ROM
(Anturane) • Edema and discoloration of surrounding tissue
• Corticosteroids: betamethasone (Celestone), hydrocortisone Key test results
(Hydrocortone) • Computed tomography scan (for complicated fractures) pin-
• NSAIDs: ibuprofen (Motrin), naproxen (Naprosyn) points abnormalities.
Key interventions • X-ray reveals a break in the continuity of the bone.
• Encourage bed rest, and use a bed cradle to reduce discom- Key treatments
fort. • Surgical immobilization or joint replacement
• Give analgesics, as needed, especially during acute attacks. • Abductor splint or trochanter roll between legs to prevent loss
• Apply hot or cold packs to inflamed joints. of alignment (postoperatively)
• Administer anti-inflammatory medication and other drugs. • Anticoagulant: warfarin (Coumadin) (postoperatively)
• Urge the patient to drink plenty of fluids (up to 2 L/day). Key interventions
• When encouraging fluids, record intake and output accurately. • Monitor neurovascular and respiratory status. Most important,
• Alkalinize urine with sodium bicarbonate or another agent, as check for compromised circulation, hemorrhage, and neurologic
needed. impairment in the affected extremity and pneumonia in the bed-
• Make sure the patient understands the importance of having ridden patient.
serum uric acid levels checked periodically. • Provide active and passive ROM and isometric exercises for
HERNIATED NUCLEUS PULPOSUS unaffected limbs.
Key signs and symptoms • Provide a trapeze.
• Maintain traction before surgery at all times, if using conserva-
In lumbosacral area
tive treatment.
• Acute pain in the lower back that radiates across the buttock
and down the leg OSTEOARTHRITIS
• Pain on ambulation Key signs and symptoms
• Weakness, numbness, and tingling of the foot and leg • Crepitation (continued)
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Musculoskeletal refresher (continued)

OSTEOARTHRITIS (continued) Check the circled spot at least every 4 hours. Watch for any en-
• Joint stiffness largement.
• Pain relieved by resting the joints
OSTEOPOROSIS
Key test results
• Arthroscopy reveals bone spurs and narrowing of joint space.
• Deformity
• X-rays show joint deformity, narrowing of joint space, and
• Kyphosis
bone spurs.
• Pain
Key treatments
Key test result
• Exercise
• X-rays show typical degeneration in the lower thoracic and
• Application of warm, moist heat
lumbar vertebrae. The vertebral bodies may appear flattened
• NSAIDs: indomethacin (Indocin), ibuprofen (Motrin), naproxen
and may look denser than normal. Loss of bone mineral be-
(Naprosyn), diflunisal (Dolobid), celecoxib (Celebrex)
comes evident in later stages.
Key interventions
Key treatments
• Evaluate musculoskeletal status.
• Physical therapy consisting of weight-bearing exercise and
• Observe for increased bleeding or bruising tendency.
activity
OSTEOMYELITIS • Hormonal agents: conjugated estrogen (Premarin), calcitonin
Key signs and symptoms (Calcimar), teriparatide (Forteo)
• Pain • Vitamin D supplements
• Tenderness • Antiosteoporotics: alendronate (Fosamax), risedronate (Ac-
• Swelling tonel), raloxifene (Evista)
• Calcium supplements
Key test results
• Blood cultures identify the causative organism. Key interventions
• Erythrocyte sedimentation rate and C-reactive protein (CRP) • Check the patient’s skin daily for redness, warmth, and new
are elevated. (CRP appears to be a better diagnostic tool.) sites of pain. Encourage activity; help the patient walk several
times daily.
Key treatments
• Perform passive ROM exercises, or encourage the patient to
• Immobilization of the affected bone by plaster cast, traction, or
perform active exercises. Encourage regular attendance at
bed rest
physical therapy sessions.
• Antibiotics: large doses of I.V. antibiotics, usually a penicilli-
• Provide a balanced diet high in vitamin D, calcium, and protein.
nase-resistant penicillin, such as nafcillin and oxacillin (Bacto-
• Administer analgesics and apply heat.
cill), or a cephalosporin, such as cefazolin (Ancef), after blood
cultures are taken
Key interventions
• Use strict aseptic technique when changing dressings and irri-
gating wounds.
• Check vital signs and wound appearance daily, and monitor for
new pain.
• Check circulation and drainage. If a wet spot appears on the
cast, circle it with a marking pen and note the time of appear-
ance (on the cast). Be aware of how much drainage is expected.
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• Instruct the patient that the procedure may tope, which (in conjunction with a scanner) al-
cause some minor discomfort but isn’t lows a visual image of bone metabolism. A myelogram—
painful. evaluation of the
• Administer analgesics, as prescribed, after Nursing actions subarachnoid
the procedure. • Determine the patient’s ability to lie still space—requires a
during the scan. lumbar puncture.
Direct view of a joint • Make sure that written, informed consent Inspect the
Arthroscopy is a relatively simple surgical has been obtained before the procedure. insertion site, and
procedure, performed under local anesthesia, • Advise the patient that a radioisotope will be monitor neurologic
status.
that allows for direct visualization of a joint. injected I.V.
• Explain to the patient that he’ll be required
Nursing actions to drink several glasses of fluid during the
Before the procedure waiting period to enhance excretion of any
• Make sure that written, informed consent isotope that isn’t absorbed by bone tissue.
has been obtained.
• Administer prophylactic antibiotics as pre- Vertebrae visual
scribed. A myelogram involves the injection of ra-
• Explain the procedure, skin preparation, diopaque dye into the spine during a lumbar
and use of local anesthetics. puncture. This dye allows fluoroscopic visual-
After the procedure ization of the subarachnoid space, spinal cord,
• Apply a pressure dressing to the injection and vertebral bodies.
site.
• Monitor neurovascular status. Nursing actions
• Apply ice to the affected joint. Before the procedure
• Limit weight bearing or joint use until • Make sure that written, informed consent
allowed by the doctor. has been obtained.
• Administer analgesics as prescribed. • Note the patient’s allergies to iodine, sea-
food, and radiopaque dyes.
Fluid removal • Inform the patient about possible throat
With arthrocentesis, a doctor removes syn- irritation and flushing of the face from the
ovial fluid from a joint using a needle. injection.
After the procedure
Nursing actions • Maintain bed rest. (Assist the patient to the
Before the procedure bathroom, if necessary.)
• Make sure that written, informed consent • Inspect the insertion site for bleeding.
has been obtained. • Monitor neurologic status.
• Administer prophylactic antibiotics as pre- • Encourage fluids.
scribed.
• Explain the procedure to the patient. Solving for X
After the procedure An X-ray is a noninvasive procedure that pro-
• Maintain a pressure dressing on the aspira- vides a radiographic image for examination of
tion site. bones and joints.
• Monitor neurovascular status.
• Apply ice to the affected area. Nursing actions
• Limit weight bearing or joint use until al- • Use caution when moving a patient with a
lowed by the doctor. suspected fracture.
• Administer analgesics as prescribed. • Explain the procedure to the patient.
• Make sure that the patient isn’t pregnant (to
Bone image prevent possible fetal damage from radiation
A bone scan is used to reveal bone abnor- exposure).
malities. It involves the injection of a radioiso-
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Magnetic view Lab exam #3

Magnetic resonance imaging (MRI) uses A coagulation study analyzes a blood sample
magnetic and radio waves to create a detailed for prothrombin time, International Normal-
visualization of bones and their associated ized Ratio, and partial thromboplastin time.
structures.
Nursing actions
Nursing actions • Note current drug therapy before the pro-
• Make sure that written, informed consent cedure.
has been obtained. • Check the venipuncture site for bleeding af-
• Be aware that patients with pacemakers, ter the procedure.
surgical and orthopedic hardware, or shrap-
nel can’t undergo MRI scanning
• Remove jewelry and metal objects from the
patient.
• Determine the patient’s ability to lie still for
Polish up on patient
45 to 60 minutes (or longer).
• Administer sedatives as prescribed.
care
Major musculoskeletal disorders include arm
Lab exam #1 and leg fractures, carpal tunnel syndrome,
A blood chemistr y test analyzes a blood compartment syndrome, gout, herniated nu-
sample for potassium, sodium, calcium, phos- cleus pulposus, hip fracture, osteoarthritis,
phorus, glucose, bicarbonate, blood urea ni- osteomyelitis, and osteoporosis.
trogen, creatinine, protein, albumin, osmolali-
ty, creatine kinase, serum aspartate amino-
transferase, aldolase, rheumatoid factor, Arm and leg fractures
complement fixation, lupus erythematosus
cell preparation, antinuclear antibodies, Fractures of the arms and legs usually result
anti-deoxyribonucleic acid, and C-reactive from trauma and commonly cause substantial
protein (CRP). muscle, nerve, and other soft-tissue damage.
The prognosis varies with the extent of dis-
Nursing actions ability or deformity, the amount of tissue and
• Withhold food and fluid before the proce- vascular damage, the adequacy of reduction
dure, if appropriate. and immobilization, and the patient’s age,
• Monitor the venipuncture site for bleeding health, and nutritional status.
Memory after the procedure. Children’s bones usually heal rapidly and
jogger without deformity. Bones of adults in poor
When as- Lab exam #2 health or with impaired circulation may never
sessing for A hematologic study analyzes a blood sam- heal properly. Severe open fractures, especial-
fractures, remem- ple for white blood cells (WBCs), RBCs, ly of the femoral shaft, may cause substantial
ber the 5 Ps: platelets, erythrocyte sedimentation rate blood loss and life-threatening hypovolemic
Pain (ESR), hemoglobin (Hb), and hematocrit shock.
(HCT).
Pallor
CAUSES
Pulse loss Nursing actions • Bone tumors
Paresthesia • Note current drug therapy to anticipate pos- • Trauma
sible interference with test results. • Osteoporosis
Paralysis. • Assess the venipuncture site for bleeding af-
The last three oc- ter the procedure. DATA COLLECTION FINDINGS
cur distal to the • Discoloration
fracture site. • Loss of limb function
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• Acute pain Drug therapy

• Swelling • Analgesics: morphine, acetaminophen
• Deformity (Tylenol), oxycodone (Percocet), hydro-
• Crepitus codone (Vicodin)
• Prophylactic antibiotics: cefazolin (Ancef),
DIAGNOSTIC FINDINGS cefotetan disodium (Cefotan)
• Anteroposterior and lateral X-rays of the • Tetanus prophylaxis: tetanus toxoid
suspected fracture as well as X-rays of the
joints above and below it confirm the INTERVENTIONS AND RATIONALES
diagnosis. • Watch for signs of shock in the patient with
a severe open fracture of a large bone such as
NURSING DIAGNOSES the femur. Open fractures can cause increased
• Acute pain blood loss leading to hypovolemic shock.
• Impaired physical mobility • Monitor vital signs and be especially alert
• Risk for peripheral neurovascular dysfunc- for a rapid pulse, decreased blood pressure,
tion pallor, and cool, clammy skin—all of which
may indicate that the patient is in shock.
TREATMENT • Maintain I.V. fluids, as ordered, to replace Leave no
Emergency care fluid loss. stone unturned.
• Splinting the limb above and below the sus- • Offer reassurance. With any fracture, the pa- Immobilized
pected fracture tient is likely to be frightened and in pain. patients are at
• Cold pack application •Administer analgesics, as ordered, to pro- risk for renal
• Elevating the extremity to reduce edema mote comfort. calculi.
and pain • Help the patient set realistic goals for recov-
• Direct pressure to control bleeding in se- ery to prevent frustration with the recovery
vere fractures that cause blood loss process.
• Rapid fluid replacement to prevent hypo- • Reposition the immobilized patient of-
volemic shock if blood loss has occurred as a ten to increase comfort and prevent pres-
result of the fracture sure ulcers.
• Assist with active ROM exercises of the
After confirming diagnosis unaffected extremities to prevent muscle
• Closed reduction (restoring displaced bone atrophy.
segments to their normal position) • Encourage deep breathing and cough-
• Immobilization with a splint, a cast, or ing to avoid hypostatic pneumonia.
traction • Make sure that the immobilized patient re-
• Open reduction during surgery to reduce ceives adequate fluid intake to prevent urinary
and immobilize the fracture, using rods, stasis and constipation.
plates, or screws, when closed reduction is • Encourage the patient to start moving
impossible, usually followed by application of around as soon as possible to prevent compli-
a plaster cast cations of immobility such as renal calculi.
• Skin or skeletal traction (if splint or cast Help the patient to walk. Demonstrate how to
fails to maintain the reduction) use crutches properly to prevent injury.
• Watch for signs of renal calculi, such as
Open fractures flank pain, nausea, and vomiting, to ensure
• Surgery to repair soft-tissue damage early recognition and treatment.
• Thorough debridement of the wound • Provide cast care to avoid skin breakdown.
Teaching topics
• Caring for the cast
• Using assistive devices
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Any strenuous use Carpal tunnel syndrome • EMG reveals a median nerve motor con-
of the hands, including duction delay of more than 5 milliseconds.
taking the NCLEX, Carpal tunnel syndrome results from com-
aggravates carpal pression of the median nerve at the wrist, NURSING DIAGNOSES
tunnel syndrome. within the carpal tunnel. This nerve—along • Impaired physical mobility
with blood vessels and flexor tendons—pass- • Chronic pain
es through to the fingers and thumb. Com- • Risk for peripheral neurovascular dys-
pression neuropathy causes sensory and mo- function
tor changes in the median distribution of the
hand. Carpal tunnel is the most common of TREATMENT
the nerve entrapment syndromes. • Resting the hands by splinting the wrist in
Carpal tunnel syndrome usually occurs in neutral extension for 1 to 2 weeks
women between ages 30 and 60 and poses a • Possibly changing occupations (if a definite
serious occupational health problem. Assem- link has been established between the pa-
bly-line workers, packers, typists, and persons tient’s occupation and the development of
who repeatedly use poorly designed tools are carpal tunnel syndrome)
most likely to develop this disorder. Any • Correction of underlying disorder
strenuous use of the hands—sustained grasp- • Surgical decompression of the nerve by re-
ing, twisting, or flexing—aggravates this con- secting the entire transverse carpal tunnel lig-
dition. ament or by using endoscopic surgical tech-
niques (neurolysis, or releasing of nerve
CAUSES fibers, may also be necessary)
• Flexor tenosynovitis (commonly associated
with rheumatic disease) Drug therapy
• Nerve compression • Nonsteroidal anti-inflammatory drugs
• Physical trauma (NSAIDs): indomethacin (Indocin), ibuprofen
• Rheumatoid arthritis (Motrin), naproxen (Naprosyn)
• Corticosteroid injections: betamethasone
DATA COLLECTION FINDINGS (Celestone), hydrocortisone (Hydrocortone)
• Atrophic nails
• Numbness, burning, or tingling in arms INTERVENTIONS AND RATIONALES
• Pain in arms and hands • Administer NSAIDs as needed to reduce in-
• Shiny, dry skin flammation and pain.
• Weakness in arms and hands • After surgery, you may have to help the pa-
tient with eating and bathing. Mobility may be
DIAGNOSTIC FINDINGS limited with carpal tunnel syndrome surgery.
• Physical examination reveals decreased • Regularly evaluate the patient’s degree of
sensation to light touch or pinpricks in the af- physical immobility to evaluate the effective-
fected fingers. Thenar muscle atrophy occurs ness of the current treatment plan.
in about half of all cases of carpal tunnel syn- • After surgery, monitor the color, sensation,
drome. The patient exhibits a positive Tinel’s and motion of the affected hand to detect signs
sign (tingling over the median nerve on light of compromised circulation.
percussion). He also responds positively to • Advise the patient who’s about to be dis-
Phalen’s wrist-flexion test, in which holding charged to exercise his hands. If his arm is in
the forearms vertically and allowing both a sling, tell him to remove the sling several
hands to drop into complete flexion at the times each day to do exercises for his elbow
wrists for 1 minute reproduces symptoms of and shoulder to maintain ROM.
carpal tunnel syndrome.
• A blood pressure cuff on the forearm inflat- Teaching topics
ed above systolic pressure for 1 to 2 minutes • Learning about the disease process and
provokes pain and paresthesia along the dis- treatment options
tribution of the median nerve.
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• Applying the splint and removing it to per- • Acute pain

Numbers to know
form gentle ROM exercises daily • Risk for peripheral neurovascular dysfunc- for compartment
• Taking NSAIDs with food or antacids to tion syndrome: Tissue
avoid stomach upset damage after 30
• Reinforcing that maximum effects of drug TREATMENT minutes; permanent
therapy may not be seen for 2 to 4 weeks • Fasciotomy damage after
• Contacting an occupational counselor • Positioning the affected extremity lower 4 hours.
than the heart
• Removal of dressings or constrictive cover-
Compartment syndrome ings of the area (such as a cast)
Compartment syndrome occurs when in- Drug therapy

creased pressure within a compartment im- • Opioid analgesics: morphine, hydrocodone
pairs circulation, which can cause nerve and (Vicodin)
muscle damage. Tissue damage occurs after
30 minutes; after 4 hours, irreversible damage INTERVENTIONS AND RATIONALES
may occur. • Monitor vital signs to detect early changes
If compartment syndrome is suspected, and prevent complications.
pressure within muscles is assessed by insert- • Monitor the affected extremity and perform
ing a needle into a muscle. The needle is at- neurovascular checks to detect signs of im-
tached to an I.V. bag with tubing and a stop- paired circulation.
cock. Elevated pressure, as indicated by a • Maintain the extremity in a position lower
blood pressure sphygmomanometer, indi- than the heart to ensure adequate circulation
cates compartment syndrome. and reduce pressure.
• Evaluate the patient for pain and anxiety be-
CAUSES cause stress may lead to vasoconstriction.
• Application of a dressing or cast that’s too • Administer medications, as ordered, to
tight maintain or improve the patient’s condition.
• Burns • Perform dressing changes after fasciotomy
• Closed fracture injury and reinforce dressings frequently to facilitate
• Crushing injuries monitoring the extremity. (Expect a large
• Muscle swelling after exercise amount of bloody drainage.)
DATA COLLECTION FINDINGS Teaching topics

• Severe or increased pain that occurs when • Recognizing and reporting signs and symp-
the affected muscle is stretched or elevated toms of compartment syndrome
and that’s unrelieved by opioid analgesics. • Preventing future injury
• Decreased movement, strength, and
sensation
• Loss of distal pulse Gout
• Numbness and tingling distal to the in-
volved muscle Gout is a metabolic disease marked by urate
• Paralysis deposits in the joints, which cause painfully
• Tense, swollen muscle arthritic joints. It can strike any joint but fa-
vors those in the feet and legs. Primary gout
DIAGNOSTIC FINDINGS (in which there’s a metabolic cause that’s ge-
• Intracompartment pressure is elevated, as netic or inborn) usually occurs in men older
indicated by a blood pressure sphygmoma- than age 30 and in postmenopausal women.
nometer. Secondary gout (which involves drug therapy
or a metabolic cause that isn’t genetic or in-
NURSING DIAGNOSES born) occurs in older people.
920107.qxd 8/7/08 3:00 PM Page 224
Gout follows an intermittent course and • Corticosteroids: betamethasone (Cele-

Shout about
gout. Urate may leave patients free from symptoms for stone), hydrocortisone (Hydrocortone)
deposits cause years between attacks. Gout can lead to • NSAIDs: ibuprofen (Motrin), naproxen
painful, arthritic chronic disability or incapacitation and, (Naprosyn)
joints. rarely severe hypertension and progressive
renal disease. The prognosis is good with INTERVENTIONS AND RATIONALES
treatment. • Encourage bed rest and use a bed cradle to
keep bedcovers off extremely sensitive, inflamed
CAUSES joints.
• Genetic predisposition • Give analgesics as needed, especially dur-
• Increased uric acid ing acute attacks, to promote comfort.
• Apply hot or cold packs to inflamed joints to
DATA COLLECTION FINDINGS promote comfort. (See Applying cold therapy,
• History of hypertension and Applying heat therapy, page 226.)
• Back pain • Administer anti-inflammatory medication
• Inflamed, painful joints and other drugs to decrease inflammation and
• Tophi increase excretion of uric acid.
• Be alert for GI disturbances with colchicine
DIAGNOSTIC FINDINGS administration to prevent complications.
• Arthrocentesis reveals the presence of • Urge the patient to drink plenty of fluids
monosodium urate monohydrate crystals or (up to 2 L/day) to prevent formation of renal
needlelike intracellular crystals of sodium calculi.
urate in synovial fluid taken from an inflamed • When encouraging fluids, record intake and
joint or a tophus. output accurately to detect fluid volume excess.
• Blood studies show a serum uric acid level • Alkalinize urine with sodium bicarbonate or
that’s above normal. The urine uric acid level another agent, as needed, to prevent formation
is usually higher in secondary gout than in of renal calculi.
primary gout. • Make sure the patient understands the im-
• X-rays are normal initially. With chronic portance of having serum uric acid levels
gout, they show damage of the articular carti- checked periodically to help ensure compli-
lage and subchondral bone as well as outward ance.
displacement of the overhanging margin from • Advise the patient receiving allopurinol,
the bone contour. probenecid, and other drugs to immediately
report adverse effects, such as drowsiness,
NURSING DIAGNOSES dizziness, nausea, vomiting, urinary frequen-
• Chronic pain cy, and dermatitis, to prevent complications.
• Impaired physical mobility • Warn the patient taking probenecid or
• Risk for injury sulfinpyrazone to avoid aspirin and other
salicylates. Their combined effect causes urate
TREATMENT retention.
• Bed rest • Inform the patient that long-term colchicine
• Immobilization and protection of the in- therapy is essential during the first 3 to 6
flamed joints months of treatment with uricosuric drugs or
• Local application of heat and cold allopurinol to prevent further acute attacks.
• Diet changes (with the goal of weight loss)
Teaching topics
Drug therapy • Avoiding alcohol, especially beer and wine
• Antigout drugs: colchicine (Colgout), allo- • Minimizing intake of purine-rich foods,
purinol (Zyloprim) such as anchovies, liver, sardines, kidneys,
• Uricosuric drugs: probenecid (Probalan), sweet-breads, and lentils
sulfinpyrazone (Anturane) • Losing weight, if obese
• Alkalinizing drug: sodium bicarbonate
920107.qxd 8/7/08 3:00 PM Page 225
Stepping up
Applying cold therapy

WHY YOU DO IT • Expose only the treatment site to avoid chilling
The application of cold constricts blood vessels; the patient.
inhibits local circulation, suppuration, and tissue • Make sure to time all cold therapies and apply
metabolism; relieves vascular congestion; them for the ordered amount of time.
slows bacterial activity in infections; reduces • Because tissue damage may result from di-
body temperature; and may act as a temporary rect cold application, monitor the temperature
anesthetic during brief, painful procedures. Be- of the cold device carefully. Frequently evaluate
cause treatment with cold also relieves inflam- the condition of the patient’s skin under the cold
mation, reduces edema, and slows bleeding, it application device.
may provide effective initial treatment after eye Applying dry cold
injuries, strains, sprains, bruises, muscle • Place the covered cold device on the treat-
spasms, and burns. Cold doesn’t reduce existing ment site.
edema, however, because it inhibits reabsorp- • Refill or replace the cold device as necessary
tion of excess fluid. to maintain the correct temperature. Change the
Cold may be applied in dry or moist forms, but protective cover if it becomes wet.
ice shouldn’t be placed directly on a patient’s
Applying moist cold
skin because it may further damage tissue.
• Place a linen-saver pad under the treatment
Moist forms are more penetrating than dry be-
site.
cause moisture facilitates conduction. Devices
• Remove the compress or pack from the water,
for applying dry cold include an ice bag or col-
and wring it out to prevent dripping. Apply it to
lar, K pad (which can produce cold or heat), and
the treatment site.
chemical cold packs and ice packs. Devices for
• Cover the compress or pack with a waterproof
applying moist cold include cold compresses for
covering to provide insulation and to keep the
small body areas and cold packs for large ar-
surrounding area dry. Secure the covering with
eas.
tape or roller gauze to prevent it from slipping.
Apply cold treatments cautiously on patients
• Check the application site frequently for signs
with impaired circulation, on children, and on el-
of tissue intolerance, and note complaints of
derly or arthritic patients because of the risk of
burning or numbness. If these symptoms devel-
ischemic tissue damage.
op, discontinue treatment and notify the doctor.
Apply cold immediately after an injury to mini-
• Change the compress or pack as needed to
mize edema. Although colder temperatures can
maintain the correct temperature. Remove it af-
be tolerated for a longer time when the treat-
ter the prescribed treatment period (usually 20
ment site is small, you should remove the appli-
minutes).
cation after 1 hour to avoid reflex vasodilation.
• Record the time, date, and duration of cold ap-
Applying temperatures below 59° F (15° C) also
plication; type of device used (ice bag or collar,
causes local reflex vasodilation.
K pad, or chemical cold pack); site of applica-
HOW YOU DO IT tion; temperature or temperature setting; pa-
• Check the doctor’s order and evaluate the patient’s temperature, pulse, and respirations be-
tient’s condition. fore and after application; skin appearance be-
• Explain the procedure to the patient, provide fore, during, and after application; signs of
privacy, and make sure the room is warm and complications; and the patient’s tolerance of the
free from drafts. Wash your hands thoroughly. treatment.
• Record the patient’s temperature, pulse, and
respirations to serve as a baseline.
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Stepping up
Applying heat therapy

WHY YOU DO IT the patient’s body temperature, monitor temperature, pulse,
Heat applied directly to the patient’s body raises tissue temper- and respirations throughout the application.
ature and enhances the inflammatory process by causing va- • Expose only the treatment area because vasodilation will
sodilation and increasing local circulation. This promotes make the patient feel chilly.
leukocytosis (an increase in leukocytes), suppuration, • Make sure to time heat therapies and apply them for the or-
drainage, and healing. Heat also increases tissue metabolism, dered amount of time.
reduces pain caused by muscle spasm, and decreases con- • Because tissue damage may result from direct heat applica-
gestion in deep visceral organs. tion, monitor the temperature of the heating device carefully.
Direct heat may be dry or moist. Dry heat can be delivered at a Frequently evaluate the condition of the patient’s skin under the
higher temperature and for a longer time than moist heat. De- heat application device.
vices for applying dry heat include the hot-water bottle, electric Applying dry heat
heating pad, K pad, and chemical hot pack. • Before applying the heating device, press it against your in-
Moist heat softens crusts and exudates, penetrates deeper ner forearm to test its temperature and heat distribution. If it
than dry heat, is less drying to the skin, produces less perspira- heats unevenly, obtain a new device.
tion, and is usually more comfortable for the patient. Devices • Apply the device to the treatment area and, if necessary, se-
for applying moist heat include warm compresses for small cure it with tape or roller gauze.
body areas and warm packs for large areas. • Check the patient for tolerance and skin reaction.
Direct heat treatment can’t be used on a patient at risk for
Applying moist heat
hemorrhage. It’s also contraindicated if the patient has a
• Place a linen-saver pad under the treatment site.
sprained limb in the acute stage (because vasodilation increas-
• Remove the warm compress or pack from the bowl or basin.
es pain and swelling) or if he has a condition associated with
(Use sterile forceps throughout the procedure, if needed.)
acute inflammation, such as appendicitis. Direct heat should be
• Wring excess solution from the compress or pack. Excess
applied cautiously to pediatric and elderly patients and to pa-
moisture increases the risk of burns.
tients with impaired renal, cardiac, or respiratory function; arte-
• Apply the compress gently to the affected site. After ten sec-
riosclerosis; atherosclerosis; or impaired sensation. It should
onds, check for tolerance and skin reaction.
be applied with extreme caution to heat-sensitive areas, such
• Apply a waterproof covering (sterile, if necessary) to the
as scar tissue and stomas.
compress. Secure it with tape or roller gauze to prevent it from
HOW YOU DO IT slipping.
• Check the doctor’s order and evaluate the patient’s condition. • Place a hot-water bottle, K pad, or chemical hot pack over
• Position the patient comfortably in the bed. the compress and waterproof covering to maintain the correct
• Explain the procedure to the patient, and tell him not to lean temperature.
or lie directly on the heating device because this reduces air • Record the date and time; the duration of heat application;
space and increases the risk of burns. Warn him against ad- the device used; the temperature of the heat setting, the site of
justing the temperature of the heating device or adding hot wa- application; the patient’s temperature, pulse, respirations, and
ter to a hot-water bottle. Advise him to report pain immediately skin condition before, during, and after treatment; signs of com-
and to remove the device if necessary. plications; and the patient’s tolerance of the treatment.
• Record the patient’s temperature, pulse, and respirations to
serve as a baseline. If heat treatment is being applied to raise
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Herniated nucleus pulposus • Myelogram shows compression of the

spinal cord.
In herniated nucleus pulposus, the interverte- • X-ray shows narrowing of disk space.
In herniated
bral disk ruptures, causing a protrusion of the • MRI identifies the herniated disk. nucleus pulposus, the
nucleus pulposus (the soft, central portion of soft, central portion
a spinal disk) into the spinal canal. This com- NURSING DIAGNOSES of a spinal disk
presses the spinal cord or nerve roots, caus- • Impaired physical mobility protrudes into the
ing pain, numbness, and loss of motor func- • Posttrauma syndrome spinal canal.
tion. Commonly known as a herniated disk, • Acute pain
herniated nucleus pulposus can be further de-
scribed as lumbosacral (affecting the lumbar TREATMENT
vertebrae L4 and L5 and the sacral vertebra • Bed rest with active and passive ROM
S1) or cervical (affecting the cervical verte- and isometric exercises
brae C5, C6, and C7). • Diet that includes increased fiber and
fluids
CAUSES • Heating pad and moist, hot compress-
• Back or neck strain es
• Congenital bone deformity • Laminectomy
• Degeneration of disk • Orthopedic devices, including back
• Heavy lifting brace and cervical collar
• Trauma • Transcutaneous electrical nerve stimulation
• Weakness of ligaments
Drug therapy
DATA COLLECTION FINDINGS • Analgesic: oxycodone (OxyContin)
In lumbosacral area • Corticosteroid: cortisone (Cortone)
• Acute pain in the lower back that radiates • Muscle relaxants: diazepam (Valium),
across the buttock and down the leg cyclobenzaprine (Flexeril)
• Pain on ambulation • NSAIDs: indomethacin (Indocin), ibuprofen
• Weakness, numbness, and tingling of the (Motrin), sulindac (Clinoril), piroxicam
foot and leg (Feldene), flurbiprofen (Ansaid), diclofenac
sodium (Voltaren), naproxen (Naprosyn), di-
In cervical area flunisal (Dolobid)
• Atrophy of biceps and triceps • Stool softener: docusate sodium (Colace)
• Neck pain that radiates down the arm to the
hand INTERVENTIONS AND RATIONALES
• Neck stiffness • Monitor neurovascular status to determine
• Straightening of normal lumbar curve with baseline and detect early changes.
scoliosis away from the affected side • Monitor and record vital signs, intake and
• Weakness of the affected upper extremities output, and results of laboratory studies to de-
• Weakness, numbness, and tingling of the tect changes in the patient’s condition.
hand • Maintain the patient’s diet; increase fluid in-
take to maintain hydration.
DIAGNOSTIC FINDINGS • Keep the patient in semi-Fowler’s position
• Deep tendon reflexes are depressed or ab- with moderate hip and knee flexion to pro-
sent in the upper extremities or Achilles mote comfort.
tendon. • Administer medications, as prescribed, to
• EMG shows spinal nerve involvement. maintain or improve the patient’s condition.
• Lasègue’s sign is positive (back pain occurs • Encourage the patient to express feelings
when the patient assumes a supine position about changes in body image and about fears
with his legs extended fully and the examiner of disability to help him resolve his feelings.
raises the patient’s legs).
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Treatment for
• Provide skin and back care to promote com- DATA COLLECTION FINDINGS
herniated nucleus fort and prevent skin breakdown. • Shorter appearance and outward rotation of
pulposus ranges from • Turn the patient every 2 hours, using the affected leg, resulting in limited or abnormal
bed rest to surgery. logrolling technique, to prevent injury. ROM
Provide emotional • Maintain bed rest and body alignment to • Edema and discoloration of surrounding
support and maintain joint function and prevent neuromus- tissue
reinforcement during cular deformity. • History of a fall or other trauma to the
the treatment and • Maintain traction, braces, and cervical col- bones
recovery period. lar to prevent further injury and to promote • Pain in the affected hip and leg, exacerbat-
healing. ed by any movement
• Promote independence in activities of daily
living (ADLs) to maintain self-esteem. DIAGNOSTIC FINDINGS
• Computed tomography scan (for complicat-
Teaching topics ed fractures) pinpoints abnormalities.
• Exercising regularly, with special attention • Hematology shows decreased Hb and HCT.
to exercises that strengthen and stretch the • X-ray reveals a break in the continuity of the
muscles bone.
• Avoiding lifting, sleeping prone, climbing
stairs, and riding in a car NURSING DIAGNOSES
• Avoiding flexion, extension, or rotation of • Impaired physical mobility
the neck, if cervical • Risk for impaired skin integrity
• Using one pillow for support while sleeping • Ineffective role performance
• Using a back brace or cervical collar
TREATMENT
• Isometric exercises, such as tensing and re-
Hip fracture laxing the muscles of the leg
• Physical therapy to teach the patient non-
A fracture occurs when too much stress is weight-bearing transfers and to work with
A hip placed on the bone. As a result, the bone changes in weight-bearing status
fracture occurs
breaks and local tissue becomes injured, • Skin traction: Buck’s or Russell
when too much
stress is placed causing muscle spasm, edema, hemorrhage, • Surgical immobilization or joint replace-
on the bone. See compressed nerves, and ecchymosis. ment
what happens Sites of hip fractures include intracapsular • Abductor splint or trochanter roll between
when you go out (within the capsule of the femur), extracapsu- legs to prevent loss of alignment (postopera-
on a limb? lar (outside the capsule of the femur), inter- tively)
trochanteric (within the trochanter), or sub-
trochanteric (below the trochanter). Drug therapy
• Analgesics: morphine, ketorolac (Toradol),
CAUSES oxycodone (Oxycontin), hydrocodone
• Aging (Percocet)
• Bone tumors • Anticoagulant: warfarin (Coumadin) (post-
• Cushing’s syndrome operatively)
• Immobility
• Malnutrition INTERVENTIONS AND RATIONALES
• Multiple myeloma • Monitor neurovascular and respiratory sta-
• Osteomyelitis tus. Most important, check for compromised
• Osteoporosis circulation, hemorrhage, and neurologic im-
• Steroid therapy pairment in the affected extremity and pneu-
• Trauma monia in the bedridden patient to detect
changes and prevent complications.
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• Monitor and record vital signs, intake and Osteoarthritis Don’t get soft
output, and results of laboratory studies to de- on me. In
tect early changes in the patient’s condition. Also known as degenerative joint disease, os- osteoarthritis,
• Maintain the patient’s diet; increase fluid in- teoarthritis is characterized by degeneration cartilage softens,
take to maintain hydration. of cartilage in weight-bearing joints, such as narrowing the joint
• Keep the patient who’s in traction in a flat the spine, knees, and hips. It occurs when car- space and allowing
position with the foot of the bed elevated 25 tilage softens with age, narrowing the joint bones to rub
degrees to prevent further injury. space. This allows bones to rub together, together.
• Keep the legs abducted using an abductor causing pain and limiting joint movement.
splint to prevent dislocation of the hip joint. Osteoarthritis can be primary or secondary.
• Administer medications, as prescribed, to Primary osteoarthritis, a normal part of ag-
improve or maintain the patient’s condition. ing, results from metabolic, genetic, chemical,
• Provide skin care and logroll the patient and mechanical factors. Secondary osteoar-
every 2 hours to maintain skin integrity and thritis usually follows an identifiable cause,
prevent pressure ulcers. such as obesity or congenital deformity, and
• Assist with coughing, deep breathing, and leads to degenerative changes.
incentive spirometry to maintain a patent air-
way. CAUSES
• Keep the hip extended to prevent further in- • Aging
jury and maintain circulation. • Congenital abnormalities
• Promote independence in ADLs to promote • Joint trauma
self-esteem. • Obesity
• Provide active and passive ROM and iso-
metric exercises for unaffected limbs to main- DATA COLLECTION FINDINGS
tain joint mobility. • Crepitation
• Provide a trapeze to promote independence • Enlarged, edematous joints
in self-care. • Heberden’s nodes
• Maintain traction before surgery at all • Increased pain in damp, cold weather
times, if using conservative treatment, to en- • Joint stiffness
sure proper body alignment and promote heal- • Limited ROM
ing. • Pain relieved by resting joints
• Keep side rails up to prevent injury. • Smooth, taut, shiny skin
• Provide appropriate sensory stimulation
with frequent reorientation to reduce anxiety. DIAGNOSTIC FINDINGS
• Encourage increased fiber and fluid intake, • Arthroscopy reveals bone spurs and nar-
activity as allowed, and medication as needed rowing of joint space.
to prevent constipation. • Hematology studies show increased ESR.
• Provide diversional activities to promote self- • X-rays show joint deformity, narrowing of
esteem. joint space, and bone spurs.
• Apply antiembolism stockings and a se-
quential compression device to promote ve- NURSING DIAGNOSES
nous circulation and prevent thromboembolism • Activity intolerance
formation. • Impaired physical mobility
• Chronic pain
Teaching topics
• Attending physical therapy sessions TREATMENT
• Avoiding putting weight on the affected • Cane or walker
limb • Low-calorie diet, if the patient isn’t at opti-
• Performing skin and foot care daily mal weight
• Avoiding crossing legs • Exercise
• Using assistive devices • Scheduled rest periods
• Application of warm, moist heat
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Drug therapy Osteomyelitis

• Analgesics: aspirin, acetaminophen
(Tylenol) Osteomyelitis is a pyogenic (pus-producing)
• NSAIDs: indomethacin (Indocin), ibuprofen bone infection. It may be chronic or acute and
(Motrin), naproxen (Naprosyn), diflunisal commonly results from a combination of local
(Dolobid), celecoxib (Celebrex) trauma—usually quite trivial but resulting in
hematoma formation—and an acute infection
INTERVENTIONS AND RATIONALES originating elsewhere in the body. Although
• Evaluate musculoskeletal status to deter- osteomyelitis commonly remains localized, it
mine baseline and detect changes. can spread through the bone to the marrow,
• Monitor and record vital signs and intake cortex, and periosteum (the membrane that
and output to evaluate hydration. covers the bone).
• Evaluate pain. Correlating the patient’s pain Acute osteomyelitis is usually a blood-borne
with time of day and visits may be useful in disease that most commonly affects rapidly
modifying tasks. growing children. Chronic osteomyelitis
• Check the degree of joint mobility to deter- (rare) is characterized by multiple draining si-
mine baseline and detect changes. nus tracts and metastatic lesions.
• Maintain the patient’s diet to promote nutri- Osteomyelitis occurs more commonly in
tion and healing. children—particularly in boys—than adults
• Keep joints extended to prevent contractures usually as a complication of an acute, local-
and maintain joint mobility. ized infection. The most common sites in chil-
• Administer medications, as prescribed, to dren are the lower end of the femur and the
relieve pain and encourage mobility. upper end of the tibia, humerus, and radius.
• Observe for increased bleeding or bruising In adults, the most common sites are the
tendency to facilitate early intervention for pelvis and vertebrae, generally the result of
drug adverse effects. contamination associated with surgery or
• Urge the patient to express feelings about trauma.
changes in body image to encourage accep-
tance of changes. CAUSES
• Provide skin care to promote skin integrity. • Exposure to disease-causing organisms
• Provide rest periods to conserve energy.
• Maintain calorie count to promote nutrition DATA COLLECTION FINDINGS
and healing. • Pain
• Provide moist compresses, as prescribed, to • Tenderness
promote comfort. • Swelling
• Teach proper body mechanics to prevent
injury. DIAGNOSTIC FINDINGS
• Provide passive ROM exercises to maintain • Blood culture results identify the causative
joint mobility. organism.
• Bone scan identifies the area of infection.
Teaching topics • ESR and CRP are elevated. (CRP appears to
• Avoiding certain exercises (jumping, lifting) be a better diagnostic tool.)
• Identifying ways to reduce physical stress • WBC count shows leukocytosis.
(weight loss, exercise)
• Performing complete skin and foot care NURSING DIAGNOSES
daily • Impaired tissue integrity
• Contacting the Arthritis Foundation • Impaired physical mobility
• Acute pain
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TREATMENT • Check circulation and drainage: If a wet

• Early surgical drainage to relieve pressure spot appears on the cast, circle it with a mark-
buildup and sequestrum formation (seques- ing pen and note the time of appearance (on
trum is dead bone that has separated from the cast). Be aware of how much drainage is Antibiotic
sound bone) expected. Check the circled spot at least treatment for
osteomyelitis usually
• High-protein diet with extra vitamin C every 4 hours. Watch for any enlargement.
includes large doses of
• Immobilization of the affected bone by plas- These measures help detect early signs of hem- a penicillinase-
ter cast, traction, or bed rest orrhage. resistant penicillin and
• I.V. fluids • Protect the patient from mishaps, such as may begin even before
jerky movements and falls, which may threat- the diagnosis is
Drug therapy en bone integrity, to prevent injury. confirmed.
• Antibiotics: large doses of I.V. antibiotics, • Be alert for sudden pain, crepitus, or defor-
usually a penicillinase-resistant penicillin, mity. Watch for sudden malposition of the
such as nafcillin and oxacillin (Bactocill), or a limb to detect fracture.
cephalosporin, such as cefazolin (Ancef), after • Provide emotional support and appropriate
blood cultures are taken diversions to reduce anxiety.
• Analgesics: ibuprofen (Motrin), acetamino-
phen (Tylenol), oxycodone (Percocet), hy- Teaching topics
drocodone (Vicodin) • Cleaning the wound
• Recognizing signs of infection
INTERVENTIONS AND RATIONALES • Following up with the doctor as recom-
• Use strict aseptic technique when changing mended
dressings and irrigating wounds to prevent in- • Seeking prompt treatment for possible
fection. sources of recurrence—blisters, boils, styes,
• If the patient is in skeletal traction for com- and impetigo
pound fractures, provide pin care and then
cover insertion points of pin tracks with small,
dry dressings. Tell the patient not to touch Osteoporosis
the skin around the pins and wires to prevent
infection. With osteoporosis, a metabolic bone disorder,
• Monitor I.V. fluids to maintain adequate hy- the rate of bone resorption accelerates while
dration as necessary. the rate of bone formation slows down, caus-
• Provide a diet high in protein and vitamin C ing a loss of bone mass. Bones affected by
to promote healing. this disease lose calcium and phosphate salts
• Check vital signs and wound appearance and, thus, become porous, brittle, and abnor-
daily and monitor daily for new pain, which mally vulnerable to fracture.
may indicate secondary infection. Osteoporosis may be primary or secondary
• Support the affected limb with firm pillows. to an underlying disease. Primary osteoporo-
Keep the limb level with the body; don’t let it sis is often called senile or postmenopausal
sag to prevent injury. osteoporosis because it most commonly de-
• Provide good skin care. Turn the patient velops in elderly, postmenopausal women.
gently every 2 hours to prevent skin break-
down, and watch for signs of developing pres- CAUSES
sure ulcers to ensure early intervention and • Decreased hormonal function
treatment. • Negative calcium balance
• Provide good cast care. Support the cast
with firm pillows and “petal” the edges with DATA COLLECTION FINDINGS
pieces of adhesive tape or moleskin to smooth • Aged appearance
rough edges to prevent skin breakdown, which • Deformity
may lead to infection. • Kyphosis
• Pain
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DIAGNOSTIC FINDINGS • Provide a balanced diet high in vitamin D,

• Bone biopsy shows thin and porous but oth- calcium, and protein to support skeletal metab-
erwise normal-looking bone. olism.
• Dual or single photon absorptiometry al- • Administer analgesics and apply heat to re-
lows measurement of bone mass, which helps lieve pain.
to assess the extremities, hips, and spine. • Advise the patient to sleep on a firm mat-
• Serum calcium, phosphorus, and alkaline tress to promote comfort and avoid excessive
phosphatase are all within normal limits, but bed rest to slow disease progression.
parathyroid hormone may be elevated. • Make sure the patient knows how to wear
• X-rays show typical degeneration in the low- her back brace to prevent back injury.
er thoracic and lumbar vertebrae. The verte-
bral bodies may appear flattened and may Teaching topics
look denser than normal. Loss of bone miner- • Consuming foods high in calcium
al becomes evident in later stages. • Using good body mechanics while lifting
• Importance of regular weight-bearing exer-
NURSING DIAGNOSES cise
• Impaired physical mobility • Understanding the prescribed drug regi-
• Risk for injury men and reporting adverse reactions immedi-
• Chronic pain ately
• Reporting any new pain sites immediately,
TREATMENT especially after trauma, no matter how slight
• Physical therapy consisting of weight-bear- • Using proper technique for self-examination
ing exercise and activity of the breasts, if receiving estrogen therapy
• Supportive devices for weakened vertebrae • Understanding the need for regular gyneco-
• Balanced diet high in vitamin D, calcium, logic examinations and reporting abnormal
and protein bleeding promptly while receiving estrogen
therapy
Drug treatment • Contacting the National Osteoporosis Foun-
• Analgesics: aspirin, indomethacin (Indocin) dation
• Hormonal agents: conjugated estrogen
(Premarin), calcitonin (Calcimar), teriparatide
(Forteo)
• Vitamin D supplements
• Antiosteoporotics: alendronate (Fosamax),
risedronate (Actonel), raloxifene (Evista)
• Calcium supplements Changes in the
diet and activity of
INTERVENTIONS AND RATIONALES the patient with
• Focus on the patient’s fragility, stressing osteoporosis may help
careful positioning, ambulation, and pre- avoid fractures.
scribed exercises, to prevent injury.
• Check the patient’s skin daily for redness,
warmth, and new sites of pain, which may in-
dicate new fractures. Encourage activity; help
the patient walk several times daily to slow
progress of the disease.
• Perform passive ROM exercises, or encour-
age the patient to perform active exercises.
Make sure she regularly attends scheduled
physical therapy sessions. These measures
help slow disease progression.
920107.qxd 8/7/08 3:00 PM Page 233
Answer: 1. Headache following a lumbar punc-

ture is usually caused by cerebrospinal fluid
(CSF) leakage. Increased fluid intake will
help restore CSF volume. Antihypertensives
don’t address the problem. Roll lenses reduce
light irritation to the eyes and cooling packs
may reduce site pain, but neither intervention
addresses the problem of reduced CSF vol-
ume, which caused the headache.
integrity
risk potential
Pump up on practice Cognitive level: Analysis
questions
1. A client with a sports injury undergoes a
diagnostic arthroscopy of his left knee. After
the procedure, the nurse assesses the client’s
leg. What are the priority data collection fac-
tors?
1. Wound and skin
2. Mobility and sensation
3. Vascular and integumentary
4. Circulatory and neurologic
Answer: 4. Following a procedure on an ex-
tremity, data collection should focus on neu- 3. A nurse is caring for a client with osteo-
rovascular status of the extremity. Swelling of arthritis of the knees. The nurse would most
the extremity can impair both neurologic and likely detect crepitation during:
circulatory function of the leg. After the neu- 1. palpation.
rovascular stability of the extremity has been 2. percussion.
established, the nurse can address the other 3. auscultation.
concerns. 4. inspection.
Client needs category: Physiological Answer: 1. Crepitus is a grating sensation as-
integrity sociated with degenerative joint disease and
Client needs subcategory: Reduction of can be felt and heard. It’s best detected by
risk potential palpation of the affected joint.
Cognitive level: Application Client needs category: Physiological
integrity
2. A client undergoes a lumbar puncture for a Client needs subcategory: Physio-
myelogram. Shortly after the procedure, he logical adaptation
reports a severe headache. What should the Cognitive level: Comprehension
nurse do?
1. Increase the client’s fluid intake.
2. Administer prescribed antihyperten-
sives.
3. Offer roll lenses to the client.
4. Place cooling packs over the lumbar
puncture site.
920107.qxd 8/7/08 3:00 PM Page 234
sion of osteoarthritis. Weight reduction can

reduce the manifestations of osteoarthritis.
Certain aggravating exercises may need to be
avoided, but exercise can be beneficial. Caf-
feine isn’t associated with clinical manifesta-
tions of osteoarthritis. Alcohol intake isn’t
prohibited.
integrity
logical adaptation
4. A client with osteoarthritis develops coag-
ulopathy secondary to long-term NSAID use.
The coagulopathy is most likely the result of:
1. impaired vitamin K synthesis.
2. blocked prothrombin conversion.
3. decreased platelet adhesiveness.
4. factor VIII destruction.
Answer: 3. NSAIDs reduce platelet adhesive-
ness and can impair coagulation. They don’t
impair vitamin K synthesis, block prothrom-
bin conversion, or destroy factor VIII.
integrity
Client needs subcategory: Physio- 6. A client develops L5-S1 herniated nucleus
logical adaptation pulposus, which impinges on the left nerve
Cognitive level: Analysis root. Most likely, the client would experience
pain that radiates:
5. A nurse is teaching a client with os- 1. up the spinal column.
teoarthritis about lifestyle changes. Which 2. to the lower abdomen.
lifestyle change will most likely reduce the 3. down the left leg.
signs and symptoms associated with osteo- 4. across to the right pelvis.
arthritis? Answer: 3. The pain associated with herniated
1. Avoiding exercise nucleus pulposus of L5-S1 primarily affects
2. Restricting caffeine the lower back, with radiation down one leg.
3. Abstaining from alcohol Client needs category: Physiological
4. Reducing weight integrity
Answer: 4. Osteoarthritis (degenerative joint Client needs subcategory: Physio-
disease) is a disorder caused by wear and tear logical adaptation
on the joints. Excess body weight is a risk fac- Cognitive level: Comprehension
tor associated with development and progres-
920107.qxd 8/7/08 3:00 PM Page 235
1. Exercising of bilateral extremities si-

multaneously
2. Periodic monitoring of his heart rate
3. Forced resistance against stable objects
4. Swinging of limbs through full ROM
Answer: 3. Isometric exercises involve apply-
ing pressure against a stable object, such as
pressing the hands together or pushing an
arm against a wall. Exercising extremities si-
multaneously isn’t a characteristic of isomet-
rics. Heart rate monitoring is associated with
aerobic exercising. Limb swinging isn’t iso-
7. A nurse is walking in a local park and wit- metric.
nesses an elderly woman fall. The woman re- Client needs category: Physiological
ports severe pain, has difficulty moving her integrity
left leg, and is unable to bear weight on the af- Client needs subcategory: Physio-
fected leg. The nurse notices her left leg ap- logical adaptation
pears shorter than her right. The nurse sus- Cognitive level: Application
pects a femoral fracture. The greatest risk to
the client is:
1. infection.
2. fat embolus.
3. neurogenic shock.
4. hypovolemia.
Answer: 4. The greatest risk to the client with
a femoral fracture is hypovolemia from hem-
orrhage, which may be covert and can be fa-
tal if not detected. Infection and fat emboli are
potential complications less commonly seen
in femoral fracture. Neurogenic shock isn’t di-
rectly associated with femoral fracture.
Client needs category: Physiological 9. A client in balanced suspension traction for
integrity a fractured femur needs to be repositioned to-
Client needs subcategory: Reduction of ward the head of the bed. During reposition-
risk potential ing, the nurse should:
Cognitive level: Comprehension 1. place slight additional tension on the
traction cords.
8. A client is undergoing rehabilitation fol- 2. release the weights and replace them
lowing a fracture. As part of his regimen, the immediately after positioning.
client performs isometric exercises. Which of 3. lift the traction and the client during
the following provides the best evidence that repositioning.
the client understands the proper technique? 4. maintain the same degree of traction
tension.
920107.qxd 8/7/08 3:00 PM Page 236
Answer: 4. Traction is used to reduce the frac- Answer: 1. Pain is the most common symptom
ture and must be maintained at all times, in- of compartment syndrome. Because the pain
cluding during repositioning. It isn’t appropri- is the result of ischemia, elevating the limb re-
ate to increase traction tension or release or duces circulation, worsens the ischemia, and
lift the traction during repositioning. intensifies the pain.
integrity integrity
Client needs subcategory: Physio- Client needs subcategory: Physio-
logical adaptation logical adaptation
Cognitive level: Comprehension Cognitive level: Comprehension
10. A client undergoes cast placement for a

fractured left radius. The nurse should sus-
pect compartment syndrome if the client ex-
periences pain that:
1. intensifies with elevation of the left arm.
2. disappears with left arm flexion.
3. increases with the arm in a dependent
position.
4. radiates up the arm to the left scapula.
Time to give your

bones a break. Take a
brief stretch; then
jump right into the
next chapter.
920108.qxd 8/7/08 3:01 PM Page 237
8 Gastrointestinal
system
Digestion central
In this chapter,
you’ll review:
Brush up on key The small intestine consists of the duode-
num, jejunum, and ileum (proximal, central,
✐ components of the GI concepts and distal portions). Nearly all digestion takes
place in the small intestine, which contains di-
system and their
function The GI system is the body’s food processing gestive agents, such as bile and pancreatic se-
complex. The GI tract is basically a hollow, cretions. The small intestine is also lined with
muscular tube through which food is digest- villi, which contain capillaries and lymphatics
nose GI disorders
ed. In addition, accessory organs, such as the that transport nutrients from the small intes-
✐ common GI disor- liver, gallbladder, and pancreas, play an im- tine to the body.
ders. portant role in digestion.
At any time, you can review the major points Absorb, synthesize, and store
of this chapter by consulting the Cheat sheet The large intestine consists of the ascending
on pages 238 to 243. colon, transverse colon, descending colon,
sigmoid colon, and rectum. It absorbs fluid
The breakdown begins and electrolytes, synthesizes vitamin K, and
The digestive process begins in the mouth, stores fecal material.
where a mechanical (tongue and teeth) and
chemical (saliva) combination starts to break Not just bile
down food. The liver is the largest organ in the body. Its
many functions include:
Straight to the stomach • producing and conveying bile
The esophagus transfers food from the • metabolizing carbohydrates, fats, and pro-
oropharynx (area between the soft palate in teins
the mouth and the upper portion of the • synthesizing coagulation factors VII, IX, and
throat) to the stomach. The esophagus con- X, and prothrombin
I’m a key tains two structures, the epiglottis and the • storing copper, iron, and vitamins A, D, E,
member of the cardiac sphincter. The epiglottis closes to pre- K, and B12
GI system.
vent food from entering the trachea, while the • detoxifying chemicals, excreting bilirubin,
cardiac sphincter closes to prevent reflux of and producing and storing glycogen.
gastric contents.
Pear-shaped storage
Chyme time The gallbladder is a hollow, pear-shaped or-
The stomach is a hollow muscular pouch gan that stores bile that isn’t immediately
that secretes pepsin, mucus, and hydrochloric needed for digestion and concentrates it.
acid for digestion. In the stomach, food mixes When the bile is needed, the gallbladder con-
with these gastric juices to create chyme, tracts and expels bile into its duct, known as
which the stomach stores before parceling it the cystic duct. From the cystic duct, bile
into the small intestine. The stomach also se- flows into the common bile duct. Bile then en-
cretes the intrinsic factor necessary for ab- ters the duodenum.
sorption of vitamin B12.

920108.qxd 8/7/08 3:01 PM Page 238
238 Gastrointestinal system
et
heat she
C
Gastrointestinal refresher
APPENDICITIS and record T-tube drainage, monitor the incision
Key signs and symptoms for signs of infection, get the patient out of bed as
• Anorexia soon as possible, and encourage the use of
• Generalized abdominal pain that localizes in the patient-controlled analgesia).
right lower abdomen (McBurney’s point) • Maintain the position, patency, and low suction
• Nausea and vomiting of the nasogastric (NG) tube.
• Sudden cessation of pain (indicates rupture) CIRRHOSIS
Key test result Key signs and symptoms
• Hematology shows moderately elevated white • Abdominal pain (possibly because of an en-
blood cell count. larged liver)
Key treatment • Anorexia
• Appendectomy • Ascites
Key interventions • Fatigue
• Monitor GI status and pain. • Jaundice
• Maintain nothing-by-mouth status until bowel • Nausea
Have time for
just a 5-minute sounds return postoperatively and then advance • Vomiting
review? I think I see diet as tolerated. Key test results
a Cheat sheet in • Monitor dressings for drainage and the incision • Liver biopsy, the definitive test for cirrhosis, de-
your future. for infection postoperatively. tects destruction and fibrosis of hepatic tissue.
• Computed tomography scan with I.V. contrast
CHOLECYSTITIS
reveals enlarged liver, identifies liver masses, and
Key signs and symptoms visualizes hepatic blood flow and obstruction, if
• Episodic colicky pain in epigastric area, which present.
radiates to back and shoulder Key treatments
• Indigestion or chest pain after eating fatty or
• Blood transfusions, as indicated
fried foods
• Gastric intubation and esophageal balloon
• Nausea, vomiting, and flatulence
tamponade for bleeding esophageal varices
Key test results • I.V. therapy using colloid volume expanders or
• Blood chemistry reveals increased alkaline crystalloids
phosphatase, bilirubin, direct bilirubin transami- • Hemostatic: vasopressin (Pitressin) for
nase, amylase, lipase, aspartate aminotrans- esophageal varices
ferase (AST), and lactate dehydrogenase (LD) • Diuretics: furosemide (Lasix), spironolactone
levels. (Aldactone) for edema (diuretics require careful
• Cholangiogram shows stones in the biliary tree. monitoring; fluid and electrolyte imbalance may
Key treatments precipitate hepatic encephalopathy)
• Laparoscopic cholecystectomy or open chole- • Vitamin K: phytonadione (AquaMEPHYTON) for
cystectomy bleeding tendencies due to hypoprothrombine-
• Analgesic: morphine mia
• Monitor abdominal status and pain. • Check respiratory status frequently. Position the
• Provide postoperative care (monitor dressings patient.
for drainage; if open cholecystectomy, monitor • Check skin, gums, stool, and emesis regularly
for bleeding.
920108.qxd 8/7/08 3:01 PM Page 239
Gastrointestinal refresher (continued)

CIRRHOSIS (continued) • Antidiarrheal: diphenoxylate (Lomotil)
• Observe the patient closely for signs of behavioral or personal- • Corticosteroid: prednisone (Deltasone)
ity changes—especially increased stupor, lethargy, hallucina- • Immunosuppressants: mercaptopurine (Purinethol), azathio-
tions, and neuromuscular dysfunction. prine (Imuran)
• Monitor level of consciousness. Key interventions
• Monitor ammonia levels. • Monitor GI status (note excessive abdominal distention) and
• Carefully evaluate before, during, and after paracentesis. fluid balance.
COLORECTAL CANCER • Minimize stress and encourage verbalization of feelings.
• Provide postoperative care if indicated (monitor vital signs;
monitor dressings for drainage; apply a sequential compression
• Abdominal cramping device; monitor ileostomy drainage and perform ileostomy care
• Change in bowel habits and shape of stools as needed; evaluate the incision for signs of infection; assist with
• Diarrhea and constipation turning, coughing, deep breathing, and incentive spirometry; and
• Weight loss get the patient out of bed on the first postoperative day if stable).
Key test results
• Colonoscopy identifies and locates the mass. DIVERTICULAR DISEASE
• Digital rectal examination reveals the mass. Key signs and symptoms
• Fecal occult blood test is positive. • Anorexia
Key treatments • Change in bowel habits
• Radiation therapy to reduce tumor size • Flatulence
• Surgery depending on tumor location • Left lower quadrant pain or midabdominal pain that radiates
• Antineoplastics: doxorubicin (Adriamycin), 5-fluorouracil to the back
(Adrucil) • Nausea
Key intervention Key test result
• Provide postoperative care if indicated (monitor vital signs and • Sigmoidoscopy shows a thickened wall in the diverticula.
intake and output; make sure the NG tube is kept patent; monitor Key treatments
dressings for drainage; apply a sequential compression device • Colon resection (for diverticulitis refractory to medical treat-
and maintain while on bedrest; evaluate the wound for infection; ment)
assist with turning, coughing, deep breathing, and incentive • Liquid diet for mild diverticulitis or diverticulosis before pain
spirometry; and medicate for pain as necessary or guide the pa- subsides; high-fiber, low-fat diet after pain subsides
tient in use of patient-controlled analgesia). • Temporary colostomy possible for perforation, peritonitis, ob-
struction, or fistula that accompanies diverticulitis
CROHN’S DISEASE • Analgesic: morphine
Key signs and symptoms • Antibiotics: metronidazole (Flagyl), ciprofloxacin (Cipro), co-
• Abdominal cramps and spasms after meals trimoxazole (Bactrim) for mild diverticulitis
• Chronic diarrhea with blood • Anticholinergic: propantheline (Pro-Banthine)
• Pain in lower right quadrant • Stool softener: docusate sodium (Colace) for diverticulosis or
Key test result mild diverticulitis
• Upper GI series shows classic string sign: segments of stric- Key interventions
ture separated by normal bowel. • Monitor abdominal distention and bowel sounds.
Key treatments • Prepare the patient for surgery, if necessary (administer cleans-
• Colectomy with ileostomy in many patients with extensive dis- ing enemas, osmotic purgative, oral and parenteral antibiotics).
ease of the large intestine and rectum • Provide postoperative care (watch for signs of infection; per-
• Antibiotics: sulfasalazine (Azulfidine), metronidazole (Flagyl) form meticulous wound care; watch for signs of postoperative
• Anticholinergics: propantheline (Pro-Banthine), dicyclomine
(Bentyl)
(continued)
920108.qxd 8/7/08 3:01 PM Page 240

DIVERTICULAR DISEASE (continued) Key treatments
bleeding; assist with turning, coughing, and deep breathing; and • Gastric surgery: gastroduodenostomy, gastrojejunostomy, par-
teach ostomy self-care). tial gastric resection, total gastrectomy
• Antineoplastics: carmustine (BiCNU), 5-fluorouracil (Adrucil)
ESOPHAGEAL CANCER
• Vitamin supplements: folic acid (Folvite), cyanocobalamin (vita-
Key signs and symptoms min B12) for patients who have undergone total gastrectomy
• Dysphagia Key interventions
• Substernal pain
• Monitor GI status postoperatively.
• Weight loss
• Maintain the position, patency, and low suction of NG tube
Key test result (without irrigating or repositioning the NG tube because it may
• Endoscopic examination of the esophagus, punch and brush put pressure on the suture line).
biopsies, and an exfoliative cytologic test confirm esophageal tu-
mors. GASTRITIS
• Gastrostomy or jejunostomy to help provide adequate nutrition • Abdominal cramping
• Radiation therapy • Epigastric discomfort
• Radical surgery to excise the tumor and resect either the • Hematemesis
esophagus alone or the stomach and the esophagus • Indigestion
• Antineoplastics: fluorouracil (5-FU), cisplatin (Platinol) Key test result
Key interventions • Upper GI endoscopy with biopsy confirms the diagnosis when
• Before surgery, answer the patient’s questions and let him performed within 24 hours of bleeding.
know what to expect after surgery (gastrostomy tubes, closed Key treatments
chest drainage, and NG suctioning). • I.V. fluid therapy
• After surgery, monitor vital signs and watch for unexpected • NG lavage to control bleeding
changes. If surgery included an esophageal anastomosis, keep • Histamine2-receptor antagonists: cimetidine (Tagamet), raniti-
the patient flat on his back. dine (Zantac), famotidine (Pepcid), nizatidine (Axid)
• Promote adequate nutrition, and evaluate the patient’s nutri- Key interventions
tional and hydration status. • If the patient is vomiting, give antiemetics and I.V. fluids.
• Place the patient in Fowler’s position for meals and allow plen- • Monitor fluid intake and output and electrolyte levels.
ty of time to eat. • Provide a bland diet. Monitor the patient for recurrent symp-
• Provide high-calorie, high-protein, pureed food as needed. toms as food is reintroduced.
• If the patient has a gastrostomy tube, give food slowly, using • Offer small, frequent meals. Eliminate foods that cause gastric
gravity to adjust the flow rate. Offer him something to chew be- upset.
fore each feeding. • If surgery is necessary, prepare the patient preoperatively and
• Provide emotional support for the patient and his family. provide appropriate postoperative care.
GASTRIC CANCER • Administer antacids and other prescribed medications.
• Provide emotional support to the patient.
• Anorexia GASTROENTERITIS
• Epigastric fullness and pain Key signs and symptoms
• Nausea and vomiting • Abdominal discomfort
• Pain after eating that isn’t relieved by antacids • Diarrhea
• Weight loss • Nausea and vomiting
Key test results
• Gastric analysis shows positive cancer cells and achlorhydria.
• Gastroscopy biopsy is positive for cancer cells.
920108.qxd 8/7/08 3:01 PM Page 241

GASTROENTERITIS (continued) • Fatigue
Key test result • Right upper quadrant pain
• Stool culture identifies the causative bacteria, parasites, or • Weight loss
amoebae. During icteric phase (usually 1 to 2 weeks)
Key treatments • Clay-colored stools
• Fatigue
• I.V. fluid and electrolyte replacement
• Jaundice
• Antidiarrheals: camphorated opium tincture (Paregoric), diphe-
• Pruritus
noxylate with atropine (Lomotil), loperamide (Imodium)
• Weight loss
Key interventions During posticteric or recovery phase (usually 2 to 12 weeks,
• Administer medications; correlate dosages, routes, and times sometimes longer in patients with hepatitis B, C, or E)
appropriately with the patient’s meals and activities; for example, • Decreased hepatomegaly
give antiemetics 30 to 60 minutes before meals. • Decreased jaundice
• If the patient is unable to tolerate food, replace lost fluids and • Fatigue
electrolytes with clear liquids and sports drinks.
Key test results
• Record strict intake and output. Watch for signs of dehydra-
• Blood chemistry shows increased alanine aminotransferase,
tion, such as dry skin and mucous membranes, fever, and
AST, alkaline phosphatase, LD, bilirubin, and erythrocyte sedi-
sunken eyes.
mentation rate.
• Wash your hands thoroughly after giving care.
• Serologic tests identify hepatitis A virus, hepatitis B virus,
GASTROESOPHAGEAL REFLUX DISEASE hepatitis C virus, and delta antigen, if present.
Key signs and symptoms Key treatment
• Dysphagia • Vitamins and minerals: vitamin K (AquaMEPHYTON), vitamin C
• Heartburn (burning sensation in the upper abdomen) (ascorbic acid), vitamin B-complex (mega-B)
Key test results Key interventions
• Barium swallow fluoroscopy indicates reflux. • Monitor GI status and watch for bleeding and fulminant hepati-
• Esophagoscopy shows reflux. tis.
• Endoscopy allows visualization and confirmation of pathologic • Maintain standard precautions.
changes in the mucosa. HIATAL HERNIA
• Positional therapy to help relieve symptoms by decreasing in- • Dysphagia
tra-abdominal pressure • Regurgitation
• GI stimulants: metoclopramide (Reglan), bethanechol (Ure- • Sternal pain after eating
choline)
Key test results
Key interventions • Barium swallow reveals protrusion of the hernia.
• Develop a diet for the patient that takes his food preferences • Chest X-ray shows protrusion of abdominal organs into the
into account. thorax.
• Have the patient sleep in reverse Trendelenburg’s position • Esophagoscopy shows incompetent cardiac sphincter.
(with the head of the bed elevated 6⬙ to 12⬙ [15 to 30 cm]).
Key treatments
After surgery
• Bland diet in small, frequent meals with decreased intake of
• If needed, perform chest physiotherapy and give oxygen.
caffeine and spicy foods
• Place the patient with an NG tube in semi-Fowler’s position.
• Anticholinergic: propantheline (Pro-Banthine)
HEPATITIS • Histamine2-receptor antagonists: cimetidine (Tagamet), raniti-
Key signs and symptoms dine (Zantac), famotidine (Pepcid)
During preicteric phase (usually 1 to 5 days)
• Clay-colored stools (continued)
920108.qxd 8/7/08 3:01 PM Page 242

HIATAL HERNIA (continued) eliminated; then each food is gradually reintroduced to identify
Key interventions which foods, if any, trigger the patient’s symptoms)
• Monitor respiratory status. • Avoiding high-fat foods
• Avoid flexion at the waist when positioning the patient. • Diet containing 15 to 20 g daily of bulky foods, such as wheat
bran, oatmeal, oat bran, rye cereals, prunes, dried apricots, and
INTESTINAL OBSTRUCTION figs (if the patient has constipation and abdominal pain)
Key signs and symptoms • Stress management
• Abdominal distention • Antispasmodic: propantheline (Pro-Banthine)
• Cramping pain • Antidiarrheal: diphenoxylate with atropine (Lomotil)
• Diminished or absent bowel sounds Key intervention
Key test results • Help the patient deal with stress, and warn against depen-
• Abdominal X-ray shows increased amount of gas in bowel. dence on sedatives or antispasmodics.
• Barium enema stops at obstruction.
PANCREATITIS
Key treatments
• Bowel resection with or without anastomosis if other treatment
• Abdominal tenderness and distention
fails
• Abrupt onset of pain in the epigastric area that radiates to
• GI decompression using NG, Miller-Abbott, or Cantor tube
the shoulder, substernal area, back, and flank
• Fluid and electrolyte replacement
• Aching, burning, stabbing, pressing abdominal pain
Key interventions • Nausea and vomiting
• Monitor GI status. Assess and record bowel sounds once per • Tachycardia
shift.
Key test results
• Measure and record the patient’s abdominal girth.
• Blood chemistry shows increased amylase, lipase, LD, glu-
• Maintain the position, patency, and low intermittent suction of
cose, AST, and lipid levels and decreased calcium and potassi-
NG and Miller-Abbott tubes.
um levels.
• Provide postoperative care if indicated (monitor vital signs and
• Cullen’s sign is positive.
intake and output; make sure the NG tube is kept patent; monitor
• Grey Turner’s sign is positive.
dressings for drainage; evaluate the wound for infection; assist
• Ultrasonography reveals cysts, bile duct inflammation, and di-
with turning, coughing, deep breathing, and incentive spirome-
lation.
try; apply a sequential compression device while the patient is
on bedrest; and medicate for pain as necessary or guide the pa- Key treatments
tient in use of postoperative patient-controlled analgesia). • Bed rest
• I.V. fluids (vigorous replacement of fluids and electrolytes)
IRRITABLE BOWEL SYNDROME • Transfusion therapy with packed red blood cells
Key signs and symptoms • Analgesic: morphine
• Abdominal bloating • Antidiabetic: insulin
• Constipation, diarrhea, or both • Corticosteroid: hydrocortisone (Solu-Cortef)
• Lower abdominal pain • Potassium supplement: I.V. potassium chloride
• Passage of mucus Key interventions
• Pasty, pencil-like stools • Monitor abdominal, cardiac, and respiratory status (as the dis-
Key test result ease progresses, watch for respiratory failure, tachycardia, and
• Sigmoidoscopy may disclose spastic contractions. worsening GI status).
Key treatments • Evaluate fluid balance.
• Elimination diet to determine if symptoms result from food intol- • Perform bedside glucose monitoring.
erance (in this type of diet, certain foods, such as citrus fruits, • Monitor I.V. fluids.
coffee, corn, dairy products, tea, and wheat, are sequentially • Turn the patient every 2 hours, or use a specialty rotation bed.
920108.qxd 8/7/08 3:01 PM Page 243

PEPTIC ULCER DISEASE Key treatment
Key signs and symptoms • Surgical intervention when the patient’s condition is stabilized
• Anorexia (surgery is chosen to treat the cause [for example, if the patient
• Hematemesis has a perforated appendix, then an appendectomy is indicated];
• Left epigastric pain 1 to 2 hours after eating drains will also be placed for drainage of infected material)
• Relief of pain after administration of antacids Key interventions
Key test results • Monitor abdominal and respiratory status and fluid balance.
• Barium swallow shows ulceration of the gastric mucosa. • Monitor and record vital signs, intake and output, laboratory
• Upper GI endoscopy shows the location of the ulcer. studies, daily weight, and urine specific gravity.
Key treatments • Provide postoperative care (monitor vital signs and intake and
output, including drainage from drains; assist with turning, incen-
• If GI hemorrhage: Gastric surgery that may include gastroduo-
tive spirometry, coughing, and deep breathing; apply a sequen-
denostomy, gastrojejunostomy, partial gastric resection, and to-
tial compression device while the patient is on bedrest; and get
tal gastrectomy
the patient out of bed on the 1st postoperative day if his condi-
• Saline lavage by NG tube until return is clear (if bleeding is pre-
tion allows).
sent)
• Antibiotic if Helicobacter pylori is present ULCERATIVE COLITIS
• Histamine2-receptor antagonists: cimetidine (Tagamet), raniti- Key signs and symptoms
dine (Zantac), nizatidine (Axid), famotidine (Pepcid) • Abdominal cramping
• Mucosal barrier fortifier: sucralfate (Carafate) • Bloody, purulent, mucoid, watery stools (15 to 20 per day)
Key interventions • Hyperactive bowel sounds
• Monitor GI and cardiovascular status. • Weight loss
• Maintain the position, patency, and low suction of NG tube if Key test results
gastric decompression is ordered. • Barium enema shows ulcerations.
• Provide postoperative care if necessary (don’t reposition the • Sigmoidoscopy shows ulceration and hyperemia.
NG tube; irrigate it gently if ordered; medicate for pain as needed
Key treatments
and ordered; monitor dressings for drainage; evaluate bowel
sounds; assist with incentive spirometry; apply a sequential • Colectomy or pouch ileostomy
compression device while the patient is on bedrest; and get the • Total parenteral nutrition (TPN) if necessary to rest the GI tract
patient out of bed as tolerated). • Antibiotic: sulfasalazine (Azulfidine)
• Anticholinergics: propantheline (Pro-Banthine), dicyclomine
PERITONITIS (Bentyl)
Key signs and symptoms • Antidiarrheals: diphenoxylate (Lomotil), loperamide (Imodium)
• Abdominal resonance and tympany on percussion • Antiemetic: prochlorperazine (Compazine)
• Abdominal rigidity and distention • Corticosteroid: hydrocortisone (Solu-Cortef)
• Constant, diffuse, and intense abdominal pain • Immunosuppressants: azathioprine (Imuran), cyclophos-
• Decreased or absent bowel sounds phamide (Cytoxan)
• Decreased urine output Key interventions
• Fever • Montor GI status and fluid balance.
• Rebound tenderness • Monitor the number, amount, and character of stools.
• Shallow respirations • Maintain I.V. fluids and TPN.
• Weak, rapid pulse • Maintain the position, patency, and low suction of NG tube.
Key test result
• Abdominal X-ray shows free air in the abdomen under the di-
aphragm.
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Enzymes and hormones Barium below

The pancreas secretes three digestive en- A lower GI series, also known as a barium
zymes: amylase, lipase, and trypsin into the enema, uses an X-ray to examine the large in-
duodenum. It also secretes the hormones intestine after the instillation of barium.
sulin, glucagon, and somatostatin from the
islets of Langerhans into the blood. In addi- Nursing actions
tion, the pancreas secretes large amounts of Before the procedure
sodium bicarbonate, which is used to neutral- • Withhold food and fluids for at least 8
ize the acid in chyme. hours.
• Administer bowel preparation (laxatives and
enemas), as prescribed.
After the procedure
Visualize. Imagine
Keep abreast of • Force fluids unless contraindicated.
• Administer enemas and laxatives, as pre-
that you’re caring for
a real-life patient and
diagnostic tests scribed.
• Monitor color and consistency of stool.
performing each Here are some important tests used to diag-
nursing action. It will nose GI disorders, along with common nurs- Stomach cam
make information
ing interventions associated with each test. Endoscopy uses an endoscope to view the
more meaningful and
help you remember. esophagus and stomach.
Barium above
A barium swallow test involves fluoroscopic Nursing actions
examination of the pharynx and esophagus. Before the procedure
• Withhold food and fluids for at least 8
Nursing actions hours.
• Before the procedure, withhold food and • Make sure that written, informed consent
fluids for at least 8 hours and evaluate the pa- has been obtained.
tient’s ability to swallow. • Obtain baseline vital signs.
• After the procedure, force fluids unless con- • Administer sedatives, as prescribed.
traindicated and administer laxatives, as pre- After the procedure
scribed. • Monitor gag and cough reflexes.
Barium between • Evaluate vasovagal response.
An upper GI series uses an X-ray to exam- • Withhold food and fluids until the gag re-
ine the esophagus, stomach, duodenum, and flex returns.
other portions of the small bowel after the pa-
tient swallows barium. Blood search
A fecal occult blood test analyzes stools for
Nursing actions the presence of blood.
• Withhold food and fluids for at least 8 Nursing actions
hours. • Instruct the patient to avoid red meat for 3
• Maintain I.V. fluids and administer cathar- days before the test.
tics and enemas, as prescribed. • Document administration of aspirin, antico-
After the procedure agulants, vitamin C, and anti-inflammatory
• Inform the patient that stool will be drugs. (See Testing for occult blood.)
light-colored for several days.
• Administer cathartics, fluids, and enemas, Fat search
as prescribed. A fecal fat test analyzes stool for the pres-
ence of fat.
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Stepping up
Testing for occult blood

WHY YOU DO IT • Obtain a small specimen from two different areas of the stool
A minute quantity of fecal occult blood can be detected by mi- to allow for any variation in the distribution of blood.
croscopic analysis or chemical test for hemoglobin, such as the • Use a commercially prepared Hemoccult card and developer
guaiac or orthotolidine tests. Small amounts of blood (2 to 2.5 as instructed. Apply two drops of the chemical developer to the
ml/day) normally appear in the feces; these tests are designed paper covering the sample. Note the color after 1 minute.
to detect greater-than-normal quantities. They’re used to detect • A normal result is indicated by a green reaction (less than 2
GI bleeding and to aid early diagnosis of colorectal cancer. ml of blood are present); an abnormal result (positive for fecal
occult blood) is indicated by a blue reaction that occurs within
HOW YOU DO IT
30 to 60 seconds. If the blue color appears within this period,
• Explain the purpose of the test to the patient. Instruct him to
consider it strongly positive. A faint blue reaction is weakly pos-
avoid contaminating the stool specimen with toilet tissue or
itive and not necessarily abnormal.
urine.
• Document the appearance of the stool and test results.
Nursing actions Nursing actions

• Instruct the patient to abstain from alcohol Before the procedure
and to maintain a high-fat diet (100 g/day) for • Encourage a low-residue, high-fat diet 1 day
3 days before and during the 72-hour stool before the examination.
collection. • Make sure that written, informed consent
• Refrigerate the specimen. has been obtained.
• Document current medications. • Withhold food and fluids after midnight.
• Note the patient’s allergies to iodine, sea-
From colon to canal food, and radiopaque dyes.
Proctosigmoidoscopy uses a lighted scope • Inform the patient about possible throat irri-
to view the sigmoid colon, rectum, and anal tation and flushing of the face.
canal. After the procedure
• Check the injection site for bleeding. Pass it on! A
Nursing actions • Monitor the patient’s vital signs. biliary duct, also
Before the procedure • Administer fluids to flush the dye out called a bile duct, is a
• Administer bowel preparation, as pre- through the kidneys. duct by which bile
scribed. passes from the liver
• Make sure that written, informed consent Flow glow or gallbladder to the
has been obtained. A liver scan produces an image of blood flow duodenum.
After the procedure in the liver using an injection of a radioiso-
• Document iron intake. tope.
• Check the patient for bleeding.
• Monitor the patient’s vital signs. Nursing actions
• Monitor the patient for complications such Before the procedure
as perforated bowel (abdominal tenderness, • Determine the patient’s ability to lie still
rigidity, and distention). during the procedure.
• Check the patient for possible allergies.
A biliary duct to dye for • Make sure that written, informed con-
Cholangiography uses dye injection to pro- sent has been obtained.
duce a radiographic picture of the biliary duct
system.
920108.qxd 8/7/08 3:01 PM Page 246
After the procedure Blood study 2

• Monitor the patient for signs and symptoms A hematologic study is used to analyze a
of delayed allergic reaction to the radioiso- blood sample for red blood cells (RBCs),
tope, such as itching and hives. white blood cells (WBCs), platelets, hemoglo-
bin (Hb level), hematocrit (HCT), and ery-
Acid basics throcyte sedimentation rate (ESR).
A gastric analysis is performed after the pa-
tient has fasted. Results indicate the acidity of Nursing actions
gastric secretions aspirated through a naso- • Note current drug therapy.
Liver biopsy gastric (NG) tube. • Check the venipuncture site for bleeding.
involves percutaneous
removal of liver tissue Nursing actions Blood study 3
with a needle. Before the procedure A coagulation study is a laboratory test of a
Afterward, watch for • Withhold food and fluids after midnight. blood sample that analyzes prothrombin time
signs of shock and • Instruct the patient not to smoke for 8 to 12 (PT), international normalized ratio (INR),
pneumothorax. hours before the test. and partial thromboplastin time (PTT).
• Withhold medications that can affect gastric
secretions for 24 hours before the procedure. Nursing actions
After the procedure • Note current drug therapy.
• Obtain vital signs. • Check the venipuncture site for bleeding.
• Note reactions to gastric acid stimulant, if
used. Tissue bye-bi
A liver biopsy, which is used to diagnose dis-
Organ organ echo echo orders such as cirrhosis and cancer, involves
Ultrasonography uses echoes from sound percutaneous removal of liver tissue with a
waves to visualize body organs. needle.

• Evaluate the patient’s ability to lie still dur- Before the procedure
ing the procedure. • Withhold food and fluids after midnight.
• Explain the procedure to the patient. • Make sure that written, informed consent
has been obtained.
Blood study 1 • Obtain baseline clotting studies and vital
Blood chemistr y tests are used to analyze signs.
the patient’s blood. Samples may be obtained • Instruct the patient to exhale and hold his
to analyze potassium, sodium, calcium, phos- breath during insertion of the needle.
phorus, glucose, bicarbonate, blood urea ni- After the procedure
trogen, creatinine, protein, albumin, osmolali- • Check the insertion site for bleeding.
ty, amylase, lipase, alkaline phosphatase, am- • Monitor the patient’s vital signs.
monia, bilirubin, lactate dehydrogenase (LD), • Observe the patient for signs of shock (hy-
aspartate aminotransferase (AST), serum ala- potension, tachycardia, oliguria) and pneumo-
nine aminotransferase (ALT), hepatitis- thorax (decreased breath sounds on the af-
associated antigens, and carcinoembryonic fected side, tachypnea, shortness of breath).
antigen (CEA). • Position the patient on his right lateral side
for hemostasis.
Nursing actions
• Note current drug therapy. Lighting the large intestine
• Check the venipuncture site for bleeding. Colonoscopy uses a lighted scope to directly
visualize the large intestine.
920108.qxd 8/7/08 3:01 PM Page 247

Quick! Name
Before the procedure Before the procedure three important
• Make sure that written, informed consent • Inform the patient that the X-ray table will diagnostic tests
has been obtained. be tilted and rotated during the procedure. for GI disorders.
• Provide a clear liquid diet 48 hours before • Make sure that written, informed consent
the test. has been obtained.
• Administer a bowel preparation the day be- • Check for allergies to iodine or seafood.
fore the test. • Check PT, INR, and PTT before the proce-
• Explain that the patient will feel cramping dure.
and the sensation of needing to have a bowel • Type and cross-match the patient’s blood.
movement. • Withhold food and fluids after midnight.
• Explain the use of air to distend the bowel After the procedure
lumen. • Require the patient to rest on his side for at
After the procedure least 6 hours.
• Monitor for gross bleeding. • Check for bleeding at the injection site.
• Monitor for signs and symptoms of colon • Monitor vital signs.
perforation (abdominal distention, pain, and • Withhold food and fluids for 2 hours.
rigidity).
• Withhold food and fluids for 2 hours.
• Check for blood in stool if polyps were re-
moved.
• Monitor the patient’s vital signs.
Duct tapes
care
Endoscopic retrograde cholangiopancre- Major GI disorders include appendicitis,
atography (ERCP) is radiographic examina- cholecystitis, cirrhosis, colorectal cancer,
tion of the hepatobiliary tree and pancreatic Crohn’s disease, diverticular disease,
ducts using a contrast medium and a lighted esophageal cancer, gastric cancer, gastritis,
scope. gastroenteritis, gastroesophageal reflux dis-
ease (GERD), hepatitis, hiatal hernia, intesti-
Nursing actions nal obstruction, irritable bowel syndrome,
Before the procedure pancreatitis, peptic ulcer disease, peritonitis,
• Make sure that written, informed consent and ulcerative colitis.
has been obtained.
• Withhold food and fluids after midnight.
• Check for allergies to iodine or seafood. Appendicitis
After the procedure
• Check for respiratory depression. Appendicitis is an inflammation of the appen-
• Check for urine retention. dix. Although the appendix has no known
•Monitor gag reflex and withhold food until function, it regularly fills with and empties it-
gag reflex returns. self of food. Appendicitis occurs when the ap-
• Watch for signs and symptoms of proce- pendix becomes inflamed from ulceration of
dure-induced pancreatitis (abdominal pain, the mucosa or from obstruction of the lumen.
nausea, and vomiting).
CAUSES
Croco-bile hunter • Barium ingestion
Percutaneous transhepatic cholangiogra- • Fecal mass
phy is fluoroscopic examination of the biliary • Stricture
ducts. It involves injection of a contrast me- • Viral infection
dium.
920108.qxd 8/7/08 3:01 PM Page 248
Stepping up
Using an incentive spirometer

WHY YOU DO IT • Instruct the patient to insert the mouthpiece
The purpose of incentive spirometry is for the and to close his lips tightly around it to create a
patient to achieve maximum ventilation. Maxi- seal.
mum ventilation is necessary to help prevent • Tell the patient to exhale normally and then in-
and reverse alveolar collapse, which can cause hale as slowly and as deeply as possible; in-
atelectasis and pneumonitis. struct him to retain the entire volume of air in-
haled for 3 seconds or, if he’s using a device
HOW YOU DO IT
with a light indicator, until the light turns off.
• Evaluate the patient’s condition.
• Tell the patient to remove the mouthpiece and
• Explain the procedure and the importance of
exhale normally. Repeat this sequence 5 to 10
regularly performing incentive spirometry to
times during every waking hour.
maintain alveolar inflation.
• Document the patient’s response and tidal vol-
• Place the patient in a comfortable sitting or
umes.
semi-Fowler position to promote optimal lung
expansion.
DATA COLLECTION FINDINGS NURSING DIAGNOSES

• Anorexia • Imbalanced nutrition: Less than body re-
• Constipation quirements
When pain • Generalized abdominal pain that becomes • Acute pain
suddenly stops localized in the right lower abdomen (McBur- • Risk for infection
during ney’s point)
appendicitis, it
indicates rupture.
• Lies in bent-knee position TREATMENT
Prepare the • Low-grade fever • Appendectomy
patient for • Malaise • I.V. fluids to prevent dehydration
emergency surgery. • Nausea and vomiting • Nothing by mouth
• Psoas sign (abdominal pain on hip hyperex-
tension) Drug therapy
• Rovsing’s sign (right lower quadrant pain • Analgesics: morphine (administered only
resulting from palpation of left lower quad- when diagnosis is confirmed)
rant) • Antbiotics: cefoxitin (Mefoxin)
• Sudden cessation of pain (indicates rup- • Antipyretics: acetaminophen (Tylenol)
ture)
DIAGNOSTIC FINDINGS • Monitor GI status and pain. Sudden cessa-
• Hematology shows moderately elevated tion of pain preoperatively may indicate appen-
WBC count. dix rupture.
• An abdominal X-ray with radiographic con- • Monitor and record vital signs and intake
trast agent reveals failure of the appendix to and output to determine fluid volume.
fill with contrast. • Administer medications as ordered to main-
• An abdominal CT scan shows inflammation tain or improve the patient’s condition.
or rupture of the appendix. • Maintain nothing-by-mouth status until bow-
• An abdominal ultrasound shows inflamma- el sounds return postoperatively; then ad-
tion of the appendix.
920108.qxd 8/7/08 3:01 PM Page 249
vance diet as tolerated to promote healing and DIAGNOSTIC FINDINGS

meet metabolic needs. • Blood chemistry reveals increased alkaline
• Assist patient with incentive spirometry, phosphatase, bilirubin, direct bilirubin trans-
turning, coughing, and deep breathing to mo- aminase, amylase, lipase, AST, and LD levels. Memory
bilize secretions and promote lung expansion. • Cholangiogram shows stones in the biliary jogger
(See Using an incentive spirometer.) tree.
• Monitor dressings for drainage and incision • Gallbladder series shows stones in the bil- Cholecys-
for infection postoperatively to detect early iary tree. titis oc-
signs of infection and prevent complications. • Hematology shows increased WBC count.
curs most often in
overweight women
• Liver scan shows obstruction of the biliary over age 40 who
Teaching topics tree. haven’t gone
• Completing follow-up medical care • Ultrasound shows bile duct distention and through meno-
• Following activity restrictions calculi. pause. To remember
• Recognizing the signs and symptoms of in- • ERCP reveals the presence of ductal stones. risk factors associ-
fection ated with cholecys-
NURSING DIAGNOSES titis, think of the
• Deficient fluid volume four Fs:
Cholecystitis • Acute pain Female
Fertile
Cholecystitis is acute or chronic inflammation
of the gallbladder most commonly associated TREATMENT Forty
with cholelithiasis (presence of gallstones). It • Small, frequent meals of a low-fat, low- Fat.
occurs when an obstruction, such as calculi calorie diet high in carbohydrates, protein,
or edema, prevents the gallbladder from con- and fiber with restricted intake of gas-forming
tracting when fatty foods enter the duode- foods or no foods or fluids, as directed
num. • Extracorporeal shock wave lithotripsy
• Incentive spirometry (postoperatively)
CAUSES • Laparoscopic cholecystectomy or open
• Cholelithiasis cholecystectomy
• Estrogen therapy
• High-fat diet Drug therapy
• Infection of the gallbladder • Analgesic: morphine
• Major surgery • Antibiotics: ceftazidime (Fortaz), clin-
• Obesity damycin (Cleocin), gentamicin (Gentak)
• Trauma • Anticholinergics: propantheline (Pro-Ban-
thine), dicyclomine (Bentyl)
DATA COLLECTION FINDINGS • Antiemetic: prochlorperazine (Compazine)
• Belching • Antipruritic: diphenhydramine (Benadryl)
• Clay-colored stools
• Dark amber urine INTERVENTIONS AND RATIONALES
• Ecchymosis • Monitor abdominal status and pain to deter-
• Episodic colicky pain in the epigastric area mine baseline and detect changes in the pa-
that radiates to the back and shoulder tient’s condition.
• Fever • Monitor and record vital signs, intake and
• Flatulence output, laboratory studies, and urine specific
• Indigestion or chest pain after eating fatty gravity to evaluate fluid and electrolyte bal-
or fried foods ance.
• Jaundice • Maintain the patient’s diet; withhold food
• Nausea and vomiting and fluids to rest the GI tract and prevent re-
• Pruritus currence of the condition.
• Steatorrhea
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Stepping up
Performing nasogastric tube care

WHY YOU DO IT • When suction is applied to a Salem sump tube or a Levin tube,
Providing effective nasogastric (NG) tube care requires meticu- unclamp and disconnect the tube from the suction equipment
lous monitoring of the patient and the equipment. Monitoring while holding it over a linen-saver pad or an emesis basin to
the patient involves checking drainage from the NG tube and collect any drainage.
assessing GI function. Monitoring the equipment involves veri- • Slowly instill the irrigant into the NG tube. When irrigating a
fying correct tube placement and irrigating the tube to ensure Salem sump tube, you may instill small amounts of solution into
patency and to prevent mucosal damage. the vent lumen without interrupting suction; instill greater
amounts into the larger, primary lumen.
HOW YOU DO IT
• Gently aspirate the solution with the bulb syringe or a 60-ml
• Explain the procedure to the patient and provide privacy.
catheter-tip syringe or connect the tube to the suction equip-
• Wash your hands and put on gloves.
ment as ordered. Gentle aspiration prevents excessive pres-
• Aspirate stomach contents and check the pH of the aspirate
sure on the suture line and the delicate gastric mucosa. Report
to check correct positioning in the stomach. The color of the
any bleeding.
aspirate should be green or brown with mucous and the pH
• Reconnect the tube to suction after completing the irrigation.
should be less than or equal to 5.
• Document tube placement confirmation (usually every 4 to 8
• To irrigate the tube, draw up irrigant in a bulb syringe or 60-ml
hours). Keep a precise record of fluid intake and output, includ-
catheter tip syringe (usually 30 ml of normal saline solution). Be
ing the instilled irrigant in fluid intake. Track the irrigation
sure to accurately measure the amount of irrigant to maintain
schedule and note the actual time of each irrigation. Describe
an accurate intake and output record.
drainage color, consistency, odor, and amount. Also, note tape
change times and the condition of the nares.
• Maintain I.V. fluids to provide the patient • Provide skin, nares, and mouth care to pro-
with necessary fluids and electrolytes. mote patient comfort and prevent tissue break-
• Administer medications as prescribed to down.
treat infection, decrease pain, and promote • Maintain a quiet environment to promote
comfort. rest.
• Provide postoperative care (monitor dress- • Apply a sequential compression device to
ings for drainage; if open cholecystectomy, prevent thrombosis formation.
Talkin’ ’bout monitor and record T-tube drainage, monitor
regeneration…The
the incision for signs of infection, get the pa- Teaching topics
process whereby
necrotic cells are tient out of bed as soon as possible, and en- • Using patient-controlled analgesia
replaced by fibrous courage the use of patient-controlled analge- • Using incentive spirometry
cells is called fibrotic sia) to maintain the patient’s condition and • Completing skin care daily
regeneration. prevent postoperative complications. • Recognizing the signs and symptoms of in-
• Assist with turning, incentive spirometry, fection
coughing, and deep breathing to mobilize se- • Importance of early ambulation postopera-
cretions and promote lung expansion. tively to prevent complications of immobility
• Maintain the position, patency, and low suc-
tion of NG tube to prevent nausea and vomit-
ing. (See Performing nasogastric tube care.) Cirrhosis
• Place the patient in semi-Fowler’s position
to promote comfort and facilitate GI emptying. Cirrhosis is a chronic hepatic disease charac-
terized by diffuse destruction of hepatic cells,
which are replaced by fibrous cells. Necrotic
920108.qxd 8/7/08 3:01 PM Page 251
tissue yields to fibrosis. Cirrhosis alters liver terol, alkaline phosphatase, AST, ALT, and LD
In cirrhosis, drug
structure and normal vasculature, impairs and increased thymol turbidity. therapy requires
blood and lymph flow, and eventually causes • Urine studies show increased levels of special caution
hepatic insufficiency. Cirrhosis is irre- bilirubin and urobilinogen. because the cirrhotic
versible. • Stool studies reveal decreasing urobilino- liver can’t detoxify
gen levels. harmful substances
CAUSES • Hepatitis profile identifies antibodies specif- efficiently.
• Alcoholism and resulting malnutrition ic to the causative virus.
• Autoimmune disease such as sarcoidosis or
chronic inflammatory bowel disease NURSING DIAGNOSES
• Exposure to hepatitis (types A, B, C, D, and • Imbalanced nutrition: Less than body
E viral hepatitis) or toxic substances requirements
• Risk for injury
DATA COLLECTION FINDINGS • Ineffective breathing pattern
• Abdominal pain (possibly because of an en-
larged liver) TREATMENT
• Anorexia • Blood transfusions, as indicated
• Ascites • Fluid restriction (usually to 1,500 ml/day)
• Clay-colored stools • Gastric intubation and esophageal balloon
• Constipation tamponade for bleeding esophageal varices
• Diarrhea (Sengstaken-Blakemore method, esophago-
• Fatigue gastric tube method, Minnesota tube method)
• Headache • I.V. therapy using colloid volume expanders
• Hepatomegaly or crystalloids
• Indigestion • Oxygen therapy (may require endotracheal
• Jaundice (ET) intubation and mechanical ventilation)
• Muscle cramps • Paracentesis to reduce abdominal pressure
• Nausea from ascites
• Pruritus • Transjugular intrahepatic portal-systemic
• Spider telangiectases shunting performed by a radiologist as a last
• Vomiting resort for patients with bleeding esophageal
varices and portal hypertension (may help
DIAGNOSTIC FINDINGS until liver transplantation is possible)
• Liver biopsy, the definitive test for cirrhosis, • Sclerotherapy, if the patient continues to
shows hepatic tissue destruction and fibrosis. experience repeated hemorrhagic episodes
• Computed tomography (CT) scan with I.V. despite conservative treatment
contrast medium reveals enlarged liver, iden- • Sodium restriction (usually 500 mg/day)
tifies liver masses, and visualizes hepatic • Low-protein diet
blood flow and obstruction, if present. • Liver transplantation
• Magnetic resonance imaging is used to fur- • Total parenteral nutrition (TPN) may be
ther assess hepatic nodules. necessary during the acute stages
• Esophagogastroduodenoscopy reveals
bleeding esophageal varices, stomach irrita- Drug therapy
tion or ulceration, or duodenal bleeding and • Antiemetic: ondansetron (Zofran)
irritation. • Somastatin analog: octreotide (Sandostatin)
• Blood studies reveal elevated WBC count, • Hemostatic: vasopressin (Pitressin) for
decreased platelets and HCT, and decreased esophageal varices
levels of Hb, albumin, serum electrolytes • Diuretics: furosemide (Lasix), spironolac-
(sodium, potassium, chloride, magnesium), tone (Aldactone) for edema (diuretics require
and folate. Prolonged PT. careful monitoring; fluid and electrolyte im-
• Blood studies reveal elevated levels of glob- balance may precipitate hepatic encepha-
ulin, ammonia, total bilirubin, total choles- lopathy)
920108.qxd 8/7/08 3:01 PM Page 252
• Vitamin K: phytonadione (AquaMEPHY- • Handle the patient gently, and turn and
Watch ammonia
levels in a patient TON) for bleeding tendencies due to hypo- reposition often to keep skin intact.
with cirrhosis. prothrombinemia • Encourage rest and good nutrition to help
Elevated ammonia • Beta-adrenergic blocker: propranolol (In- the patient conserve energy and decrease meta-
levels may lead to deral) to decrease pressure from varices bolic demands on the liver.
encephalopathy. • Laxative: lactulose (Cephulac) to reduce • Encourage frequent, small meals to ensure
serum ammonia levels nutritional needs are met.
• Bile acid sequestrant: cholestyramine
(Questran) controls itching Teaching topics
• Avoiding infections and abstaining from al-
INTERVENTIONS AND RATIONALES cohol
• Check respiratory status frequently because • Contacting Alcoholics Anonymous if appro-
abdominal distention may interfere with lung priate
expansion. • Avoiding activities that increase intra-
• Position the patient to facilitate breathing. abdominal pressure, such as heavy lifting, vig-
• Check skin, gums, stool, and emesis regu- orous coughing, and straining during a bowel
larly for bleeding to recognize early signs of movement
bleeding and prevent hemorrhage.
• Warn the patient against taking aspirin,
straining during defecation, and blowing his Colorectal cancer
nose or sneezing too vigorously to avoid bleed-
ing. Colorectal cancer is a malignant tumor of the
• Suggest using an electric razor and soft colon or rectum. It may be primary or meta-
toothbrush. These measures also prevent bleed- static. It begins when unregulated cell growth
ing. and uncontrolled cell division develop into a
• Observe the patient closely for signs of be- neoplasm. Adenocarcinomas then infiltrate
havioral or personality changes—especially and cause obstruction, ulcerations, and hem-
increased stupor, lethargy, hallucinations, and orrhage.
neuromuscular dysfunction. Behavioral or
personality changes may indicate increased am- CAUSES
monia levels. • Aging
• Monitor ammonia levels. Elevated levels • Chronic constipation
may lead to encephalopathy. • Chronic ulcerative colitis
•Monitor for signs and symptoms of alcohol • Diverticulosis
withdrawl to ensure prompt treatment. • Familial polyposis
• Monitor level of consciousness. • Low-fiber, high-fat diet
• Watch for asterixis, a sign of developing he-
patic encephalopathy. DATA COLLECTION FINDINGS
• Weigh the patient and measure his abdomi- • Abdominal cramping
nal girth daily (at the level of the umbilicus), • Abdominal distention
inspect the ankles and sacrum for dependent • Anorexia
edema, and accurately record intake and out- • Change in bowel habits and shape of stools
put to evaluate fluid retention. • Diarrhea and constipation
• Carefully evaluate the patient before, dur- • Fecal oozing
ing, and after paracentesis because this drastic • Melena
loss of fluid may induce shock. • Pallor
• Avoid using soap when bathing the patient; • Palpable mass
instead, use lubricating lotion or moisturizing • Rectal bleeding
agents to prevent skin breakdown associated • Vomiting
with edema and pruritus. • Weakness
• Weight loss
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The lowdown on location

Surgery for colorectal cancer depends on the transverse colon and mesentery, or segmental
tumor location: resection of the transverse colon and associat-
• Cecum and ascending colon: Surgery is a right ed midcolic vessels.
hemicolectomy. This surgery may include resec- • Sigmoid colon: Surgery is limited to the sig-
tion of the terminal segment of the ileum, cecum, moid colon and mesentery.
ascending colon, and right half of the transverse • Upper rectum: Surgery is an anterior or low
colon with corresponding mesentery. anterior resection.
• Proximal and middle transverse colon: • Lower rectum: Surgery is an abdominoperineal
Surgery is a right colectomy that includes the resection and permanent sigmoid colostomy.
DIAGNOSTIC FINDINGS • Monitor and record vital signs, intake and

• Barium enema is used to locate the mass. output, laboratory studies, and daily weight to
• Biopsy is positive for cancer cells. assess fluid and electrolyte status.
• CEA test is positive. • Monitor and record the color, consistency,
• Colonoscopy is used to identify and locate amount, and frequency of stools to detect early
the mass. changes and bleeding.
• Digital rectal examination reveals the mass. • Monitor for bleeding, infection, and elec-
• Fecal occult blood test is positive. trolyte imbalance to detect early changes and
• Lower GI series shows mass location. prevent complications.
• Hematology shows decreased Hb level and • Maintain the patient’s diet to meet metabolic
HCT. needs and promote healing.
• Sigmoidoscopy is used to identify and locate • Keep the patient in semi-Fowler’s position to
the mass. promote emptying of the GI tract. Patient-controlled
• Maintain TPN to improve nutritional status analgesia allows the
NURSING DIAGNOSES when the patient is unable to consume ade- patient to control I.V.
• Anxiety quate calories through the GI tract. delivery of an
• Deficient fluid volume • Administer postoperative care if indicated analgesic, usually
• Acute pain (monitor vital signs and intake and output; morphine.
make sure the NG tube is kept patent; moni-
TREATMENT tor dressings for drainage; apply a sequential
• Radiation therapy to reduce tumor size compression device and maintain while on
• Surgery depending on tumor location (see bedrest; evaluate wound for infection; assist
The lowdown on location) with turning, coughing, deep breathing, and
incentive spirometry; medicate for pain as
Drug therapy necessary or guide the patient in use of
• Antiemetics: prochlorperazine (Com- patient-controlled analgesia) to prevent com-
pazine), ondansetron (Zofran) plications and promote healing.
• Antineoplastics: doxorubicin (Adriamycin), • Encourage the patient to express feelings
5-fluorouracil (Adrucil) about changes in body image and a fear of dy-
• Folic acid derivative: leucovorin (Wellcov- ing and support coping mechanisms to in-
orin) crease potential for further adaptive behavior.
• Immunomodulator: levamisole (Ergamisol) • Provide skin and mouth care to maintain
tissue integrity.
INTERVENTIONS AND RATIONALES • Provide rest periods to promote healing and
• Monitor GI status to determine baseline and conserve energy.
detect changes in patient’s condition.
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• Provide postchemotherapeutic and postradi- • Upper GI series shows classic string sign:
ation nursing care to promote healing and pre- segments of stricture separated by normal
vent complications. bowel.
• Monitor dietary intake to determine nutri-
tional adequacy. NURSING DIAGNOSES
• Administer antiemetics and antidiarrheals, • Anxiety
as prescribed, to prevent further fluid loss. • Diarrhea
Teaching topics quirements
• Performing ostomy self-care if indicated
• Monitoring changes in bowel elimination TREATMENT
• Self-monitoring for infection • Colectomy with ileostomy in many patients
• Alternating rest periods with activity with extensive disease of the large intestine
• Contacting the United Ostomy Association and rectum
and the American Cancer Society • Small, frequent meals of a diet high in pro-
• Importance of follow-up care and future tein, calories, and carbohydrates and low in
screening fat, fiber, and residue with bland foods and re-
stricted intake of milk and gas-forming foods
Crohn’s disease is or no food or fluids
a chronic disorder. Crohn’s disease • TPN to rest the bowel
Patient care involves
long-term concerns Crohn’s disease is a chronic inflammatory Drug therapy
such as reducing disease of the small intestine, usually affect- • Analgesics: morphine, hydromorphone (Di-
stress. ing the terminal ileum. It also sometimes af- laudid)
fects the large intestine, usually in the ascend- • Antianemics: ferrous sulfate (Feosol), fer-
ing colon. It’s slowly progressive with exacer- rous gluconate (Fergon)
bations and remissions. • Antibiotics: sulfasalazine (Azulfidine),
metronidazole (Flagyl)
CAUSES • Anticholinergics: propantheline (Pro-
• Emotional upsets Banthine), dicyclomine (Bentyl)
• Family history • Antidiarrheal: diphenoxylate (Lomotil)
• Immune factors • Antiemetic: prochlorperazine (Compazine)
• Unknown • Anti-inflammatory: olsalazine (Dipentum)
DATA COLLECTION FINDINGS • Immunosuppressants: mercaptopurine
• Abdominal cramps and spasms after meals (Purinethol), azathioprine (Imuran)
• Chronic diarrhea with blood • Potassium supplements: potassium chloride
• Fever (K-Lor) administered with food, potassium
• Flatulence gluconate (Kaon)
• Nausea
• Pain in lower right quadrant INTERVENTIONS AND RATIONALES
• Steatorrhea • Monitor GI status (note excessive abdomi-
• Weight loss nal distention) and fluid balance to determine
baseline and detect changes in patient’s condi-
DIAGNOSTIC FINDINGS tion.
• Abdominal X-ray shows congested, thick- • Monitor and record vital signs and intake
ened, fibrosed, narrowed intestinal wall. and output, daily weight, urine specific gravi-
• Barium enema shows lesions in terminal ty, and fecal occult blood to detect bleeding and
ileum. dehydration.
• Fecal fat test shows increased fat. • Monitor the number, amount, and character
• Fecal occult blood test is positive. of stools to detect deterioration in GI status.
• Proctosigmoidoscopy shows ulceration.
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•Maintain TPN to rest the bowel and promote DATA COLLECTION FINDINGS
nutritional status. • Anorexia
• Administer medications, as prescribed, to • Bloody stools
maintain or improve patient’s condition. • Change in bowel habits
• Maintain the patient’s diet; withhold food • Constipation and diarrhea
and fluids as necessary to minimize GI dis- • Fever
comfort. • Flatulence
• Minimize stress and encourage verbaliza- • Left lower quadrant pain or midabdominal
tion of feelings to allay the patient’s anxiety. pain that radiates to the back
• Provide skin and perianal care to prevent • Nausea
skin breakdown. • Rectal bleeding
• If surgery is necessary, provide postopera-
tive care (monitor vital signs; monitor dress- DIAGNOSTIC FINDINGS
ings for drainage; apply a sequential compres- • Barium enema (contraindicated in acute di-
sion device to prevent blood clot formation verticulitis) shows inflammation, narrow lu-
while on bed rest; monitor ileostomy drainage men of the bowel, and diverticula.
and perform ileostomy care as needed; evalu- • Hematologic study shows increased WBC
ate the incision for signs of infection; assist count and ESR.
with turning, coughing, deep breathing, and • Sigmoidoscopy shows a thickened wall in
incentive spirometry; get the patient out of the diverticula.
bed on the first postoperative day if stable) to
promote healing and prevent complications. NURSING DIAGNOSES
• Constipation
Teaching topics • Diarrhea
• Performing ileostomy self-care • Acute pain
• Avoiding laxatives and aspirin
• Performing perianal care daily TREATMENT
• Reducing stress • Generally no treatment for diverticulosis
• Recognizing the signs and symptoms of rec- that produces no symptoms
tal hemorrhage and intestinal obstruction • Colon resection (for diverticulitis refractory
to medical treatment)
• Bland diet, stool softeners, and occasional
Diverticular disease doses of mineral oil for diverticulosis with
pain, mild GI distress, constipation, or diffi-
Diverticular disease has two clinical forms: di- cult defecation
verticulosis and diverticulitis. Diverticulosis • Diet: high fiber, low fat for diverticulosis af-
occurs when the intestinal mucosa protrudes ter pain subsides, liquid for mild diverticulitis
through the muscular wall. The common sites or diverticulosis before pain subsides
for diverticula are in the descending and sig- • Temporary colostomy possible for perfora-
moid colon, but they may develop anywhere tion, peritonitis, obstruction, or fistula that ac-
from the proximal end of the pharynx to the companies diverticulitis
anus.
Diverticulitis is an inflammation of the di- Drug therapy
verticula that may lead to infection, hemor- • Analgesic: morphine
rhage, or obstruction. • Antibiotics: metronidazole (Flagyl),
ciprofloxacin (Cipro), co-trimoxazole
CAUSES (Bactrim) for mild diverticulitis
• Age (most common in people over age 40) • Anticholinergic: propantheline (Pro-
• Chronic constipation Banthine)
• Congenital weakening of the intestinal wall • Laxative: L psyllium (Metamucil)
• Low intake of roughage and fiber • Stool softener: docusate sodium (Colace)
• Straining during defecation for diverticulosis or mild diverticulitis
920108.qxd 8/7/08 3:01 PM Page 256
Stepping up
Caring for surgical wounds

WHY YOU DO IT the dressing and gloves in a waterproof Applying a fresh gauze dressing
Proper care of surgical wounds helps trash bag. • Place a sterile 4⬙ ⫻ 4⬙ gauze pad at the
prevent infection, protects the skin from Caring for the wound or incision wound center, and move the pad out-
maceration and excoriation, allows re- • Establish a sterile field for equipment ward to the edges of the wound site. Ex-
moval and measurement of wound drain- and supplies. If ointment is prescribed, tend the gauze at least 1⬙ beyond the in-
age, and promotes comfort. When a sur- squeeze the needed amount onto the cision in each direction. Use enough
gical incision is closed, the incision is sterile field. Put on sterile gloves. sterile dressings to absorb all drainage
covered with a sterile dressing for 24 to • If you aren’t using prepackaged swabs, until the next dressing change.
48 hours. After 48 hours, the incision can saturate sterile gauze pads with the pre- • Secure the dressing with strips of tape
be covered by a dressing or left open to scribed cleaning agent. or Montgomery straps.
air. • Squeeze excess solution from the pad Dressing a wound with a drain
HOW YOU DO IT or swab. Wipe once from the top to the • Use a precut sterile 4⬙ ⫻ 4⬙ gauze pad.
• Because many doctors prefer to bottom of the incision and then discard • Place the pad close to the skin around
change the first postoperative dressing, the pad or swab. With a second pad, the drain so that the tubing fits into the
avoid changing it unless ordered. If you wipe from top to bottom in a vertical path slit. Press a second pad around the drain
have no such order and drainage is next to the incision and then discard the from the opposite direction to encircle
seeping through the dressing, reinforce pad. the tubing.
the dressing with fresh sterile gauze. To • Continue to work outward from the in- • Layer as many uncut sterile pads
prevent bacterial growth, don’t allow a cision in lines running parallel to it. Al- around the tubing as needed to absorb
reinforced dressing to remain in place ways wipe from the clean area toward drainage. Secure the dressing with tape
longer than 24 hours. Replace any dress- the less-clean area. Use each pad or or Montgomery straps.
ing that becomes wet from the outside as swab for only one stroke. Use sterile Pouching a wound
soon as possible. cotton-tipped applicators to clean tight- • To create a pouch, measure the wound
• Check the doctor’s order for wound fitting wire sutures, deep wounds, or and then cut an opening in the collection
care instructions. wounds with pockets. pouch facing that’s 1⁄8⬙ (0.3 cm) larger
• Explain the procedure to the patient. • If the patient has a surgical drain, clean than the wound.
• Position the patient as comfortably as the drain’s surface last. Clean the sur- • Make sure the surrounding skin is
possible, with the wound site exposed. rounding skin by wiping in half or full cir- clean and dry, and then apply a skin pro-
• Wash your hands. cles from the drain site outward. tectant.
• Put on a gown, if necessary, and gloves • Clean at least 1⬙ (2.5 cm) beyond the • Make sure the drainage port at the bot-
(clean gloves to remove the soiled dress- new dressing or 2⬙ (5 cm) beyond the in- tom of the pouch is closed. Then press
ings; sterile gloves to redress the inci- cision. the contoured pouch opening around the
sion). • Check for signs of infection, dehis- wound, beginning at its lower edge.
• When the procedure is complete, doc- cence, or evisceration. If you observe • To empty the pouch, put on gloves, in-
ument the appearance of the wound site such signs or the patient reports pain, sert bottom half of the pouch into a grad-
and the color, consistency, amount, and notify the doctor. uated container, and open the drainage
odor of any drainage. • Wash the surrounding skin with soap port.
and water, and pat it dry. Apply pre- • Wipe the bottom of the pouch and the
Removing the old dressing
scribed topical medication and a skin drainage port with a sterile gauze pad;
• Hold the skin and pull the tape or
protectant, if warranted. then reseal the port. Change the pouch if
dressing toward the wound. Remove the
• Pack open wounds with sterile moist it leaks or becomes loose.
soiled dressing. If needed, loosen gauze
gauze using the wet-to-damp method.
with sterile normal saline solution.
Avoid using cotton-lined gauze pads.
• Check the dressing for the amount,
type, color, and odor of drainage. Discard
920108.qxd 8/7/08 3:01 PM Page 257
INTERVENTIONS AND RATIONALES occurs worldwide, but incidence varies geo-

• Monitor abdominal distention and bowel graphically. It’s most common in Japan, Chi-
sounds to determine baseline and detect na, the Middle East, and parts of South Africa.
changes in the patient’s condition.
• Monitor and record vital signs, intake and CONTRIBUTING FACTORS
output, and laboratory studies to evaluate • Excessive use of alcohol
fluid status. • Nutritional deficiency
• Monitor stools for occult blood to detect • Reflux esophagitis
bleeding. • Smoking
• Maintain the patient’s diet to improve nutri-
tional status and promote healing. DATA COLLECTION FINDINGS
• Maintain position, patency, and low suction • Dysphagia
of NG tube to prevent nausea and vomiting. • Substernal pain
• Place the patient in semi-Fowler’s position • Weight loss
to promote comfort and GI emptying.
• Prepare the patient for surgery, if necessary DIAGNOSTIC FINDINGS
(administer cleansing enemas, osmotic purga- • Endoscopic examination of the esophagus,
tive, and oral and parenteral antibiotics), to punch and brush biopsies, and an exfoliative
avoid wound contamination from bowel con- cytologic test confirm esophageal tumors.
tents during surgery. • X-rays of the esophagus, with barium swal-
• Provide postoperative care (watch for signs low and motility studies, reveal structural and
of infection; perform meticulous wound care; filling defects and reduced peristalsis.
watch for signs of postoperative bleeding; ap-
ply sequential compression device while the NURSING DIAGNOSES
patient is on bedrest; assist with turning, • Imbalanced nutrition: Less than body re-
coughing, deep breathing, and incentive quirements
spirometry; teach ostomy self-care) to pro- • Impaired swallowing
mote healing and prevent complications. (See • Risk for aspiration
Caring for surgical wounds.)
• Maintain TPN to improve nutritional status TREATMENT
when the patient is unable to receive nutrition • Endoscopic laser treatment and bipolar Esophageal cancer
through the GI tract. electrocoagulation can help restore swallow- is usually advanced
• Administer medications as prescribed to ing by vaporizing cancerous tissue when diagnosed;
maintain or improve the patient’s condition. • Esophageal dilation surgery and other
• Gastrostomy or jejunostomy to help provide treatments can only
Teaching topics adequate nutrition relieve symptoms.
• Decreasing constipation • Radiation therapy
• Following dietary recommendations and re- • Radical surgery to excise the tumor and re-
strictions sect either the esophagus alone or the stom-
• Monitoring stools for bleeding ach and the esophagus
Drug therapy
Esophageal cancer • Antineoplastics: fluorouracil (5-FU), cis-
platin (Platinol)
Esophageal cancer attacks the esophagus, the • Analgesics: morphine (MS Contin), fentanyl
muscular tube that runs from the back of the (Duragesic-25)
throat to the stomach. Cells in the lining of
the esophagus start to multiply rapidly and INTERVENTIONS AND RATIONALES
form a tumor that may spread to other parts • Before surgery, answer the patient’s ques-
of the body. tions and let him know what to expect after
Nearly always fatal, esophageal cancer usu- surgery (gastrostomy tubes, closed chest
ally develops in men over age 60. This disease drainage, NG suctioning) to allay anxiety.
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Stepping up
Delivering a gastric feeding

WHY YOU DO IT • Open the flow regulator clamp on the gavage bag tubing, and
Gastric tube feedings involve delivery of a liquid feeding formu- adjust the flow rate as appropriate. When using a bulb syringe,
la directly to the stomach (known as gastric gavage). Tube fill the syringe with formula and release the feeding tube to al-
feedings may also be delivered to the duodenum or jejunum. low formula to flow through it. The height at which you hold the
Gastric gavage is typically indicated for a patient who can’t eat syringe determines the flow rate. When the syringe is three-
normally due to dysphagia or oral or esophageal obstruction or quarters empty, pour more formula into it.
injury. Gastric feedings may also be given to an unconscious or • To prevent air from entering the tube and the patient’s stom-
intubated patient or to a patient recovering from GI tract sur- ach, never allow the syringe to empty completely. If you’re us-
gery who can’t ingest food orally. ing an infusion pump, set the flow rate according to the
manufacturer’s directions. Always administer a tube feeding
HOW YOU DO IT
slowly—typically 200 to 350 ml over 15 to 30 minutes, depending
on the patient’s tolerance and the doctor’s order—to prevent
• Place the patient in semi-Fowler's or high Fowler’s position (if
sudden stomach distention, which can cause nausea, vomiting,
possible).
cramps, and diarrhea.
• If the patient has a nasal or oral tube, cover his chest with a
• After administering the appropriate amount of formula, flush
towel or linen-saver pad to protect him and the bed linens from
the tubing by adding about 60 ml of water to the gavage bag or
spills.
bulb syringe, or manually flush it using a barrel syringe. This
• Check the patient’s abdomen for bowel sounds and distention.
maintains the tube’s patency by removing excess formula,
• Check placement of the feeding tube to ensure that it hasn’t
which could occlude the tube.
slipped out since the last feeding. Never give a tube feeding
• If you’re administering a continuous feeding, flush the feeding
until you’re certain the tube is properly positioned in the pa-
tube every 4 hours to help prevent tube occlusion. Monitor gas-
tient’s stomach.
tric emptying every 4 hours.
• To check tube patency and position, remove the cap or plug
• To discontinue gastric feeding (depending on the equipment
from the feeding tube and use a bulb or piston syringe to aspi-
you’re using), close the regulator clamp on the gavage bag tub-
rate stomach contents and check the pH. The pH of stomach
ing, disconnect the syringe from the feeding tube, or turn off the
contents should be less than or equal to 5. The color of the as-
infusion pump.
pirate should be green or brown with mucous.
• Cover the end of the feeding tube with its plug or cap to pre-
• To check gastric emptying, aspirate and measure residual
vent leakage and contamination.
gastric contents. Hold feedings if residual volume is greater
• Leave the patient in semi-Fowler’s or high Fowler’s position
then the amount specified in the doctor’s order (usually 50 to
for at least 30 minutes.
100 ml). Reinstill any aspirate obtained.
• On the intake and output sheet, record the date, volume of
• Connect the gavage bag tubing to the feeding tube.
formula, and volume of water. In your notes, document abdomi-
• If you’re using a bulb or piston syringe, remove the bulb or
nal assessment findings (including tube exit site, if appropriate);
plunger and attach the syringe to the pinched-off feeding tube
amount of residual gastric contents; verification of tube place-
to prevent excess air from entering the patient’s stomach,
ment; amount, type, and time of feeding; and tube patency. Dis-
which causes distention. If you’re using an infusion pump,
cuss the patient’s tolerance of the feeding, including nausea,
thread the tube from the formula container through the infusion
vomiting, cramping, diarrhea, and distention.
pump, according to the manufacturer’s directions. Purge the
tubing of air, and attach it to the feeding tube.
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• After surgery, monitor vital signs and watch cancers occur in the pyloric area of the stom-
for unexpected changes to detect early signs of ach.
complications and avoid treatment delay.
• If surgery included an esophageal anasto- CONTRIBUTING FACTORS
mosis, keep the patient flat on his back to • Achlorhydria
avoid tension on the suture line. • Chronic gastritis
• Promote adequate nutrition, and evaluate • Helicobacter pylori infection
the patient’s nutritional and hydration status • High intake of salted and smoked foods
to determine the need for supplementary par- • Low intake of vegetables and fruits
enteral feedings. • Peptic ulcer
• Place the patient in Fowler’s position for • Pernicious anemia
meals and allow plenty of time to eat to avoid
aspiration of food. DATA COLLECTION FINDINGS
• Assist with incentive spirometry hourly dur- • Anorexia
ing the waking hours to prevent atelectasis. • Epigastric fullness and pain
• Apply a sequential compression device • Fatigue
while patient is on bedrest to prevent thrombus • Hematemesis
formation. • Indigestion
• Provide high-calorie, high-protein, pureed • Malaise
food as needed to meet increased metabolic de- • Melena
mands and prevent aspiration. • Nausea and vomiting
• If the patient has a gastrostomy tube, give • Pain after eating that isn’t relieved by
food slowly, using gravity to adjust the flow antacids
rate to prevent abdominal discomfort. • Regurgitation
• Offer him something to chew before each • Rigid abdomen In gastric cancer,
feeding to promote gastric secretions and a • Shortness of breath pain after eating isn’t
semblance of normal eating. (See Delivering a • Syncope relieved by antacids
gastric feeding.) • Weakness and weight loss is
• Instruct the family in gastrostomy tube care • Weight loss common.
(checking tube patency before each feeding,
providing skin care around the tube, and DIAGNOSTIC FINDINGS
keeping the patient upright during and after • CEA test is positive.
feedings) to avoid complications. • Fecal occult blood test is positive.
• Provide emotional support for the patient • Gastric analysis shows positive cancer cells
and his family to help them cope with terminal and achlorhydria.
illness. • Gastroscopy biopsy is positive for cancer
cells.
Teaching topics • Upper GI series reveals a gastric mass.
• Caring for the gastrostomy tube • Hematology shows decreased Hb level and
• Contacting the American Cancer Society HCT.
• Gastric hydrochloric acid level is decreased.
Gastric cancer NURSING DIAGNOSES

• Anxiety
Gastric cancer involves a malignant stomach • Imbalanced nutrition: less than body re-
tumor. It may be primary or metastatic. Its quirements
precise cause is unknown, but it’s commonly • Risk for deficient fluid volume
associated with gastritis, gastric atrophy, and
other conditions. About one-half of gastric
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• Gastric surgery: gastroduodenostomy, gas- • Avoiding exposure to people with infections
trojejunostomy, partial gastric resection, total • Alternating rest periods with activity
gastrectomy • Monitoring temperature
• TPN • Recognizing the signs and symptoms of
• High-calorie diet wound infection
• Radiation therapy • Recognizing the signs and symptoms of ul-
ceration
Drug therapy • Completing skin care daily
• Analgesics: morphine, hydromorphone (Di- • Contacting the American Cancer Society
laudid)
• Antiemetics: prochlorperazine (Com-
pazine), metoclopramide (Reglan) Gastritis
• Antineoplastics: carmustine (BiCNU),
5-fluorouracil (Adrucil) Gastritis is an inflammation of the gastric mu-
• Vitamin supplements: folic acid (Folvite), cosa (the stomach lining). It may be acute or
cyanocobalamin (vitamin B12) for patients chronic:
who have undergone total gastrectomy • Acute gastritis produces mucosal redden-
ing, edema, hemorrhage, and erosion.
INTERVENTIONS AND RATIONALES • Chronic gastritis is common among elderly
• Monitor GI status postoperatively to moni- people and people with pernicious anemia. In
tor the patient for dumping syndrome (weak- chronic atrophic gastritis, all stomach mucos-
ness, nausea, flatulence, and palpitations 30 al layers are inflamed.
minutes after a meal).
• Monitor and record vital signs, intake and CAUSES
output, laboratory studies, and daily weight to Acute gastritis
determine baseline and early changes in condi- • Chronic ingestion of irritating foods, spicy
tion. foods, or alcohol
• Monitor the consistency, amount, and fre- • Drugs, such as aspirin and other non-
quency of stools to detect GI compromise. steroidal anti-inflammatory drugs (NSAIDs)
• Monitor the color of stools to detect bleeding (in large doses), cytotoxic agents, caffeine,
and prevent hemorrhage. corticosteroids, antimetabolites, phenylbuta-
• Maintain the patient’s diet to promote nutri- zone, and indomethacin
tional balance. • Endotoxins released from infecting bacte-
• Maintain the position, patency, and low suc- ria, such as staphylococci, Escherichia coli,
tion of NG tube (without irrigating or reposi- and Salmonella
tioning the NG tube because it may put pres- • Helicobacter pylori infection
sure on the suture line) to prevent complica- • Ingestion of poisons, especially DDT, am-
tions, nausea, and vomiting. monia, mercury, carbon tetrachloride, and
• Maintain TPN for 1 week or longer if gastric corrosive substances
surgery is extensive to meet metabolic needs
and promote wound healing. Chronic gastritis
• Administer medications, as prescribed, to • Alcohol ingestion
maintain or improve the patient’s condition. • Cigarette smoke
• Support patient coping mechanisms to in- • Environmental irritants
crease the potential for adaptive behavior. • Peptic ulcer disease
• Provide skin and mouth care to prevent skin
breakdown and damage to the oral mucosa and DATA COLLECTION FINDINGS
to improve nutritional intake. • Abdominal cramping
• Provide rest periods to conserve energy. • Epigastric discomfort
920108.qxd 8/7/08 3:01 PM Page 261
• Hematemesis • Monitor fluid intake and output and elec-

• Indigestion trolyte levels to detect early signs of dehydra-
tion and electrolyte loss.
DIAGNOSTIC FINDINGS • Provide a bland diet to prevent recurrence. Of course we have
a special diet for the
• Occult blood test shows occult blood in • Monitor the patient for recurrent symptoms
patient with gastritis:
vomitus and stools if the patient has gastric as food is reintroduced to detect early signs of smaller, more frequent
bleeding. intolerance. meals of bland food.
• Blood studies show low Hb level and HCT • Offer smaller, more frequent meals to re-
when significant bleeding has occurred. duce irritating gastric secretions.
• Upper GI endoscopy with biopsy results • Eliminate foods that cause gastric upset to
confirm the diagnosis when performed within prevent gastric irritation.
24 hours of bleeding. • If surgery is necessary, prepare the patient
• Upper GI series may be performed to ex- preoperatively and provide appropriate post-
clude serious lesions. operative care to decrease preoperative anxiety
and prevent intraoperative and postoperative
NURSING DIAGNOSES complications.
• Risk for deficient fluid volume • Administer antacids and other prescribed
• Imbalanced nutrition: Less than body re- medications to promote gastric healing.
quirements • Urge the patient to seek immediate atten-
• Acute or chronic pain (depending on the tion for recurring symptoms, such as he-
type of gastritis) matemesis, nausea, and vomiting to prevent
complications such as GI hemorrhage.
TREATMENT • Urge the patient to take prophylactic med-
• Angiography with vasopressin infused in ications as prescribed to prevent recurring
normal saline solution (when gastritis causes symptoms.
massive bleeding) • Provide emotional support to the patient to
• Blood transfusion, if indicated help him manage his symptoms.
• I.V. fluid therapy
• NG lavage to control bleeding Teaching topics
• Oxygen therapy, if necessary • Taking an antacid between meals and at
• Partial or total gastrectomy (rare) bedtime and avoiding aspirin-containing com-
• Vagotomy and pyloroplasty (limited success pounds
when conservative treatments have failed) • Taking steroid medication with milk, food,
or an antacid
Drug therapy • Counseling for smoking cessation
• Antacids: calcium carbonate (Maalox), alu- • Avoiding spicy foods and foods and bever-
minum hydroxide (AlternaGEL) ages containing caffeine
• Antibiotics according to sensitivity of infect-
ing organism (if the cause is bacterial)
• Antidote according to the ingested poison Gastroenteritis
(if the cause is poisoning)
• Antiemetics: prochlorperazine (Com- Gastroenteritis is an irritation and inflamma-
pazine), ondansetron (Zofran) tion of the digestive tract characterized by di-
• Histamine2-receptor antagonists: cimetidine arrhea, nausea, vomiting, and abdominal
(Tagamet), ranitidine (Zantac), famotidine cramping. It occurs in all age-groups and is
(Pepcid), nizatidine (Axid) usually self-limiting in adults.
It can be life-threatening in young children,
INTERVENTIONS AND RATIONALES elderly, and debilitated persons. It’s a major
• If the patient is vomiting, give an antiemetic cause of morbidity and mortality in develop-
and I.V. fluid to prevent dehydration and elec- ing nations.
trolyte imbalance.
920108.qxd 8/7/08 3:01 PM Page 262
This disorder is also called intestinal flu, INTERVENTIONS AND RATIONALES

What’s the recipe traveler’s diarrhea, viral enteritis, and food • Administer medications; correlate dosages,
for preventing
poisoning. routes, and times appropriately with the pa-
gastroenteritis?
Use clean utensils, tient’s meals and activities; for example, give
cook food thoroughly, CAUSES antiemetics 30 to 60 minutes before meals to
and wash hands with • Amoebae, especially Entamoeba histolytica prevent the onset of symptoms.
warm water and soap • Bacteria (responsible for acute food poison- • If the patient is unable to tolerate food, re-
before and after ing): Staphylococcus aureus, Salmonella, Shi- place lost fluids and electrolytes with clear liq-
handling foods. gella, Clostridium botulinum, Escherichia coli, uids and sport drinks to prevent dehydration.
Clostridium perfringens • Vary the patient’s diet to make it more enjoy-
• Drug reactions (especially antibiotics) able and allow some choice of foods.
• Enzyme deficiencies • Instruct the patient to avoid milk and milk
• Food allergens products, which may exacerbate the condition.
• Ingestion of toxins: plants or toadstools • Record strict intake and output. Watch for
(mushrooms) signs of dehydration, such as dry skin and
• Parasites: Ascaris, Enterobius, Trichinella mucous membranes, fever, and sunken eyes,
spiralis to prevent complications of dehydration.
• Viruses (may be responsible for traveler’s • Wash your hands thoroughly after giving
diarrhea): adenovirus, echovirus, or coxsack- care to avoid spread of infection.
ievirus • Instruct the patient to perform warm sitz
baths three times per day to relieve anal irri-
DATA COLLECTION FINDINGS tation.
• Abdominal discomfort • Maintain contact precautions as indicated to
• Diarrhea prevent the spread of infection.
• Nausea and vomiting
Teaching topics
DIAGNOSTIC FINDINGS • Cleaning utensils thoroughly; avoiding
• Stool culture identifies causative bacteria, drinking water or eating raw fruit or vegeta-
parasites, or amoebae. bles when visiting a foreign country; eliminat-
• Blood culture identifies causative organism. ing flies and roaches in the home
• Thoroughly cooking foods, especially pork;
NURSING DIAGNOSES refrigerating perishable foods
• Diarrhea • Washing hands with warm water and soap
• Risk for deficient fluid volume before handling food, especially after using
Tell your
patient to drink up. • Acute pain the bathroom
Increased fluid
intake helps relieve TREATMENT
gastroenteritis. • Increased fluid intake Gastroesophageal reflux
• I.V. fluid and electrolyte replacement
• Nutritional support disease
Drug therapy GERD refers to the esophageal irritation
• Antibiotic therapy according to the sensitivi- caused by backflow, or reflux, of gastric and
ty of the causative organism duodenal contents past the lower esophageal
• Antidiarrheals: camphorated opium tincture sphincter and into the esophagus. Reflux may
(Paregoric), diphenoxylate with atropine (Lo- or may not cause symptoms or pathologic
motil), loperamide (Imodium) changes. The prognosis varies with the un-
• Antiemetics: prochlorperazine (Compa- derlying cause.
zine), trimethobenzamide (Tigan) (These
medications should be avoided in patients CAUSES AND CONTRIBUTING FACTORS
with viral or bacterial gastroenteritis.) • Any action that decreases lower esophageal
sphincter pressure, such as smoking ciga-
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rettes and ingesting food, alcohol, anticholin- • Surgery: fundoplication (the fundus of the Get back. In
ergics (atropine, belladonna, propantheline), stomach is sutured in place around the lower GERD, duodenal
and other drugs (morphine, diazepam, mepe- esophagus) contents get back to
ridine) where they don’t
belong—into the
• Any condition or position that increases Drug therapy
esophagus.
intra-abdominal pressure • Antacid: aluminum hydroxide, magnesium
• Hiatal hernia (especially in children) hydroxide (Mylanta)
• Long-term NG intubation (more than 5 • GI stimulants: metoclopramide (Reglan),
days) bethanechol (Urecholine)
• Pressure within the stomach that exceeds • Histamine2-receptor antagonists: cimetidine
lower esophageal sphincter pressure (Tagamet), ranitidine (Zantac), famotidine
• Pyloric surgery (alteration or removal of (Pepcid), nizatidine (Axid)
the pylorus), which allows reflux of bile or • Proton pump inhibitors: esomeprazole
pancreatic juice (Nexium), lansoprazole (Prevacid)
DATA COLLECTION FINDINGS INTERVENTIONS AND RATIONALES

• Dysphagia • Develop a diet that takes food preferences
• Heartburn (burning sensation in the upper into account while helping to minimize reflux
abdomen) symptoms to ensure compliance.
• Have the patient sleep in reverse Trende-
Atypical symptoms lenburg’s position (with the head of the bed
• Asthma elevated 6⬙ to 12⬙ [15 to 30 cm]) to reduce
• Atypical chest pain intra-abdominal pressure.
• Chronic cough • After surgery, evaluate the incisions for
• Laryngitis signs of drainage, assist with turning, cough-
• Sore throat ing, deep breathing, and incentive spirometry.
Apply a sequential compression device to pre-
DIAGNOSTIC FINDINGS vent thrombus formation while on bedrest.
• Barium swallow fluoroscopy indicates re- • If needed, perform chest physiotherapy and
flux. administer oxygen to mobilize secretions and
• Esophageal pH probe reveals a low pH, prevent hypoxemia.
which indicates reflux. • Place the patient with an NG tube in semi-
• Esophagoscopy shows reflux. Fowler’s position to help prevent reflux.
• Acid perfusion (Bernstein) test shows that • Offer reassurance and emotional support to
reflux is the cause of symptoms. help the patient cope with pain and discomfort.
• Endoscopy allows visualization and confir-
mation of pathologic changes in the mucosa. Teaching topics
• Biopsy allows visualization and confirmation • Avoiding reflux through diet and lifestyle
of pathologic changes in the mucosa. changes
NURSING DIAGNOSES
• Risk for aspiration Hepatitis
• Chronic pain
• Deficient knowledge (disease process and Hepatitis is an inflammation of liver tissue
treatment plan) that causes inflammation of hepatic cells, hy-
pertrophy and proliferation of Kupffer’s cells,
TREATMENT and bile stasis. Hepatitis is typically caused by
• Diet: low fat, high fiber with no caffeine or one of five viruses: hepatitis A, B, C, D, or E.
carbonated beverages
• Oxygen therapy CAUSES
• Positional therapy to help relieve symptoms • Hepatitis A: contaminated food, milk, water,
by decreasing intra-abdominal pressure feces (most commonly foodborne)
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Recognizing fulminant hepatitis

A rare but severe form of hepatitis, fulminant hepatitis rapidly As the disease progresses quickly to the terminal phase, the
causes massive liver necrosis. It usually occurs in patients with patient may experience cerebral edema, brain stem compres-
hepatitis B, D, or E. Although mortality is extremely high (more sion, GI bleeding, sepsis, respiratory failure, cardiovascular col-
than 80% of patients lapse into deep coma), patients who sur- lapse, and renal failure.
vive may recover completely.
EMERGENCY ACTIONS
DATA COLLECTION If you suspect fulminant hepatitis, you should:
In a patient with viral hepatitis, suspect fulminant hepatitis if you • notify the physician immediately
detect: • provide supportive care, such as maintaining fluid volume,
• confusion supporting ventilation through mechanical means, controlling
• somnolence bleeding, and correcting hypoglycemia
• ascites • restrict protein intake
• edema • expect to administer oral lactulose or neomycin and, possibly,
• rapidly increasing bilirubin level massive doses of glucocorticoids
• markedly prolonged prothrombin time • prepare the patient for a liver transplant if necessary and if
• elevated ammonia level the patient meets the criteria.
• Hepatitis B: parenteral (needle sticks), During icteric phase (usually 1 to 2 weeks)

blood, sexual contact, secretions • Clay-colored stools
• Hepatitis C: blood or serum (blood transfu- • Dark urine
sion, exposure to contaminated blood), sexual • Fatigue
contact, body piercing, tatoos • Hepatomegaly
• Hepatitis D: similar to causes of type B • Jaundice
virus • Pruritus
• Hepatitis E: fecal-oral route • Splenomegaly
• Weight loss
DATA COLLECTION FINDINGS During posticteric or recovery phase (usually 2
Findings are consistent for the different types to 12 weeks, sometimes longer in patients with
of hepatitis, but signs and symptoms progress hepatitis B, C, or E)
over several stages. • Decreased hepatomegaly
During preicteric phase (usually 1 to 5 days) • Decreased jaundice
• Anorexia • Fatigue
• Arthralgia • Improved appetite
• Clay-colored stool (at end of preicteric
phase) DIAGNOSTIC FINDINGS
• Constipation and diarrhea • Blood chemistry shows increased ALT,
• Fatigue AST, alkaline phosphatase, LD, bilirubin, and
• Fever ESR.
• Headache • Serologic tests identify hepatitis A virus
• Hepatomegaly (HAV), HBV, HCV, and delta antigen, if pre-
• Malaise sent.
• Nasal discharge • Coagulation studies show increased PT.
• Nausea and vomiting • Stool specimen reveals HAV (in hepatitis A
• Pharyngitis cases).
• Pruritus • Urine chemistry shows increased urobilino-
• Right upper quadrant pain gen.
• Splenomegaly
• Weight loss
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NURSING DIAGNOSES • Maintain standard precautions to prevent the

• Deficient fluid volume spread of pathogens to others. (See Standard
• Chronic pain precautions.)
• Imbalanced nutrition: Less than body re- • Provide rest periods to conserve patient en-
quirements ergy and reduce metabolic demands.
• Encourage small, frequent meals to improve
TREATMENT the patient’s nutritional status.
• High-calorie, high-carbohydrate, moderate- • Change the patient’s position every 2 hours
protein, low-fat diet in small, frequent meals to reduce the risk of skin breakdown.
• Monitor for signs of bleeding to prevent he-
Drug therapy morrhage.
• Antiemetic: prochlorperazine (Compazine)
• Vitamins and minerals: vitamin K (Aqua- Teaching topics
MEPHYTON), vitamin C (ascorbic acid), vita- • Avoiding exposure to people with infections
min B complex (mega-B) • Avoiding alcohol
• Antipyretics: ibuprofen (Motrin) • Maintaining good personal hygiene
• Interferon: alfacon-1 (Infergen) (for hepati- • Refraining from donating blood
tis C) • Increasing fluid intake to 3,000 ml/day (ap- Maintaining
proximately 12 8-oz glasses) standard precautions
INTERVENTIONS AND RATIONALES • Abstaining from sexual intercourse until affects your safety
• Monitor GI status and watch for bleeding serum liver studies are within normal limits and the patient’s
and fulminant hepatitis to detect early compli- safety; it’s an
cations. (See Recognizing fulminant hepatitis.) important topic to
• Maintain the patient’s diet to meet his meta- Hiatal hernia cover.
bolic needs.
• Monitor and record vital signs, intake and A hiatal hernia is a defect in the diaphragm
output, and laboratory studies to detect early that permits a portion of the stomach to pass
signs of fluid volume deficit. through the diaphragmatic opening into the
• Administer medications, as prescribed, to chest.
maintain or improve the patient’s condition.
Standard precautions
Standard precautions apply to blood; all body fluids, secretions, GLOVES
and excretions except sweat, regardless of whether they con- Wear gloves when in contact with blood, body fluids, secre-
tain visible blood; nonintact skin; and mucous membranes. tions, excretions, or contaminated items. Put on clean gloves
just before touching mucous membranes and nonintact skin.
HAND WASHING
Remove gloves promptly after use and wash hands.
Wash hands after touching blood, body fluids, secretions, ex-
cretions, and contaminated items, whether or not gloves are MASK, EYE PROTECTION, AND FACE SHIELD
worn. Wash hands immediately after gloves are removed, be- Wear a mask, eye protection, and a face shield to protect the
tween patient contacts, and when otherwise indicated to avoid mucous membranes of your eyes, nose, and mouth during pro-
transfer of microorganisms to other patients or environments. It cedures and patient care activities that are likely to generate
may be necessary to wash hands between tasks and proce- splashes of blood, body fluids, secretions, or excretions.
dures on the same patient to prevent cross-contamination to
GOWN
different body sites.
Wear a gown to protect skin and prevent soiling of clothing dur-
ing procedures and patient care activities that are likely to gen-
erate splashes of blood, body fluids, secretions, or excretions.
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• Aging • Monitor respiratory status to detect early
• Congenital weakness signs of respiratory distress.
• Increased abdominal pressure • Monitor and record vital signs, intake and
• Obesity output, and daily weight to determine baseline
• Pregnancy and detect early signs of nutritional deficit.
• Trauma • Administer oxygen to help relieve respiratory
• Unknown distress.
• Avoid flexion at the waist in positioning the
DATA COLLECTION FINDINGS patient to promote comfort.
• Cough • Maintain the patient’s diet to maintain and
• Dysphagia improve nutritional status.
• Dyspnea • Maintain position, patency, and low suction
• Feeling of fullness of NG tube to prevent nausea and vomiting.
• Pyrosis • Place the patient in semi-Fowler’s position
• Regurgitation to promote comfort.
• Sternal pain after eating • Administer medications, as prescribed, to
• Tachycardia improve GI function.
• Vomiting
Teaching topics
DIAGNOSTIC FINDINGS • Eating small, frequent meals slowly
• Barium swallow reveals protrusion of the • Avoiding carbonated beverages and alcohol
hernia. • Remaining upright for 2 hours after eating
• Chest X-ray shows protrusion of abdominal • Avoiding constrictive clothing
organs into the thorax. • Avoiding lifting, bending, straining, and
• Esophagoscopy shows incompetent cardiac coughing
sphincter. • Sleeping with upper body elevated to re-
duce gastric reflux
NURSING DIAGNOSES
• Anxiety
• Imbalanced nutrition: Less than body re- Intestinal obstruction
quirements
Patients with • Chronic pain An intestinal obstruction occurs when the in-
hiatal hernia should testinal lumen becomes blocked, causing gas,
junk the java and skip TREATMENT fluid, and digested substances to accumulate
the spicy stuff. I • Antireflux surgical repair, if complications near the obstruction and increasing peristal-
guess that rules out
develop sis in the area of the obstruction. Water and
pizza with extra
pepperoni. • Bland diet in small, frequent meals, with de- electrolytes are then secreted into the
creased intake of caffeine and spicy foods blocked bowel, causing inflammation and in-
• Weight loss, if necessary hibiting absorption.
Drug therapy CAUSES

•Anticholinergic: propantheline • Adhesions
(Pro-Banthine) • Diverticulitis
•Histamine2-receptor antagonists: • Fecal impaction
cimetidine (Tagamet), ranitidine (Zan- • Hernias
tac), famotidine (Pepcid) • Inflammation (Crohn’s disease)
•GI stimulant: metoclopramide • Intussusception
(Reglan) • Mesenteric thrombosis
• Paralytic ileus
• Tumors
• Volvulus
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DATA COLLECTION FINDINGS • Maintain I.V. fluids to maintain hydration.

Withhold food and
• Abdominal distention • Maintain position, patency, and low inter- fluids from the patient
• Constipation mittent suction of NG tube and Miller-Abbott with intestinal
• Cramping pain tube to prevent nausea and vomiting and re- obstruction.
• Diminished or absent bowel sounds solve the obstruction if possible.
• Fever • Place the patient in semi-Fowler’s position
• Nausea to promote comfort.
• Vomiting fecal material • Administer postoperative care if indicated
• Weight loss (monitor vital signs and intake and output;
make sure NG tube is kept patent; monitor
DIAGNOSTIC FINDINGS dressings for drainage; evaluate wound for in-
• Abdominal ultrasound shows distended fection; assist with turning, coughing, deep
bowel. breathing, and incentive spirometry; apply a
• Abdominal X-ray shows increased amount sequential compression device while the pa-
of gas in bowel. tient is on bedrest to prevent blood clot forma-
• Barium enema stops at obstruction. tion.
• Blood chemistry shows decreased sodium • Medicate for pain as necessary or guide the
and potassium levels. patient with use of postoperative patient-
• Hematologic study shows increased WBC controlled analgesia) to promote healing and
count. detect early postoperative complications.
• Administer medications as prescribed to
NURSING DIAGNOSES maintain or improve the patient’s condition.
• Ineffective tissue perfusion: GI
• Imbalanced nutrition: Less than body re- Teaching topics
quirements • Avoiding constipation-causing foods One good reason
• Acute pain • Monitoring the frequency and color of not to get stressed
stools out about the NCLEX:
TREATMENT • Recognizing the signs and symptoms of di- Stress contributes to
• Bowel resection with or without anastomo- verticulitis the development of
sis if other treatment fails • Contacting the American Ostomy Associa- irritable bowel
syndrome.
• GI decompression using NG tube, Miller- tion, if appropriate
Abbott tube, or Cantor tube
• Withholding food and fluids
• Fluid and electrolyte replacement Irritable bowel syndrome
Drug therapy Irritable bowel syndrome is marked by chron-
• Analgesic: morphine ic signs and symptoms of abdominal pain, al-
• Antibiotic: gentamicin (Garamycin) ternating constipation and diarrhea, and ab-
dominal distention. This disorder is common;
INTERVENTIONS AND RATIONALES a substantial portion of patients, however,
• Monitor GI status and record bowel sounds never seek medical attention.
once per shift to determine GI status. This disorder may also be referred to as
• Monitor and record vital signs, intake and spastic colon or spastic colitis.
output, and laboratory studies to detect early
signs of fluid volume deficit. CAUSES AND CONTRIBUTING FACTORS
• Withhold food and fluids to prevent nausea • Diverticular disease
and vomiting. • Family history
• Monitor and record the frequency, color, • Irritants (caffeine, alcohol)
and amount of stools to determine nutritional • Smoking
status. • Stress
• Measure and record the patient’s abdominal
girth to determine the presence of distention.
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DATA COLLECTION FINDINGS • Antidiarrheal: diphenoxylate with atropine

• Abdominal bloating (Lomotil)
• Constipation, diarrhea, or both • Corticosteroid: hydrocortisone (Solu-
• Dyspepsia Cortef)
• Faintness
• Heartburn INTERVENTIONS AND RATIONALES
• Lower abdominal pain • Help the patient deal with stress, and warn
• Passage of mucus against dependence on sedatives or antispas-
• Pasty, pencil-like stools modics because stress may be the underlying
• Weakness cause of irritable bowel syndrome.
• Encourage regular checkups. For patients
DIAGNOSTIC FINDINGS over age 40, emphasize the need for a yearly
• Barium enema may reveal colonic spasm flexible sigmoidoscopy and rectal examina-
and tubular appearance of the descending tion. Irritable bowel syndrome is associated
colon. It also rules out certain other disor- with a higher-than-normal incidence of diverti-
ders, such as diverticula, tumors, and polyps. culitis and colon cancer.
• Manometry reveals changes in interluminal
pressure. Teaching topics
• Sigmoidoscopy may disclose spastic con- • Avoiding alcohol
tractions. • Avoiding irritating foods
• Stool examination for occult blood, para- • Managing stress
sites, and pathogenic bacteria is negative. • Smoking cessation (smoking can increase
GI motility)
NURSING DIAGNOSES • Planning diet and increasing water intake
• Constipation
• Diarrhea
• Chronic pain Pancreatitis
TREATMENT Pancreatitis is the inflammation of the pan-
• Elimination diet to determine if symptoms creas. With acute pancreatitis, pancreatic en-
result from food intolerance (In this type of zymes are activated in the pancreas rather
diet, certain foods, such as citrus fruits, cof- than the duodenum, resulting in tissue dam-
fee, corn, dairy products, tea, and wheat, are age and autodigestion of the pancreas.
sequentially eliminated, and then each food is With chronic pancreatitis, chronic inflam-
gradually reintroduced to identify which mation results in fibrosis and calcification of
foods, if any, trigger the patient’s symptoms.) the pancreas, obstruction of the ducts, and
• Diet containing 15 to 20 g daily of bulky destruction of the secreting acinar cells.
foods, such as wheat bran, oatmeal, oat bran,
rye cereals, prunes, dried apricots, and figs (if CAUSES
the patient has constipation and abdominal • Alcoholism
pain); avoiding high-fat foods • Bacterial or viral infection
• Increasing fluid intake to at least eight 8-oz • Biliary tract disease
glasses per day • Blunt trauma to pancreas or abdomen
• Stress management • Drug induced: steroids, thiazide diuretics,
oral contraceptives
Drug therapy • Duodenal ulcer
• Sedatives: alprazolam (Xanax), lorazepam • Hyperlipidemia
(Ativan) • Hyperparathyroidism
• Antiflatulent: simethicone (Mylicon)
• Antispasmodic: propantheline (Pro-Ban- DATA COLLECTION FINDINGS
thine) • Abdominal tenderness and distention
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• Abrupt onset of pain in epigastric area that • Nasogastric suction to relieve nausea and
radiates to the shoulder, substernal area, vomiting and to provide decompression
back, and flank • Sequential compression device to prevent
• Aching, burning, stabbing, pressing abdom- deep vein thrombosis
inal pain • Surgical intervention to treat underlying
• Decreased or absent bowel sounds cause, if appropriate
• Dyspnea • Transfusion therapy with packed RBCs, as
• Fever indicated
• Hypotension
• Jaundice Drug therapy
• Knee-chest position, fetal position, or lean- • Analgesic: morphine
ing forward for comfort • Anticholinergics: propantheline (Pro-
• Nausea and vomiting Banthine), dicyclomine (Bentyl)
• Pain upon eating • Antidiabetic: insulin
• Steatorrhea • Antiemetics: prochlorperazine (Com-
• Tachycardia pazine), metoclopromide (Reglan)
• Weight loss • Calcium supplement: calcium gluconate
• Corticosteroid: hydrocortisone
DIAGNOSTIC FINDINGS (Solu-Cortef)
• Arteriography reveals fibrous tissue and • Digestant: pancrelipase (Pancrease)
calcification of pancreas. • Histamine2-receptor antagonists: cimetidine
• Blood chemistry shows increased amylase, (Tagamet), ranitidine (Zantac), famotidine
lipase, LD, glucose, AST, and lipid levels and (Pepcid), nizatidine (Axid)
decreased calcium and potassium levels. • Mucosal barrier fortifier: sucralfate
• CT scan shows enlarged pancreas. (Carafate)
• Cullen’s sign is positive. • Potassium supplement: I.V. potassium chlo-
• ERCP reveals biliary obstruction. ride
• Fecal fat test is positive. • Tranquilizers: lorazepam (Ativan), alprazo-
• Glucose tolerance test shows decreased tol- lam (Xanax)
erance.
• Grey Turner’s sign is positive. INTERVENTIONS AND RATIONALES
• Hematology shows increased WBC count • Monitor abdominal, cardiac, and respirato-
and decreased Hb level and HCT. ry status (as the disease progresses, watch
• Ultrasonography reveals cysts, bile duct infor respiratory failure, tachycardia, and wors-
flammation, and dilation. ening GI status) to determine baseline and de-
• Urine chemistry shows increased amylase. tect early changes and signs of complications.
• Evaluate fluid balance to detect fluid volume
NURSING DIAGNOSES deficit or excess.
• Deficient fluid volume • Monitor and record vital signs, intake and
• Imbalanced nutrition: Less than body re- output, laboratory studies, daily weight, and
quirements urine specific gravity to detect signs of fluid vol-
• Acute or chronic pain ume deficit.
• Monitor urine and stool for color, character,
TREATMENT and amount to detect bleeding.
• Bland, low-fat, high-protein diet of small, • Maintain the patient’s diet; withhold food
frequent meals with restricted intake of caf- and fluids as necessary to rest the pancreas
feine, alcohol, and gas-forming foods; as dis- and prevent nausea and vomiting.
order progresses, nothing by mouth • Perform bedside glucose monitoring to
• Bed rest check for hyperglycemia.
• I.V. fluids (vigorous replacement of fluids • Administer oxygen and maintain ET and
and electrolytes) mechanical ventilation if necessary to improve
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oxygenation and provide suctioning as needed • Gastritis

to stabilize secretions. • Helicobacter pylori infection
• Monitor I.V. fluids to treat or prevent hypo- • Smoking
volemic shock and restore electrolyte balance. • Zollinger-Ellison syndrome
• Maintain position, patency, and low suction
Keep the patient
of NG tube to prevent nausea and vomiting. DATA COLLECTION FINDINGS
with pancreatitis in • Place the patient in semi-Fowler’s position if • Anorexia
bed and turn him the patient’s blood pressure allows to promote • Hematemesis
frequently to prevent comfort and lung expansion. • Left epigastric pain 1 to 2 hours after eating
pressure ulcers. • Maintain TPN. In severe cases, reintroduc- • Melena
tion of food may be associated with pancreatic • Nausea and vomiting
abscess. TPN is necessary to meet the patient’s • Relief of pain after administration of
metabolic needs. antacids
• Place the patient in bed and turn every 2 • Weight loss
hours, or utilize a specialty rotation bed to pre-
vent pressure ulcers. DIAGNOSTIC FINDINGS
• Maintain medications, as prescribed, to im- • Barium swallow shows ulceration of the
prove or maintain the patient’s condition. gastric mucosa.
• Provide skin, nares, and mouth care to pre- • Fecal occult blood test is positive.
vent tissue damage. • H. pylori test is positive.
• Provide a quiet, restful environment to con- • Hematologic study shows decreased Hb lev-
serve energy and decrease metabolic demands. el and HCT (if bleeding is present).
• Assist with incentive spirometry hourly dur- • Serum gastrin level is normal or increased.
ing waking hours to prevent atelectasis. • Upper GI endoscopy shows the location of
the ulcer.
Teaching topics
• Avoiding alcohol NURSING DIAGNOSES
• Monitoring blood glucose levels frequently • Anxiety
• Monitoring stools for steatorrhea • Imbalanced nutrition: Less than body re-
• Monitoring self for infection quirements
• Recognizing the signs and symptoms of in- • Acute pain
creased blood glucose levels
• Adhering to activity limitations TREATMENT
• Modifying risk factors • Endoscopic laser therapy to control bleed-
• Avoiding caffeine ing
• If GI hemorrhage, gastric surgery that may
include gastroduodenostomy, gastrojejunosto-
Peptic ulcer disease my, partial gastric resection, and total gastrec-
tomy
Peptic ulcer disease (PUD) is a break in the • Diet that avoids extremes in temperature,
continuity of gastric, or duodenal mucosa. caffeine, and foods that cause pain
This occurs when normal defense mecha- • Photocoagulation to control bleeding
nisms are overwhelmed or impaired by acid • Saline lavage by NG tube until return is
or pepsin. Ulcers are circumscribed lesions clear (if bleeding is present)
that extend through the mucosa. Ulcers occur • Transfusion therapy with packed RBCs (if
in the duodenum 5 times more often than in bleeding is present and Hb level and HCT are
the stomach. low)
• Vagotomy to decrease gastric acid produc-
CAUSES tion
• Drug-induced: salicylates, steroids,
NSAIDs, reserpine
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Drug therapy • Following dietary recommendations and re-

• Antacids: magnesium and aluminum hy- strictions such as avoiding caffeine, alcohol,
droxide (Maalox), aluminum hydroxide gel and spicy and fried foods
(AlternaGEL) • Following postoperative care and restric-
• Antibiotic if H. pylori is present tions
• Histamine2-receptor antagonists: cimetidine • Smoking cessation
(Tagamet), ranitidine (Zantac), nizatidine
(Axid), famotidine (Pepcid)
• Pituitary hormone: vasopressin (Pitressin) Peritonitis
to manage bleeding
• Proton-pump inhibitor: lansoprazole (Pre- Peritonitis is a localized or generalized inflam-
vacid) mation of the peritoneal cavity. It occurs when
• Mucosal barrier fortifier: sucralfate (Cara- irritants in the peritoneal area cause inflam-
fate) matory edema, vascular congestion, and hy-
• Prostaglandin: misoprostol (Cytotec) to pro- permotility of the bowel.
tect the stomach lining
CAUSES
INTERVENTIONS AND RATIONALES • Bacterial invasion
• Monitor GI status to detect signs of bleeding. • Chemical invasion
• Monitor cardiovascular status to detect early • Trauma
signs of GI hemorrhage.
• Monitor and record vital signs, intake and DATA COLLECTION FINDINGS
output, laboratory studies, fecal occult blood, • Abdominal resonance and tympany on per-
and gastric pH to detect signs of bleeding. cussion
• Observe the consistency, color, amount, • Abdominal rigidity and distention
and frequency of stools to detect early signs of • Anorexia
GI bleeding. • Constant, diffuse, and intense abdominal
• Maintain the patient’s diet as tolerated to pain
meet metabolic needs and promote healing. • Decreased or absent bowel sounds
• Maintain position, patency, and low suction • Decreased peristalsis
of NG tube if gastric decompression is or- • Decreased urine output
dered to prevent nausea and vomiting. • Fever A patient with
peritonitis will have
• Administer medications, as prescribed, to • Malaise
abdominal resonance
maintain or improve the patient’s condition. • Nausea and tympany on
• Provide nose and mouth care to maintain • Rebound tenderness percussion.
tissue integrity. • Shallow respirations
• Provide postoperative care if necessary • Weak, rapid pulse
(don’t reposition NG tube; irrigate it gently
if ordered; medicate for pain as needed and DIAGNOSTIC FINDINGS
ordered; monitor dressings for drainage; • Abdominal X-ray shows free air in
evaluate bowel sounds; assist with incentive the abdomen under the diaphragm.
spirometry; apply a sequential compression • Hematologic study shows in-
device while the patient is on bedrest; get pa- creased WBC count and low Hb lev-
tient out of bed as tolerated) to detect early el and HCT if blood loss has occurred.
complications and promote healing. • Peritoneal aspiration is positive for
blood, pus, bile, bacteria, or amylase.
Teaching topics
• Reducing stress NURSING DIAGNOSES
• Relaxation techniques • Anxiety
• Acute pain
• Deficient fluid volume
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• Withholding food or fluid until the cause of • Recognizing the signs and symptoms of in-
peritonitis is known and condition allows. fection
• NG tube insertion to prevent nausea and • Recognizing the signs and symptoms of GI
vomiting. obstruction
• Surgical intervention when the patient’s • Performing ostomy self-care if indicated
condition is stabilized (surgery is chosen to
treat the cause [for example, if the patient has
a perforated appendix, appendectomy is indi- Ulcerative colitis
cated]; drains will also be placed for drainage
of infected material) Ulcerative colitis is an inflammatory disorder
of the colon. It’s commonly a chronic condi-
Drug therapy tion and causes damage to the large intes-
• Analgesic: morphine tine’s mucosal and submucosal layers.
• Antibiotics: gentamicin (Garamycin), clin-
damycin (Cleocin), ofloxacin (Floxin), CAUSES
meropenem (Merrem), pipercillin and • Genetics
tazobactam (Zosyn), metronidazole (Flagyl) • Idiopathic cause
• Allergies
INTERVENTIONS AND RATIONALES • Autoimmune disease
• Monitor abdominal and respiratory status • Emotional stress
and fluid balance to detect signs of fluid volume • Viral and bacterial infections
deficit.
• Monitor and record vital signs, intake and DATA COLLECTION FINDINGS
output, laboratory studies, daily weight, and • Abdominal cramping
urine specific gravity to detect signs of fluid vol- • Abdominal distention
ume deficit. • Abdominal tenderness
• Measure and record the patient’s abdominal • Anorexia
girth to detect for abdominal distention. • Bloody, purulent, mucoid, watery stools (15
• Withhold food and fluids to prevent nausea to 20 per day)
and vomiting. • Cachexia
• Administer I.V. fluids to maintain hydration • Debilitation
and electrolyte balance. • Fever
Withhold food and • Provide routine postoperative care (monitor • Hyperactive bowel sounds
fluids from the patient vital signs and intake and output, including • Nausea and vomiting
with acute peritonitis.
drainage from drains; assist with turning, in- • Signs and symptoms of dehydration
Provide TPN.
centive spirometry, coughing, and deep • Weakness
breathing; apply a sequential compression de- • Weight loss
vice when the patient is on bedrest and get
the patient out of bed on the first postopera- DIAGNOSTIC FINDINGS
tive day if his condition allows) to promote • Barium enema shows ulcerations.
healing and prevent and detect early complica- • Blood chemistry shows decreased potassi-
tions. um level and increased osmolality.
• Maintain position, patency, and low suction • Hematology shows increased WBC count
of NG tube to prevent nausea and vomiting. and decreased Hb level and HCT.
• Place the patient in semi-Fowler’s position • Sigmoidoscopy shows ulceration and hyper-
to promote comfort and prevent pulmonary emia.
complications. • Stool specimen is positive for blood and
• Maintain TPN to meet the patient’s metabolic mucus.
needs. • Urine chemistry result shows increased
• Administer medications, as prescribed, to urine specific gravity.
treat infection and control pain.
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NURSING DIAGNOSES • Maintain the position, patency, and low suc-

• Diarrhea tion of the NG tube to prevent nausea and
• Deficient fluid volume vomiting.
• Imbalanced nutrition: Less than body re- • Place the patient in semi-Fowler’s position
quirements to promote comfort.
TREATMENT maintain or improve the patient’s condition.
• Colectomy or pouch ileostomy • Provide skin, mouth, nares, and perianal
• High-protein, high-calorie, low-residue diet, care to promote comfort and prevent skin
with bland foods in small, frequent meals and breakdown.
restricted intake of milk and gas-forming
foods or no food or fluids Teaching topics
• TPN if necessary to rest the GI tract • Monitoring weight
• Transfusion therapy with packed RBCs, as • Reducing stress and performing relaxation
indicated techniques
• Recognizing the early signs and symptoms
Drug therapy of rectal hemorrhage and intestinal obstruc-
• Analgesic: morphine tion
• Antianemics: ferrous sulfate (Feosol), fer- • Contacting the United Ostomy Association
rous gluconate (Fergon) and the National Foundation of Ileitis and Co-
• Antibiotic: sulfasalazine (Azulfidine) litis
• Anticholinergics: propantheline (Pro-Ban-
thine), dicyclomine (Bentyl)
• Antidiarrheals: diphenoxylate (Lomotil),
loperamide (Imodium)
• Antiemetic: prochlorperazine (Compazine)
• Anti-inflammatory: olsalazine (Dipentum)
• Corticosteroid: hydrocortisone
(Solu-Cortef)
• Immunosuppressants: azathioprine (Imu-
ran), cyclophosphamide (Cytoxan)
• Potassium supplements: potassium chloride
(K-Lor), potassium gluconate (Kaon)
• Sedative: lorazepam (Ativan)

• Monitor GI status and fluid balance to deter-
Pump up on practice
mine fluid volume deficit.
• Monitor and record vital signs, intake and
questions
output, laboratory studies, daily weight, urine 1. A client begins a fecal fat analysis test on a
specific gravity, calorie count, and fecal occult Monday. The nurse should instruct the client
blood to determine fluid volume deficit. to begin the 3-day stool collection on:
• Monitor the number, amount, and character 1. Monday.
of stools to determine status of nutrient absorp- 2. Tuesday.
tion. 3. Wednesday.
• Maintain the patient’s diet; withhold food 4. Thursday.
and fluids as necessary to prevent nausea and Answer: 4. The fecal fat analysis test requires
vomiting. a 3-day period in which the client eats a high-
• Maintain I.V. fluids and TPN to maintain hy- fat diet. On the day after the 3-day diet, the
dration and improve nutritional status. client begins collecting his stool. In this sce-
nario, that would be Thursday. Selecting Mon-
day, Tuesday, or Wednesday would be erro-
920108.qxd 8/7/08 3:01 PM Page 274
neously teaching the client to begin the test most beneficial to the client if the nurse in-
prematurely, which may nullify the test’s structed him to sleep:
accuracy. 1. with his upper body elevated.
Client needs category: Health promo- 2. in the prone position.
tion and maintenance 3. flat or in a side-lying position.
Client needs subcategory: None 4. with his lower body slightly elevated.
Cognitive level: Application Answer: 1. Upper body elevation can reduce
the gastric reflux associated with hiatal her-
nia. The other positions won’t benefit the
client.
integrity
Client needs subcategory: Basic care
and comfort
Cognitive level: Analysis
4. A client with peptic ulcer disease sec-

ondary to chronic NSAID use is prescribed
misoprostol (Cytotec). The nurse would be
most accurate in informing the client that the
drug:
2. A client returns from an endoscopic proce- 1. reduces gas formation.
dure during which he was sedated. Before of- 2. increases the speed of gastric empty-
fering the client food, it’s most important for ing.
the nurse to: 3. protects the stomach’s lining.
1. monitor his oxygen saturation levels. 4. increases lower esophageal sphincter
2. evaluate his gag reflex. pressure.
3. place him in the side-lying position. Answer: 3. Misoprostol (Cytotec) is a synthet-
4. have him drink sips of water. ic prostaglandin that, like prostaglandin, pro-
Answer: 2. The sedation associated with a protects the gastric mucosa. NSAIDs decrease
cedure, such as endoscopy, can impair the prostaglandin production and predispose the
gag reflex. If a client is fed before the gag re- client to peptic ulceration. Cytotec is pre-
flex returns, the client can experience airway scribed to clients with peptic ulcer disease
obstruction and aspiration. Therefore, the who are also taking NSAIDs. Misoprostol
nurse should check the client’s gag reflex be- doesn’t reduce gas formation, improve empty-
fore offering the client food. Monitoring oxy- ing of the stomach, or increase lower esopha-
gen saturation levels is important after an en- geal sphincter pressure.
doscopic procedure but its results won’t sup- Client needs category: Physiological
port feeding the client. In this situation, the integrity
side-lying position isn’t necessary. Having the Client needs subcategory: Pharmaco-
client drink water isn’t the proper method of logical therapies
assessing for a gag reflex. Cognitive level: Application
integrity 5. What’s the priority nursing goal for a client
Client needs subcategory: Reduction of who has had a barium enema?
risk potential 1. To prevent fecal incontinence
Cognitive level: Application 2. To monitor for bleeding
3. To prevent constipation
3. A client with a history of hiatal hernia re- 4. To limit fluid intake
ports to the nurse that he has trouble sleep- Answer: 3. Barium should be promptly elimi-
ing because of abdominal pain. It would be nated from the client’s system after it has
920108.qxd 8/7/08 3:01 PM Page 275
been introduced into the colon to prevent 1. with food or after the client eats.
mass formation and possible bowel obstruc- 2. on an empty stomach.
tion. Therefore, laxatives or enemas are com- 3. with no other medications.
monly given after a barium enema to prevent 4. 2 hours before or after eating.
the client from becoming constipated. Fecal Answer: 1. Supplemental potassium can be ir-
incontinence isn’t an issue because the pas- ritating to the esophagus and stomach and is
sage of stool is desired. Bleeding isn’t com- best tolerated with meals or shortly after
monly anticipated after a barium enema and meals. It’s typically appropriate to give oral
the client should be encouraged to increase, potassium at the same time other medications
not decrease, fluid intake. are being administered.
integrity integrity
Client needs subcategory: Reduction of Client needs subcategory: Pharmaco-
risk potential logical therapies
6. A physician orders gastric decompression

for a client with small-bowel obstruction. The
nurse should plan for the suction to be:
1. low pressure and intermittent.
2. low pressure and continuous.
3. high pressure and intermittent.
4. high pressure and continuous.
Answer: 1. Gastric decompression is typically
low pressure and intermittent. High pressure
and continuous gastric suctioning predispos-
es the gastric mucosa to injury and ulcera-
tion.
Client needs category: Physiological 8. Which factor should be the initial focus of
integrity nursing management in a client with acute
Client needs subcategory: Reduction of pancreatitis?
risk potential 1. Dietary management
Cognitive level: Application 2. Prevention of skin breakdown
3. Management of hypoglycemia
4. Pain control
Answer: 4. The priority is to provide adequate
pain control. This is essential to minimize dis-
comfort and restlessness, which may further
stimulate pancreatic secretion. Initially, the
client with acute pancreatitis isn’t permitted
food and oral intake. Although prevention of
skin breakdown is important, it isn’t the initial
focus. Clients are at risk for hyperglycemia,
not hypoglycemia.
integrity
7. A client with Crohn’s disease has a serum Client needs subcategory: Basic care
potassium level of 3.1 mEq/dl. The client is and comfort
prescribed 30 mEq of oral potassium chloride Cognitive level: Application
(K-Lor) twice daily. The nurse should plan to
give the supplement:
920108.qxd 8/7/08 3:01 PM Page 276
9. A client with a history of peptic ulcer dis- 10. Daily abdominal girth measurements are
ease develops a fever of 101° F (38.3° C). prescribed for a client with liver dysfunction
Which accompanying sign most strongly indi- and ascites. To increase accuracy, the nurse
cates the client has peritonitis? should use which landmark?
1. Leukopenia 1. Xiphoid process
2. Hyperactive bowel sounds 2. Umbilicus
3. Abdominal rigidity 3. Iliac crest
4. Polyuria 4. Symphysis pubis
Answer: 3. Abdominal rigidity is a classic sign Answer: 2. The proper technique for abdomi-
of peritonitis. The client would more likely nal girth measurement involves circumvent-
have leukocytosis, hypoactive bowel sounds, ing the abdomen with a tape measure using
and decreased urine output with peritonitis. the umbilicus as a landmark. The other sites
Client needs category: Physiological would give inaccurate measurements.
integrity Client needs category: Physiological
Client needs subcategory: Reduction of integrity
risk potential Client needs subcategory: Reduction of
Cognitive level: Analysis risk potential
All that talk

about the GI system
makes me hungry.
Remember that
healthy eating
promotes good
studying.
920109.qxd 8/7/08 3:01 PM Page 277
9 Endocrine
system
• growth hormone, which is an insulin an-
In this chapter,
you’ll review:
Brush up on key tagonist that stimulates the growth of cells,
bones, muscle, and soft tissue.
✐ components of the
endocrine system
concepts The posterior lobe secretes:
• vasopressin (antidiuretic hormone, also
and their function The endocrine system consists of specialized called ADH), which helps the body retain wa-
✐ tests used to diag- cell clusters called glands that secrete chemi- ter
nose endocrine dis- cal transmitters called hormones. These com- • oxytocin, which stimulates uterine contrac-
orders bine to regulate growth and development, and tions during labor and milk secretion in lactat-
✐ common endocrine influence the reproductive system, energy lev- ing women.
disorders. el, metabolic rate, and the ability to adapt to
stress. Growth gland
At any time, you can review the major points The thyroid gland accelerates growth and
of this chapter by consulting the Cheat sheet cellular reactions, including basal metabolic
on pages 278 to 281. rate (BMR). It’s controlled by the pituitary
gland’s secretion of TSH.
Thermostat central The thyroid gland produces thyrocalcitonin,
The hypothalamus is an organ that controls triiodothyronine (T3), and thyroxine (T4),
temperature, respiration, and blood pressure. which are necessary for growth and develop-
Its functions affect the emotional states. The ment.
hypothalamus also produces hypothalamic-
stimulating hormones, which affect the inhibi- Coping with calcium
tion and release of pituitary hormones. The parathyroid gland secretes parathyroid
hormone (parathormone, or PTH), which reg-
Heavy on the hormones ulates calcium and phosphorus levels and pro-
The pituitar y gland is composed of anterior motes the resorption of calcium from bones.
and posterior lobes. Together these lobes pro-
duce a variety of hormones that affect the The adrenal fab 5
body. The adrenal glands are composed of the
The anterior lobe secretes: adrenal cortex and the adrenal medulla. The
• follicle-stimulating hormone, which stim- adrenal cortex secretes three major hor-
ulates graafian follicle growth and estrogen mones:
secretion in women • glucocorticoids (cortisol, cortisone, and
• luteinizing hormone, which induces ovu- corticosterone), which mediate the stress re-
lation and development of the corpus luteum sponse, promote sodium and water retention
in women and stimulates testosterone secre- and potassium secretion, and suppress ACTH
tion in men secretion
• adrenocorticotropic hormone (ACTH), • mineralocorticoids (aldosterone and de-
also called corticotropin, which stimulates se- oxycorticosterone), which promote sodium
cretion of hormones from the adrenal cortex and water retention and potassium secretion
• thyroid-stimulating hormone (TSH), • sex hormones (androgens, estrogens, and
which regulates the secretory activity of the progesterone), which develop and maintain
thyroid gland secondary sex characteristics and libido.
920109.qxd 8/7/08 3:01 PM Page 278
278 Endocrine system
et
heat she
C
Endocrine refresher
ACROMEGALY AND GIGANTISM ADDISON’S DISEASE
Acromegaly • Orthostatic hypotension
• Enlarged supraorbital ridge • Weakness and lethargy
• Thickened ears and nose • Weight loss
• Thickening of the tongue Key test results
Gigantism • Blood chemistry reveals decreased cortisol,
• Excessive growth in all parts of the body glucose, sodium, chloride, and aldosterone lev-
Key test result els; and increased blood urea nitrogen (BUN) and
• Plasma human growth hormone (HGH) levels potassium level.
measured by radioimmunoassay typically are ele- • Hematology tests reveal elevated hematocrit
vated. However, because HGH secretion is pul- and decreased hemoglobin.
satile, the results of random sampling may be • Blood or capillary glucose levels reveal hypo-
misleading. IGF-1 (somatomedin-C) levels offer a glycemia.
better screening alternative. • Urine chemistry shows decreased 17-keto-
Key treatments steroids and hydroxycorticosteroids (17-OHCS).
• Surgery to remove the affecting tumor (trans- Key treatments
sphenoidal hypophysectomy) • With adrenal crisis, I.V. hydrocortisone given
• Thyroid hormone replacement therapy after promptly along with 3 to 5 L of normal saline solu-
surgery: levothyroxine (Synthroid) tion
• Corticosteroid: cortisone (Cortone) • Glucocorticoids: cortisone (Cortone), hydrocor-
Presto chango! • Inhibitor of HGH release: bromocriptine (Par- tisone (Solu-Cortef)
I give you the lodel) • Mineralocorticoid: fludrocortisone (Florinef)
Cheat sheet. • Somatotropic hormone: octreotide (Sando- Key interventions
statin) • Administer appropriate medications.
Key interventions • Maintain I.V. fluids.
• Provide the patient with emotional support. • Don’t allow the patient to sit up or stand quickly.
• Perform or assist with range-of-motion (ROM)
CUSHING’S SYNDROME
exercises.
• Keep in mind that this disease can also cause Key signs and symptoms
inexplicable mood changes. Reassure the family • History of amenorrhea
that these mood changes result from the disease • History of mood swings
and can be modified with treatment. • Hypertension
• After surgery, monitor vital signs and neurologic • Muscle wasting
status. Be alert for any alterations in level of con- • Weight gain, especially truncal obesity, buffalo
sciousness, pupil equality, or visual acuity as well hump, and moonface
as vomiting, falling pulse rate, and rising blood Key test results
pressure. • Blood chemistry shows increased cortisol, al-
• Check blood glucose levels. dosterone, sodium, corticotropin, and glucose
• Measure intake and output hourly, watching for levels and a decreased potassium level.
large increases. • Dexamethasone suppression test shows no de-
• Encourage the patient to ambulate on the first crease in 17-OHCS.
or second day after surgery.
920109.qxd 8/7/08 3:01 PM Page 279
Endocrine refresher (continued)

CUSHING’S SYNDROME (continued) • 2-hour postprandial blood glucose level shows hyperglycemia
• Magnetic resonance imaging shows pituitary or adrenal tu- (greater than 200 mg/dl).
mors. Key treatments
Key treatments • Antidiabetic agents: insulin or oral agents, such as glimepiride
• Hypophysectomy or bilateral adrenalectomy (Amaryl), glyburide (DiaBeta, Micronase), glipizide (Glucotrol),
• Antidiabetic agents: insulin or oral agents such as glyburide metformin (Glucophage)
(DiaBeta, Micronase), glipizide (Glucotrol), metformin (Gluco- Key interventions
phage) • Monitor acid-base and fluid balance.
Key interventions • Monitor for signs of hypoglycemia (altered mental status, dizzi-
• Perform postoperative care. ness, weakness, pallor, tachycardia, diaphoresis, seizures, and
• Observe for edema. coma), ketoacidosis (acetone breath, dehydration, weak or rapid
• Limit water intake. pulse, Kussmaul’s respirations), and hyperosmolar coma (poly-
• Weigh the patient daily. uria, thirst, neurologic abnormalities, stupor).
• Be prepared to treat hypoglycemia; immediately give carbohy-
DIABETES INSIPIDUS drates in the form of fruit juice, hard candy, or honey. If the pa-
Key signs and symptoms tient is unconscious, maintain safety until glucogen or dextrose
• Polydipsia (consumption of 4 to 40 L/day) is administered I.V.
• Polyuria (greater than 5 L/day of dilute urine) • Be prepared to maintain I.V. fluid. Administer insulin and, usual-
Key test result ly, potassium replacement for ketoacidosis or hyperosmolar
• Urine chemistry shows urine specific gravity less than 1.005, coma.
osmolality 50 to 200 mOsm/kg, decreased urine pH, and de- • Monitor wound healing.
creased sodium and potassium levels. • Maintain the patient’s diet.
Key treatments • Provide meticulous skin and foot care. Patients with diabetes
are at increased risk for infection from impaired leukocyte
• I.V. therapy: hydration (when first diagnosed, intake and output
activity.
must be matched milliliter to milliliter to prevent dehydration),
• Foster independence.
electrolyte replacement
• Antidiuretic hormone replacement: vasopressin (Pitressin), GOITER
lypressin (Diapid nasal spray) Key signs and symptoms
Key interventions • Single or multinodular, firm, irregular enlargement of the thy-
• Monitor fluid balance and daily weight. roid gland
• Monitor and record vital signs, intake and output (urine output • Dizziness or syncope when the patient raises his arms above
should be measured every hour when first diagnosed), urine his head (Pemberton’s sign)
specific gravity (check every 1 to 2 hours when first diagnosed), • Dysphagia
and laboratory studies. Key test result
• Maintain I.V. fluid. • Laboratory tests reveal high or normal thyroid-stimulating hor-
DIABETES MELLITUS mone (TSH), low serum thyroxine (T4) concentrations, and in-
Key signs and symptoms creased iodine 131 uptake.
• Polydipsia Key treatments
• Polyphagia • Subtotal thyroidectomy
• Polyuria • Thyroid hormone replacement: levothyroxine (Synthroid)
• Weight loss (with type 1) Key interventions
Key test results • Measure the patient’s neck circumference. Also check for the
• Fasting blood glucose level is increased (greater than or equal development of hard nodules in the gland.
to 126 mg/dl). • Provide preoperative teaching and postoperative care if subto-
• Glycosylated hemoglobin assay is increased to 7 or above. tal thyroidectomy is indicated.
(continued)
920109.qxd 8/7/08 3:01 PM Page 280

HYPERTHYROIDISM PANCREATIC CANCER
• Atrial fibrillation • Dull, intermittent epigastric pain (early in disease)
• Bruit or thrill over thyroid • Continuous pain that radiates to the right upper quadrant or
• Diaphoresis dorsolumbar area and may be colicky, dull, or vague and unrelat-
• Palpitations ed to activity or posture
• Tachycardia • Anorexia
Key test results • Rapid, profound weight loss
• Blood chemistry shows increased triiodothyronine (T3), T4, and • Palpable mass in the subumbilical or left hypochondrial region
free thyroxine levels and decreased TSH and cholesterol levels. Key test results
• Radioactive iodine uptake (RAIU) is increased. • Percutaneous fine-needle aspiration biopsy of the pancreas
Key treatments identifies malignant cells.
• Radiation therapy • Blood studies reveal increased serum bilirubin, increased
• Thyroidectomy serum amylase and lipase, prolonged prothrombin time, elevated
• Iodine preparations: potassium iodide (SSKI), radioactive io- alkaline phosphatase (with biliary obstruction), and elevated as-
dine partate aminotransferase and alanine aminotransferase (when
liver cell necrosis is present).
Key interventions
• Fasting blood glucose may indicate hyperglycemia or hypo-
• Monitor cardiovascular status.
glycemia.
• Avoid stimulants, such as caffeine-containing drugs and foods.
• Maintain I.V. fluids. Key treatments
• Weigh the patient daily. • Blood transfusion, if indicated.
• Provide postoperative care. • I.V. fluid therapy
• Whipple’s procedure or pancreatoduodenectomy (excision of
HYPOTHYROIDISM the head of the pancreas along with the encircling loop of the
Key signs and symptoms duodenum)
• Dry, flaky skin and thinning nails • Antineoplastic combinations: fluorouracil (Adrucil), strepto-
• Fatigue zocin (Zanosar), ifosfamide (Ifex), and doxorubicin (Adriamycin)
• Hypothermia • Insulin after pancreatic resection to provide adequate exoge-
• Menstrual disorders nous insulin supply
• Mental sluggishness • Opioid analgesics: morphine and codeine, which can lead to
• Weight gain or anorexia biliary tract spasm and increase common bile duct pressure
Key test results (used only when other methods fail)
• Blood chemistry shows decreased T3, T4, free thyroxine, and • Pancreatic enzyme: pancrelipase (Pancrease)
sodium levels; TSH levels are increased with thyroid insufficien- Key interventions
cy and decreased with hypothalamic or pituitary insufficiency. Before surgery
• RAIU is decreased. • Monitor blood transfusions.
Key treatment • Administer vitamin K and antibiotics; perform gastric lavage, as
• Thyroid hormone replacement: levothyroxine (Synthroid), lio- necessary.
thyronine (Cytomel), thyroglobulin (Proloid) After surgery
• Monitor fluid balance, abdominal girth, metabolic state, and
Key interventions
weight daily. Replace nutrients I.V., orally, or by nasogastric tube.
• Avoid sedation; administer one-half to one-third the normal Maintain dietary restrictions such as a low-sodium or fluid reten-
dose of sedatives or opioids. tion diet as required). Maintain a 2,500 calorie diet for the patient.
• Check for constipation and edema. • Administer an oral pancreatic enzyme at mealtimes, if needed.
• Encourage fluids. • Administer pain medication, antibiotics, and antipyretics, as
necessary.
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PANCREATIC CANCER (continued) • Pain
• Watch for signs of hypoglycemia or hyperglycemia; administer • Tenderness and reddened skin over the gland
glucose or an antidiabetic agent as necessary. Monitor blood Key test results
glucose levels. Note: Precise diagnosis depends on the type of thyroiditis.
• Apply antiembolism stockings and a sequential compression • With autoimmune thyroiditis, high titers of thyroglobulin and
device, and assist with ROM exercises. If thrombosis occurs, el- microsomal antibodies may be present in serum.
evate the patient’s legs and give an anticoagulant, as ordered. • With subacute granulomatous thyroiditis, tests may reveal ele-
THYROID CANCER vated erythrocyte sedimentation rate, increased thyroid hor-
mone levels, and decreased thyroidal RAIU.
• With chronic infective and noninfective thyroiditis, varied find-
• Enlarged thyroid gland ings occur, depending on underlying infection or other disease.
• Painless, firm, irregular, and enlarged thyroid nodule or mass
Key treatments
Key test results
• Partial thyroidectomy to relieve tracheal or esophageal com-
• Blood chemistry shows increased calcitonin, serotonin, and pression in Riedel’s thyroiditis
prostaglandin levels. • Thyroid hormone replacement: levothyroxine (Synthroid) for
• RAIU shows a “cold,” or nonfunctioning, nodule. accompanying hypothyroidism
• Thyroid biopsy shows cytology positive for cancer cells.
Key intervention
Key treatments
• Check vital signs and examine the patient’s neck for unusual
• Radiation therapy swelling, enlargement, or redness.
• Thyroidectomy (total or subtotal); with or without radical neck • If the neck is swollen, measure and record the circumference
excision daily.
Key interventions After thyroidectomy
• Monitor respiratory status for signs of airway obstruction. • Check vital signs every 15 to 30 minutes until the patient’s con-
• Evaluate ability to swallow. dition stabilizes. Stay alert for signs of tetany secondary to acci-
• Provide postoperative thyroidectomy care. dental parathyroid injury during surgery. Keep 10% calcium glu-
conate available for I.M. use if needed.
THYROIDITIS
• Check dressings frequently for excessive bleeding.
Key signs and symptoms • Keep the head of the patient’s bed elevated.
• Thyroid enlargement • Watch for signs of airway obstruction, such as difficulty talking
• Fever and increased swallowing; keep tracheotomy equipment handy.
The adrenal medulla secretes two hor- ocrine glands secrete outwardly via a duct;
mones: the pancreas secretes enzymes into the duo-
• norepinephrine, which regulates general- denum through the pancreatic duct.
ized vasoconstriction In its endocrine function, the pancreas se-
• epinephrine, which regulates instanta- cretes hormones from the islets of Langer-
neous stress reaction and increases metabo- hans (insulin, glucagon, and somatostatin) in-
lism, blood glucose levels, and cardiac output. wardly to the blood or lymph. Insulin regu-
lates fat, protein, and carbohydrate
Endo (in) and exo (out) metabolism and lowers blood glucose levels
The pancreas is an accessory gland of diges- by promoting glucose transport into cells.
tion. In its exocrine function, it secretes Glucagon increases blood glucose levels by
digestive enzymes (amylase, lipase, and promoting hepatic glyconeogenesis. Somato-
trypsin). Amylase breaks down starches into statin inhibits the release of insulin, glucagon,
smaller carbohydrate molecules. Lipase and somatotropin. Note that endocrine glands
breaks down fats into fatty acids and glycerol. discharge secretions into the blood or lymph.
Trypsin breaks down proteins. Note that ex-
920109.qxd 8/7/08 3:01 PM Page 282
Eat carbs and test

Keep abreast of With a 2-hour postprandial glucose test, a
blood sample analyzes the body’s insulin re-
diagnostic tests sponse to carbohydrate ingestion.
Below are some diagnostic tests for evaluat- Nursing actions

ing endocrine disorders as well as common • List any medications that might interfere
nursing actions associated with each test. with the test.
• Note pregnancy, trauma, or infectious dis-
Draw blood and test, part 1 ease.
Blood chemistr y tests analyze blood sam- • Provide the patient with a 100 g carbohy-
ples for potassium, sodium, calcium, phospho- drate diet before the test and then ask him to
rus, glucose, bicarbonate, blood urea nitro- fast for 2 hours.
gen (BUN), creatinine, protein, albumin, • Instruct the patient to avoid smoking, caf-
osmolality, amylase, lipase, alkaline phospha- feine, alcohol, and exercise after the meal.
tase, lactate dehydrogenase, aldosterone, cor-
tisol, ketones, cholesterol, triglycerides, and Carbo absorption assessment
carbon dioxide. The glucose tolerance test (GTT) uses
blood and urine samples to measure absorp-
Nursing actions tion of carbohydrates.
Nursing actions
Draw blood and test, part 2 • List any medications that might interfere
A hematologic study analyzes a blood sam- with the test.
ple for red blood cells (RBCs), white blood • Note pregnancy, trauma, or infectious dis-
cells (WBCs), platelets, hemoglobin (Hb) lev- ease.
Mais oui!
In the 2-hour el, and hematocrit (HCT). • Provide the patient with a high-carbohy-
postprandial test, a drate diet for 3 days.
blood sample is Nursing actions • Instruct the patient to fast for 10 to 16 hours
used to determine • Note current drug therapy. before the test.
the body’s insulin • Check the venipuncture site for bleeding. • Advise the patient not to smoke, drink caf-
response to carbs feine or alcohol, or exercise strenuously for 8
like me! A coagulation study analyzes a blood sample hours before or during the test.
for prothrombin time (PT), international nor- • Withhold any medications that may inter-
malized ratio, partial thromboplastin time, fere with testing.
and D-dimer. • Draw a fasting blood sample and have the
patient provide a urine specimen at the same
Nursing actions time.
• Note current drug therapy. • Administer the test dose of oral glucose and
• Check the venipuncture site for bleeding. record the time of administration.
• Request laboratory collection of serum glu-
Fast and test cose and urine samples at 30, 60, 120, and 180
The fasting blood glucose test measures minutes.
plasma glucose levels following a 12- to 14- • Refrigerate samples and assess the patient
hour fast. for hypoglycemia.
Nursing actions Check those blood glucose levels

• Withhold food and fluids for 12 to 14 hours Glycosylated Hb (Hb A1c) testing uses a
before fasting sample is drawn. blood sample to measure glycosylated Hb lev-
• Withhold insulin until the test is completed. els. This provides information about average
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blood glucose levels from the preceding 2 to 3 Urine analysis (24-hour collection)
months. This test is used to evaluate the long- The 24-hour urine test for 17-ketoste-
term effectiveness of diabetes therapy. roids (17-KS) and 17-hydroxycortico-
steroids (17-OHCS) is a quantitative labora-
Nursing actions tory analysis of urine collected over 24 hours
• Explain to the patient that this test is used to determine hormone precursors.
to evaluate diabetes therapy.
• Tell the patient that he need not restrict Nursing actions
food or fluids and instruct him to maintain his • Withhold all medications for 48 hours be-
prescribed medication and diet regimen. fore the test.
• Instruct the patient to void and note the
Check for cortisol time (collection of urine starts with the next
The rapid adrenocorticotropic hormone voiding).
stimulation test, also known as the cosyn- • Place urine collection container on ice.
tropin test, is the most effective test for evalu- • Measure each voided urine collection.
ating adrenal hypofunction. • If done on an outpatient basis, teach the pa-
tient how to collect the 24-hour specimen
Nursing actions properly.
• List any medications that might interfere • List any medications that might interfere
with the test. with the test.
• Know that pregnancy contraindicates this
test. Epi-no-fun exam
• Draw a baseline blood sample and label it The urine vanillylmandelic acid test is a
“baseline.” quantitative analysis of urine collected over 24 Restrict
• Administer cosyntropin 250 mg I.V. over 2 hours to determine the end products of cate- chocolate?
minutes. cholamine metabolism (epinephrine and nor- That’s one test I
would fail!
• Draw a blood sample 30 minutes after injec- epinephrine).
tion and label it “30 minutes post injection.”
• Draw a blood sample 60 minutes after injec- Nursing actions
tion and label it “60 minutes post injection.” • List any medications, previous tests, and
medical conditions that might interfere with
Blood analysis (with drug) the test.
The dexamethasone suppression test, • Restrict foods that contain vanilla, coffee,
which involves administration of dexametha- tea, citrus fruits, bananas, nuts, and chocolate
sone, is used to analyze a blood sample for for 3 days prior to test.
serum cortisol. Dexamethasone suppresses • Withhold any medications that might inter-
levels of circulating adrenal steroid hormones fere with testing such as antihypertensives
such as cortisol in normal people but fails to and aspirin.
suppress them in patients with Cushing’s syn- • Instruct the patient to void and note the
drome and some forms of clinical depression. time (collection of urine starts with the next
voiding).
Nursing actions • Place urine container on ice.
• On the first day, give the patient 1 mg of • Measure each voided urine specimen.
dexamethasone at 11 p.m.
• On the next day, collect blood samples at Eyesight exam
4 p.m. and 11 p.m. Visual acuity and field testing is done to
• Monitor the venipuncture site; if hematoma evaluate the patient’s central and peripheral
develops, apply warm soaks. vision.
• List any medications that might interfere
with the test.
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Nursing actions • Discontinue all thyroid and cough medica-

• Ask the patient to wear or bring corrective tions 7 to 10 days before the test.
The eyes lenses for the test.
have it! Radiograph of the ‘roid
Remind
patients to
Inspecting the abdomen A thyroid scan provides visual imaging of ra-
wear or bring Computed tomography (CT) scan provides dioactivity distribution in the thyroid gland
their contacts visualization of the sella turcica and abdomen. that helps determine the size, shape, position,
or glasses for and anatomic function of the thyroid.
the eyesight Nursing actions
exam. • Note the patient’s allergies to iodine, sea- Nursing actions
food, and radiopaque dyes. • If iodine-123 (123I) or 131I is to be used, tell
• Instruct the patient to fast for 4 hours prior the patient to fast after midnight the night be-
to the procedure. fore the test. Fasting isn’t required if an I.V.
injection of 99mTc pertechnetate is used.
Echo exam • Withhold any medications that may inter-
Ultrasonography provides visualization of fere with the procedure.
the thyroid, pelvis, and abdomen through the • Instruct the patient to stop consuming
use of reflected sound waves. iodized salt, iodinated salt substitutes, and
seafood 1 week before the procedure.
Nursing actions • Imaging follows oral administration (123I or
• Evaluate whether the patient can lie still 131I) by 24 hours and I.V. injection (99mTc
during the procedure. pertechnetate) by 20 to 30 minutes.
• Remove dentures, jewelry, and other mate-
Taking thyroid tissue rials that may interfere with imaging.
A closed percutaneous thyroid biopsy is • After the procedure, tell the patient he may
the percutaneous, sterile aspiration of a small resume medications that were suspended for
amount of thyroid tissue for histologic evalua- testing.
tion.
Work of artery
Nursing actions Arteriography is a fluoroscopic examination
Before the procedure of the arterial blood supply to the parathyroid,
• Withhold food and fluids after midnight. adrenal, and pancreatic glands.
• Make sure that the patient’s written, in-
formed consent has been obtained. Nursing actions
After the procedure Before the procedure
• Maintain bed rest for 24 hours. • Check for written, informed consent.
Memory • Monitor vital signs. • Note the patient’s allergies to iodine, sea-
jogger • Watch for esophageal or tracheal puncture food, and radiopaque dyes.
To recall and bleeding or respiratory distress caused • Withhold food and fluids after midnight.
interven- by hematoma or edema. After the procedure
tions for Sulkow- • Monitor vital signs.
itch’s test, remem- Thyroid function test • Check the insertion site for bleeding and as-
ber that hyper- A thyroid uptake, also called radioactive sess pulses distal to the site.
comes before hypo-
alphabetically. Then iodine uptake or RAIU, is used to measure
remember to collect the amount of radioactive iodine taken up by Counting calcium
a urine specimen the thyroid gland in 24 hours. This measure- Sulkowitch’s test is done to analyze urine
before a meal for ment evaluates thyroid function. to measure the amount of calcium being ex-
hypercalcemia and creted.
after for hypocal- Nursing actions
cemia. • Instruct the patient not to ingest iodine-rich
foods for 24 hours before the test
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Nursing actions DATA COLLECTION FINDINGS Because endocrine

• If hypercalcemia is indicated, collect a sin- Acromegaly disorders often affect
gle urine specimen before a meal. • Bitemporal hemianopia fluid balance,
• If hypocalcemia is indicated, collect a single • Diaphoresis monitoring fluid
urine specimen after a meal. • Enlarged supraorbital ridge status is a key
• History of gradual development element of patient
• Loss of visual acuity care.
• Oily skin
Polish up on patient • Possible blindness
• Prognathism (projection of the jaw) that be-
care comes marked and may interfere with chew-
ing
Major endocrine disorders include acromeg- • Severe headache
aly and gigantism, Addison’s disease, Cush- • Thickened ears and nose
ing’s syndrome, diabetes insipidus, diabetes • Thickening of the tongue
mellitus, goiter, hyperthyroidism, hypothy-
roidism, pancreatic cancer, and thyroid can- Gigantism
cer. • Abrupt, excessive growth in all parts of the
body
• Remarkable height increases, as much as 6⬙
Acromegaly and gigantism (15.2 cm) per year; infants and children may
grow to three times the normal height for
Acromegaly and gigantism are marked by their age; adults may reach heights above
hormonal dysfunction and startling skeletal 6⬘8⬙
overgrowth. Both are chronic, progressive
diseases that occur when the pituitary gland DIAGNOSTIC FINDINGS
It’s a question of
produces too much growth hormone, causing • Plasma HGH levels measured by radioim-
timing. Acromegaly
excessive growth. Acromegaly develops slow- munoassay typically are elevated. However, may occur any time
ly; gigantism develops abruptly. because HGH secretion is pulsatile, the re- after adolescence,
Acromegaly occurs after epiphyseal closure sults of random sampling may be misleading. when the arms and
takes place (around age 18 in females and IGF-1 (somatomedin-C) levels offer a better legs have stopped
around age 21 in males), causing bone thick- screening alternative. growing. Gigantism
ening and transverse growth and vis- • Glucose normally suppresses HGH secre- begins in childhood or
ceromegaly (enlargement of the viscera). In tion; therefore, a glucose infusion that doesn’t adolescence, when the
other words, acromegaly may occur any time suppress the hormone level to below the ac- arms and legs are still
after adolescence, when the arms and legs cepted normal value of 5 ng/ml, when com- growing.
have stopped growing. Signs of this disorder bined with characteristic clinical features,
include swelling and enlargement of the strongly suggests hyperpituitarism.
arms, legs, and face. • Skull X-rays, a CT scan, arteriography, and
Gigantism begins before epiphyseal closure magnetic resonance imaging (MRI) show the
and causes proportional overgrowth of all presence and extent of the pituitary lesion.
body tissues. In other words, gigantism be-
gins in childhood or adolescence when the NURSING DIAGNOSES
arms and legs are still growing. That’s why • Disturbed body image
these patients may attain giant proportions. • Chronic pain
CAUSES
• Oversecretion of human growth hormone TREATMENT
(HGH) • Surgery to remove the affecting tumor
• Tumors of the anterior pituitary gland (transsphenoidal hypophysectomy)
(which lead to oversecretion of HGH) • Pituitary radiation therapy
920109.qxd 8/7/08 3:01 PM Page 286
Drug therapy soft-tissue deformities but won’t correct bone

• Thyroid hormone replacement therapy after changes that have already taken place.
surgery: levothyroxine (Synthroid) Arrange for counseling, if necessary, to help
• Corticosteroid: cortisone (Cortone) the child and parents cope with permanent de-
• Inhibitor of growth hormone release: fects.
bromocriptine (Parlodel) • After surgery, diligently monitor vital signs
• Somatotropic hormone: octreotide (Sando- and neurologic status. Be alert for alterations
Think about statin) in level of consciousness, pupil equality, or vi-
therapeutic sual acuity as well as vomiting, falling pulse
communication. The INTERVENTIONS AND RATIONALES rate, and rising blood pressure. These changes
patient needs help • Provide the patient with emotional support may signal an increase in intracranial pressure
coping with his body to help him cope with his changing body image. due to intracranial bleeding or cerebral edema.
image as well as mood Dramatic body changes characteristic of this • Check blood glucose level often. HGH lev-
changes brought on by disorder can cause severe psychological stress. els usually fall rapidly after surgery, removing
the disorder. • Examine the patient for skeletal manifesta- an insulin antagonist effect in many patients
tions, such as arthritis of the hands and osteo- and possibly precipitating hypoglycemia.
arthritis of the spine, to detect complications. • Measure intake and output hourly, watching
• Administer prescribed medications to im- for large increases. Transient diabetes insip-
prove the patient’s condition. idus, which sometimes occurs after surgery for
• Perform or assist with range-of-motion hyperpituitarism, can cause such increases in
(ROM) exercises to promote maximum joint urine output.
mobility. • If the transsphenoidal approach is used for
• Evaluate muscular weakness, especially in surgery, a large nasal pack should be kept in
the patient with late-stage acromegaly. Check place for several days. Because the patient
the strength of his grasp to monitor for disease must breathe through his mouth, give good
progression. If it’s weak, help with tasks such mouth care to prevent breakdown of the oral
as cutting food into bitesize pieces. mucosa.
• Keep the skin dry. Avoid using an oily lotion • Watch for cerebrospinal fluid (CSF) leaks
because the skin is already oily. from the packed surgical site. Look for in-
• Test blood glucose to detect early signs of hy- creased external nasal drainage or drainage
perglycemia. into the nasopharynx. CSF leaks may necessi-
• Check for signs of hyperglycemia (fatigue, tate additional surgery to repair the leak.
polyuria, polydipsia, polyphagia) to avoid These measures detect complications quickly
treatment delay. and avoid treatment delays.
• Be aware that the patient’s tumor may • Apply a sequential compression device
cause vision problems. If the patient has while the patient is on bedrest to prevent deep
hemianopia, stand where he can see you to re- vein thrombosis.
duce anxiety. • Encourage the patient to ambulate on the
• Keep in mind that this disease can also first or second day after surgery to prevent
cause inexplicable mood changes. Reassure complications of immobility.
the family that these mood changes result
from the disease and can be modified with Teaching topics
treatment to help the family cope with the pa- • Receiving annual follow-up checkups
tient’s illness. (there’s a slight chance that the tumor that
• Before surgery, reinforce what the surgeon caused his condition could recur)
has told the patient, if possible, and provide a • Continuing hormone replacement therapy
clear and honest explanation of the scheduled following surgery (warn against stopping the
operation to allay the patient’s fears and anxi- hormones suddenly)
ety. • Wearing a medical identification bracelet at
• If the patient is a child, explain to his par- all times and bringing his hormone replace-
ents that such surgery prevents permanent
920109.qxd 8/7/08 3:01 PM Page 287
ment schedule with him whenever he goes • Electrocardiogram demonstrates prolonged

for medical care. PR and QT intervals.
• Blood or capillary glucose levels reveal
hypoglycemia.
Addison’s disease • Urine chemistry shows decreased 17-KS
and 17-OHCS.
Addison’s disease, also known as adrenal hy-
pofunction, occurs when the adrenal gland NURSING DIAGNOSES
fails to secrete sufficient mineralocorticoids, • Deficient fluid volume
glucocorticoids, and androgens. With careful- • Imbalanced nutrition: Less than body re-
ly monitored steroid replacement therapy, quirements
most people with Addison’s disease can live a • Risk for infection
normal life.
Addisonian crisis (adrenal crisis) is a critical TREATMENT
deficiency of mineralocorticoids and gluco- • High-carbohydrate, high-protein, high-
corticoids. It generally occurs in patients who sodium, low-potassium diet in small, frequent
have chronic adrenal insufficiency and fol- feedings before steroid therapy; high-potassi-
lows acute stress, sepsis, trauma, surgery, or um and low-sodium diet while on steroid ther-
omission of steroid therapy. It’s a medical apy
emergency that necessitates immediate, • With adrenal crisis, monitor I.V. administra-
vigorous treatment. tion 3 to 5 L of normal saline solution after I.V.
hydrocortisone is administered.
CAUSES
• Autoimmune disease Drug therapy
• Histoplasmosis • Antacids: magnesium and aluminum hy-
• Idiopathic atrophy of adrenal glands droxide (Maalox), aluminum hydroxide gel
• Metastatic lesions from lung cancer (Gelusil)
• Pituitary hypofunction • Glucocorticoids: cortisone (Cortone), hy-
• Surgical removal of adrenal glands drocortisone (Solu-Cortef)
• Trauma • Mineralocorticoid: fludrocortisone (Flori-
• Tuberculosis nef)
• Vasopressor: phenylephrine (Neo-
DATA COLLECTION FINDINGS Synephrine)
• Anorexia, diarrhea, and nausea
• Bronzed skin pigmentation on nipples, INTERVENTIONS AND RATIONALES
scars, and buccal mucosa • Be prepared to maintain I.V. normal saline
• Decreased pubic and axillary hair solution after administration of I.V. hydrocor-
• Depression and personality changes tisone if the patient is in adrenal crisis to re-
• Orthostatic hypotension verse shock and hyponatremia.
• Signs and symptoms of dehydration • Monitor fluid balance (and increase fluid in-
• Weakness and lethargy take in hot weather) to prevent addisonian cri-
• Weight loss sis, which may be precipitated by salt or fluid
loss in hot weather and during exercise.
DIAGNOSTIC FINDINGS • Encourage fluid intake to improve fluid sta-
• Blood chemistry reveals decreased cortisol, tus and prevent addisonian crisis.
glucose, sodium, chloride, and aldosterone • Monitor and record vital signs, intake and
levels; and increased BUN and potassium lev- output, urine specific gravity, and laboratory
els. studies to detect fluid volume deficit.
• Hematology tests reveal elevated HCT and • Maintain the patient’s diet to promote nutri-
decreased Hb. tional balance.
• BMR is decreased.
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• Maintain I.V. fluids to maintain hydration DATA COLLECTION FINDINGS

and prevent addisonian crisis. • Acne
• Weigh the patient daily to determine nutri- • Ecchymosis
tional status and detect fluid loss. • Edema
• Administer medications, as prescribed, to • Enlarged clitoris
maintain or improve the patient’s condition. • Fragile skin
• Don’t allow the patient to sit up or stand • Gynecomastia
quickly to avoid orthostatic hypotension. • Hirsutism
• Assist with activities of daily living to con- • History of amenorrhea
serve energy and decrease metabolic demands. • History of mood swings
• Maintain a quiet environment to conserve • History of recurrent infections
energy and decrease metabolic demands. • Hypertension
• Muscle wasting
Teaching topics • Pain in joints
• Recognizing the signs and symptoms of • Poor wound healing
adrenal crisis (profound weakness, fatigue, • Purple striae on abdomen
nausea, vomiting, hypotension, dehydration • Weakness and fatigue
and, occasionally, high fever followed by hy- • Weight gain, particularly truncal obesity,
pothermia) buffalo hump, and moonface
• Carrying injectable dexamethasone
(Decadron) DIAGNOSTIC FINDINGS
• Avoiding over-the-counter drugs • Blood chemistry shows increased cortisol,
• Avoiding strenuous exercise, particularly in aldosterone, sodium, corticotropin and glu-
hot weather cose levels and a decreased potassium level.
• Learning stress-reduction techniques • CT scan shows pituitary or adrenal tumors.
• Maintaining life-long follow-up care • Dexamethasone suppression test shows no
decrease in 17-OHCS.
The signs of • GTT shows hyperglycemia.
Cushing’s syndrome Cushing’s syndrome • Hematology shows increased WBC and
are distinctive. Let’s RBC counts and decreased eosinophil count.
see…rapidly Cushing’s syndrome, also known as hypercor- • MRI shows pituitary or adrenal tumors.
developing fatty tisolism, is characterized by hyperactivity of • Ultrasonography shows pituitary or adrenal
tissue in the face, the adrenal cortex. It results in excessive se- tumors.
neck, and trunk and
cretion of glucocorticoids, particularly corti- • Urine chemistry shows increased 17-OHCS
purple streaks on the
skin. sol. An increase in mineralocorticoids and sex and 17-KS, decreased urine specific gravity,
hormones may also occur. and glycosuria.
• X-ray shows pituitary or adrenal tumor and
CAUSES osteoporosis.
• Adenoma or carcinoma of the adrenal cor-
tex NURSING DIAGNOSES
• Adenoma or carcinoma of the pituitary • Disturbed body image
gland • Deficient fluid volume
• Excessive or prolonged administration of • Impaired skin integrity
glucocorticoids or corticotropin
• Exogenous secretion of corticotropin by TREATMENT
malignant neoplasms in the lungs or gallblad- • Hypophysectomy or bilateral adrenal-
der ectomy
• Hyperplasia of the adrenal glands • Low-sodium, low-carbohydrate, low-calorie,
• Hypothalamic stimulation of the pituitary high-potassium, and high-protein diet
gland • Radiation therapy
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• Potassium supplements: potassium chloride • Avoiding exposure to people with infections

(K-Lor), potassium gluconate (Kaon) • Carrying a medical identification card (and
immediately reporting infections, which ne-
Drug therapy cessitate increased steroid dosage)
• Adrenal suppressants: metyrapone (Meto- • Recognizing signs of inadequate steroid
pirone), aminoglutethimide (Cytadren) dosage (fatigue, weakness, and dizziness) and
• Antidiabetic agents: insulin or oral agents, overdosage (severe edema, weight gain)
such as glyburide (DiaBeta, Micronase), glip- • Avoiding discontinuing steroid dosage
izide (Glucotrol), metformin (Glucophage) • Maintaining life-long follow-up care
• Diuretics: furosemide (Lasix), ethacrynic
acid (Edecrin)
Diabetes insipidus
• Provide postoperative care to prevent com- Diabetes insipidus stems from a deficiency of
plications. antidiuretic hormone (ADH; vasopressin) se-
• Monitor fluid balance to detect fluid deficit or creted by the posterior lobe of the pituitary
overload. gland. Decreased ADH reduces the ability of
• Monitor and record vital signs, intake and distal and collecting renal tubules in the kid-
output, urine specific gravity, capillary glu- neys to concentrate urine, resulting in exces-
cose levels, and laboratory studies. Changed sive urination, excessive thirst, and excessive
parameters may indicate altered fluid or elec- fluid intake.
trolyte status.
• Check for edema to detect signs of fluid vol- CAUSES
ume excess. • Brain surgery
• Apply a sequential compression device and • Head injury
antiembolism stockings to promote venous re- • Idiopathy
turn and prevent thromboembolism formation. • Meningitis
• Maintain the patient’s diet to maintain nu- • Trauma to posterior lobe of pituitary gland
tritional status. • Tumor of posterior lobe of pituitary gland
• Maintain standard precautions to protect the
patient from infection. DATA COLLECTION FINDINGS
• Provide meticulous skin care and reposition • Fatigue Thirsty for
the patient every 2 hours to prevent skin • Headache more? Keep up the
breakdown. • Muscle weakness and pain hard work!
• Limit water intake to prevent fluid volume ex- • Polydipsia (excessive thirst, consumption of
cess. 4 to 40 L/day)
• Weigh the patient daily to detect fluid reten- • Polyuria (greater than 5 L/day of dilute
tion. urine)
• Administer medications, as prescribed, to • Signs and symptoms of dehydration
maintain or improve the patient’s condition. • Tachycardia
• Encourage the patient to express feelings • Weight loss
about changes in body image and sexual func-
tion to help him cope effectively. DIAGNOSTIC FINDINGS
• Provide rest periods to prevent fatigue. • Blood chemistry shows decreased ADH by
• Provide postradiation nursing care to pre- radioimmunoassay and increased potassium,
vent complications. sodium, and osmolality levels.
• Urine chemistry shows urine specific gravi-
Teaching topics ty less than 1.005, osmolality 50 to 200
• Recognizing the signs and symptoms of in- mOsm/kg, decreased urine pH, and de-
fection and fluid retention creased sodium and potassium levels.
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NURSING DIAGNOSES Diabetes mellitus

• Impaired oral mucous membrane Diabetes mellitus is a chronic disorder result-
• Risk for imbalanced body temperature ing from a disturbance in the production, ac-
tion, and rate of utilization of insulin, which in
TREATMENT turn causes a disturbance in carbohydrate,
• I.V. therapy: hydration (when first diag- protein and fat metabolism. There are several
nosed, intake and output must be matched types of diabetes mellitus.
milliliter to milliliter to prevent dehydration), Type 1 (insulin-dependent diabetes melli-
electrolyte replacement tus) usually develops in childhood. Type 2
• Regular diet with restriction of foods that (non-insulin-dependent diabetes mellitus)
exert a diuretic effect usually develops after age 30; however, it’s be-
coming more prevalent among children and
Drug therapy young adults. Gestational diabetes mellitus
• ADH replacement: vasopressin (Pitressin), occurs with pregnancy. Secondary diabetes is
lypressin (Diapid nasal spray) induced by trauma, surgery, pancreatic dis-
• ADH stimulant: carbamazepine (Tegretol) ease, or medications and can be treated as
type 1 or type 2.
• Monitor fluid balance and daily weight to CAUSES
avoid dehydration. • Autoimmune disease
• Monitor and record vital signs, intake and • Blockage of insulin supply
output (urine output should be measured • Cushing’s syndrome
every hour when first diagnosed), urine spe- • Exposure to chemicals
cific gravity (check every 1 to 2 hours when • Genetics
first diagnosed), and laboratory studies to as- • Hyperpituitarism
sess for fluid volume deficit. • Hyperthyroidism
• Maintain the patient’s diet to maintain nu- • Infection
tritional balance. • Medications
• Force fluids to keep intake equal to output • Pregnancy
and prevent dehydration. • Receptor defect in insulin-responsive cells
• Maintain I.V. fluids to replace fluid and elec- • Stress
trolyte loss. • Surgery
• Maintain the patency of the indwelling uri- • Trauma
nary catheter to allow accurate measuring of
urine output. DATA COLLECTION FINDINGS
Memory • Administer medications, as prescribed, to • Acetone breath
jogger enable the patient to concentrate urine and pre- • Anorexia
To remem- vent dehydration. • Atrophic muscles
ber the • Weigh the patient daily to detect fluid loss. • Blurred vision
classic signs of dia- • Provide a quiet environment to promote rest. • Fatigue
betes, think of the • Flushed, warm, smooth, shiny skin
3 Ps: Teaching topics • History of multiple infections and boils
Polydipsia: exces- • Recognizing the signs and symptoms of de- • Kussmaul’s respirations (deep and rapid)
sive thirst hydration • Mottled extremities
• Increasing fluid intake in hot weather • Pain
Polyphagia: exces- • Carrying medications at all times • Paresthesia
sive hunger
• Importance of obtaining daily weight to • Peripheral and visceral neuropathies
Polyuria: excessive monitor fluid status • Polydipsia
urination. • Polyphagia
• Polyuria
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• Poor wound healing thirst, neurologic abnormalities, stupor) to en-

• Sexual dysfunction sure early intervention and prevent complica-
• Signs and symptoms of dehydration tions.
• Weakness • Be prepared to treat hypoglycemia; immedi-
• Weight loss (with type 1) ately give carbohydrates in the form of fruit
juice, hard candy, or honey. If the patient is
DIAGNOSTIC FINDINGS unconscious, maintain safety until glucagon
• Blood chemistry shows increased glucose, or dextrose is administered I.V. to prevent
potassium, chloride, ketone, cholesterol, and neurologic complications.
triglyceride levels; decreased carbon dioxide • Be prepared to maintain I.V. fluid. Adminis-
level; and pH less than 7.4. ter insulin and, usually, potassium replace-
• Fasting blood glucose level greater than or ment for ketoacidosis or hyperosmolar coma
equal to 126 mg/dl. In pre-diabetes, fasting to reduce the risk of potentially life-threatening
blood glucose levels range between 100 and complications.
125 mg/dl. • Monitor and record vital signs, intake and
• Glycosylated hemoglobin assay is increased output, glucose monitor measurements, and
to 7 or above. laboratory studies to check fluid and electrolyte
• GTT shows hyperglycemia. balance. Be prepared to
• 2-hour postprandial blood glucose test • Monitor wound healing to detect for treat hypoglycemia
shows a level greater than 200 mg/dl. If the infection. immediately. Give fruit
results range between 140 and 199 mg/dl the • Maintain the patient’s diet to prevent compli- juice, hard candy, or
patient has prediabetes. cations of diabetes, such as hyperglycemia and honey. If the patient is
• Urine chemistry shows increased glucose hypoglycemia. unconscious,
and ketone levels. • Encourage fluids to maintain the patient’s administer glucagon
hydration. or dextrose I.V.
NURSING DIAGNOSES • Administer medications, as prescribed.
• Imbalanced nutrition: More than body re- Tight glycemic control is necessary to prevent
quirements complications. Diabetic control requires a dy-
• Risk for deficient fluid volume namic balance between diet, antidiabetic agent,
• Risk for impaired skin integrity and exercise.
TREATMENT about diet, medication regimen, and body im-
• Dietary restrictions age changes to facilitate coping mechanisms.
• Exercise • Encourage exercise, as tolerated, to prevent
• Pancreas transplant long-term complications of diabetes.
• Weigh the patient weekly to determine nutri-
Drug therapy tional status.
• Antidiabetic agents: insulins or oral agents, • Provide meticulous skin and foot care. Pa-
such as glimepiride (Amaryl), glyburide (Dia- tients with diabetes are at increased risk for
Beta, Micronase), glipizide (Glucotrol), met- infection from impaired leukocyte activity.
formin (Glucophage) These health care practices minimize the risk of
infection and promote early detection of health
INTERVENTIONS AND RATIONALES problems.
• Monitor acid-base and fluid balance to moni- • Maintain a warm and quiet environment to
tor for signs of hyperglycemia. provide rest and reduce metabolic demands.
• Monitor for signs of hypoglycemia (altered • Foster independence to promote self-esteem.
mental status, dizziness, weakness, pallor, • Determine the patient’s compliance to diet,
tachycardia, diaphoresis, seizures, and coma), exercise, and medication regimens to help de-
ketoacidosis (acetone breath, dehydration, velop appropriate interventions.
weak or rapid pulse, Kussmaul’s respira-
tions), and hyperosmolar coma (polyuria,
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Teaching topics CAUSES

• Understanding the importance of routine • Insufficient thyroid gland production
follow-up care • Depletion of glandular iodine
• Exercising regularly • Ingestion of goitrogenic foods (rutabagas,
• Smoking cessation cabbage, soybeans, peanuts, peaches, peas,
• Recognizing the signs and symptoms of hy- strawberries, spinach, and radishes)
perglycemia and hypoglycemia • Use of goitrogenic drugs (propylthiouracil,
• Self-monitoring for infection, skin break- methimazole [Tapazole], iodides, and lithium
down, changes in peripheral circulation, poor [Lithobid])
wound healing, and numbness in extremities
• Adjusting diet and insulin for changes in DATA COLLECTION FINDINGS
work, exercise, trauma, infection, fever, and • Single or multinodular, firm, irregular en-
stress largement of the thyroid gland
• Administering antidiabetic agents and using • Dizziness or syncope when the patient rais-
the insulin pump (type 1) es his arms above his head (Pemberton’s
As with many • Using home blood glucose monitoring sign)
endocrine disorders, equipment • Dysphagia
therapeutic care • Completing daily skin and foot care (avoid- • Respiratory distress
requires helping the ing foot soaks, using water-soluble lotions,
patient with goiter and using nail files—not nail clippers) DIAGNOSTIC FINDINGS
cope with a change of • Carrying an emergency supply of glucose • Tests are used to rule out Graves’ disease,
body image. • Avoiding over-the-counter medication and Hashimoto’s thyroiditis, and thyroid carcino-
alcohol ma.
• Adhering to the treatment regimen to pre- • Laboratory tests reveal high or normal
vent complications TSH, low serum T4 concentrations, and in-
• Contacting the American Diabetes Associa- creased 131I uptake.
tion and local support groups
NURSING DIAGNOSES
• Risk for suffocation
Goiter • Risk for injury
• Disturbed body image
A goiter is an enlargement of the thyroid
gland that isn’t caused by inflammation or a TREATMENT
neoplasm. This condition is commonly re- • Subtotal thyroidectomy
ferred to as nontoxic or simple goiter.
Goiter is commonly classified as endemic or Drug therapy
sporadic. With appropriate treatment, the • Thyroid hormone replacement: levothyrox-
prognosis is good for either type. ine (Synthroid)
Endemic goiter usually results from inade- • Small doses of iodine (Lugol’s or potassium
quate dietary intake of iodine associated with iodide solution)
such factors as iodine-depleted soil and mal-
nutrition. Endemic goiter affects females INTERVENTIONS AND RATIONALES
more than males, especially during adoles- • Measure the patient’s neck circumference
cence and pregnancy, when the demand on to check for progressive thyroid gland enlarge-
the body for thyroid hormone increases. ment. Also check for the development of hard
Sporadic goiter follows ingestion of certain nodules in the gland.
drugs or foods. It doesn’t affect any specific • Provide preoperative teaching and postoper-
population segment more than others. ative care if subtotal thyroidectomy is indicat-
ed. These measures allay the patient’s anxiety
and prevent postoperative complications.
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Teaching topics DIAGNOSTIC FINDINGS Remember,

• Understanding the importance of iodized • Blood chemistry shows increased T3, T4, positive thinking has
salt and free thyroxine levels and decreased TSH a lot of power.
• Taking medications as prescribed and cholesterol levels. Repeat to yourself, I
• Recognizing the symptoms of thyrotoxico- • RAIU is increased. WILL PASS
sis (increased pulse rate, palpitations, diar- • Thyroid scan shows nodules. THE NCLEX!
rhea, sweating, tremors, agitation, and short-
ness of breath) NURSING DIAGNOSES
• Risk for imbalanced body temperature
Hyperthyroidism • Risk for injury
Hyperthyroidism (also known as thyrotoxico- TREATMENT

sis) is the increased synthesis of thyroid hor- • High-protein, high-carbohydrate, high-calo-
mone. It can result from overactivity (Graves’ rie diet; restricting stimulants such as caffeine
disease) or a change in the thyroid gland (tox- • Radiation therapy
ic nodular goiter). • Thyroidectomy
CAUSES Drug therapy

• Abnormal iodine metabolism • Adrenergic-blocking agents: propranolol
• Autoimmune disease (Inderal), reserpine (Serpasil), guanethidine
• Genetic (Ismelin)
• Infection • Antithyroid agents: methimazole (Tapa-
• Other endocrine abnormalities zole), propylthiouracil
• Pituitary tumors • Cardiac glycoside: digoxin (Lanoxin)
• Psychological or physiologic stress • Glucocorticoids: cortisone (Cortone), hy-
• Thyroid adenomas drocortisone (Solu-Cortef)
• Iodine preparations: potassium iodide
DATA COLLECTION FINDINGS (SSKI), radioactive iodine
• Anxiety and mood swings • Sedative: oxazepam (Serax)
• Atrial fibrillation • Vitamins: thiamine (vitamin B1), ascorbic
• Bruit or thrill over thyroid acid (vitamin C)
• Diaphoresis
• Diarrhea INTERVENTIONS AND RATIONALES
• Dyspnea • Monitor cardiovascular status to detect signs
• Exophthalmos of thyroid storm (acute, severe exacerbation of
• Fine hand tremors hyperthyroidism), such as tachycardia, in-
• Flushed, smooth skin creased blood pressure, palpitations, and atrial
• Hair loss arrhythmias. Presence of these signs may re-
• Heat intolerance quire a change in the treatment regimen.
• Increased hunger • Evaluate fluid balance to determine signs of
• Increased systolic blood pressure fluid volume deficit.
• Palpitations • Monitor and record vital signs, intake and
• Tachycardia output, and laboratory studies to detect early
• Tachypnea changes and guide treatment.
• Weakness • Maintain the patient’s diet to promote ade-
• Weight loss quate nutrition.
• Avoid stimulants, such as caffeine-contain-
ing drugs and foods, to reduce or eliminate ar-
rhythmias.
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• Maintain I.V. fluids to promote hydration. DATA COLLECTION FINDINGS

• Administer medications as prescribed to • Coarse hair and alopecia
maintain or improve the patient’s condition. • Cold intolerance
• Weigh the patient daily to evaluate metabolic • Constipation
status and determine nutritional needs. • Decreased diaphoresis
• Provide postoperative care to promote heal- • Dry, flaky skin and thinning nails
ing and prevent complications. • Edema
• Provide rest periods to reduce metabolic de- • Fatigue
mands. • Hypersensitivity to opioids, barbiturates,
• Provide a quiet, cool environment to pro- and anesthetics
mote comfort. • Hypothermia
• Provide skin and eye care to prevent compli- • Menstrual disorders
cations. • Mental sluggishness
• Encourage the patient to express feelings • Thick tongue and swollen lips
about changes in body image to reduce anxiety • Weight gain or anorexia
and facilitate coping mechanisms.
• Provide postradiation care to prevent compli- DIAGNOSTIC FINDINGS
cations associated with treatment. • Blood chemistry shows decreased T3, T4,
free thyroxine, and sodium levels; TSH levels
Teaching topics are increased with thyroid insufficiency and
• Smoking cessation decreased with hypothalamic or pituitary in-
• Recognizing the signs and symptoms of thy- sufficiency.
roid storm • RAIU is decreased.
• Adhering to activity limitations
• Avoiding exposure to people with infections NURSING DIAGNOSES
• Self-monitoring for infection • Activity intolerance
Hypothyroidism
TREATMENT
Hypothyroidism, which affects women more • High-fiber, high-protein, low-calorie diet
often than men, occurs when the thyroid
gland fails to produce sufficient thyroid hor- Drug therapy
Avoid sedation. mone. This causes an overall decrease in me- • Thyroid hormone replacement: levothyrox-
Give patients with tabolism. ine (Synthroid), liothyronine (Cytomel), thy-
hypothyroidism one-
Hypothyroidism can be classified as prima- roglobulin (Proloid)
half to one-third the
normal dose of ry or secondary. Primary hypothyroidism oc-
sedatives or opioids. curs when the loss of thyroid tissue leads to a INTERVENTIONS AND RATIONALES
decrease in thyroid hormone protection. Sec- • Avoid sedation: administer one-half to one-
ondary hypothyroidism stems from either the third the normal dose of sedatives or opioids
pituitary’s failure to synthesize or secrete to prevent complications.
enough TSH or from target tissue failing to • Patients taking warfarin (Coumadin) with
respond to normal levels of thyroid hormone. levothyroxine may require lower doses of
warfarin because levothyroxine enhances the
CAUSES effects of warfarin.
• Hashimoto’s thyroiditis • Monitor fluid balance to determine fluid vol-
• Malfunction of pituitary gland ume deficit or excess.
• Overuse of antithyroid drugs • Encourage fluids to maintain hydration.
• Thyroidectomy • Check for constipation and edema to detect
• Use of radioactive iodine early changes.
920109.qxd 8/7/08 3:01 PM Page 295
• Monitor and record vital signs, intake and The two main tissue types are cylinder cell
output, and laboratory studies to determine and large, fatty, granular cell.
fluid status.
• Maintain the patient’s diet to facilitate nutri- CONTRIBUTING FACTORS
tional balance. • Smoking
• Administer medications as prescribed to • Foods high in fat and protein
maintain or improve the patient’s condition. • Food additives
• Encourage the patient to express feelings of • Industrial chemicals, such as beta-
depression to promote coping. naphthalene, benzidine, and urea
• Encourage physical activity and mental • Chronic pancreatitis
stimulation to enhance self-esteem. • Alcohol abuse
• Provide a warm environment to promote
comfort because the patient with hypothy- DATA COLLECTION FINDINGS
roidism may be sensitive to cold. • Dull, intermittent epigastric pain (early in
• Turn the patient every 2 hours and provide disease)
skin care to prevent skin breakdown. • Continuous pain that radiates to the right
• Provide frequent rest periods because pa- upper quadrant or dorsolumbar area and that
tients with hypothyroidism are easily fatigued. may be colicky, dull, or vague and unrelated
to activity or posture
Teaching topics • Anorexia
• Exercising regularly • Nausea
• Taking thyroid medication (patient may de- • Vomiting
velop myxedema coma if not taken) • Diarrhea
• Recognizing the signs and symptoms of hy- • Jaundice
perthyroidism and myxedema coma (progres- • Rapid, profound weight loss
sive stupor, hypoventilation, hypoglycemia, • Palpable mass in the subumbilical or left
hyponatremia, hypotension, and hypother- hypochondrial region
mia)
• Self-monitoring for constipation DIAGNOSTIC FINDINGS
• Making dietary changes to prevent consti- • Percutaneous fine-needle aspiration biopsy
pation of the pancreas identifies malignant cells
• Seeking additional protection and limiting • Laparotomy with a biopsy allows definitive
exposure during cold weather diagnosis.
• Avoiding sedatives • Ultrasound and CT scan can show a mass
but not its histology.
• Angiography can reveal the vascular supply
Pancreatic cancer of a tumor. In most patients,
• MRI shows tumor size and location in great pancreatic cancer has
Pancreatic cancer progresses rapidly and is detail. widely metastasized
by the time it’s
deadly. Treatment is rarely successful be- • Blood studies reveal increased serum
diagnosed and
cause the disease has usually widely metasta- bilirubin, increased serum amylase and li- treatment is rarely
sized by the time it’s diagnosed. pase, prolonged PT, elevated alkaline phos- successful.
Pancreatic cancer has a swift and deadly phatase (with biliary obstruction), aspartate
course. Therapeutic care means helping the aminotransferase and alanine aminotrans-
patient and family come to terms with the end ferase are elevated (when liver cell necrosis is
of life. present).
Pancreatic tumors are almost always adeno- • Fasting blood glucose may indicate hyper-
carcinomas and most arise in the head of the glycemia or hypoglycemia.
pancreas. Rarer tumors are those of the body • Plasma insulin immunoassay shows mea-
and tail of the pancreas and islet cell tumors. surable serum insulin in the presence of islet
cell tumors.
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• Stool studies may show occult blood if ul- • Opioid analgesics: morphine, codeine,
Don’t forget:
If the place in which ceration in the GI tract or ampulla of Vater which can lead to biliary tract spasm and in-
you’re studying isn’t has occurred. crease common bile duct pressure (used only
conducive to effective • Tumor markers for pancreatic cancer, in- when other methods fail)
learning, find a new cluding carcinoembryonic antigen, alpha- • Pancreatic enzyme: pancrelipase (Pan-
place to study. fetoprotein, and serum immunoreactive elas- crease)
tase I, are elevated. • Vitamin K: phytonadione (AquaMEPHY-
TON)
NURSING DIAGNOSES • Stool softener: docusate (Colace)
• Chronic pain • Laxative: bisacodyl (Dulcolax)
quirements INTERVENTIONS AND RATIONALES
• Grieving Before surgery
• Make sure that the patient is medically sta-
TREATMENT ble, particularly regarding nutrition (this may
• Blood transfusion, if indicated take 4 to 5 days). If the patient can’t tolerate
• I.V. fluid therapy oral feedings, provide total parenteral nutri-
• Total pancreatectomy tion and I.V. fat emulsions to correct deficien-
• Cholecystojejunostomy (surgical anastomo- cies and maintain positive nitrogen balance.
sis of the gallbladder and the jejunum) • Monitor blood transfusions to combat ane-
• Choledochoduodenostomy (surgical anasto- mia.
mosis of the common bile duct to the duode- • Administer vitamin K to overcome prothrom-
num) bin deficiency, antibiotics to prevent postopera-
• Choledochojejunostomy (surgical tive infection.
anastomosis of the common bile duct to the • Perform gastric lavage to maintain gastric
jejunum) decompression, as necessary.
• Whipple’s procedure or pancreatoduo- • Teach the patient about expected postopera-
denectomy (excision of the head of the pan- tive procedures and expected adverse effects
creas along with the encircling loop of the of radiation and chemotherapy to allay
duodenum) anxiety.
• Gastrojejunostomy (surgical creation of an
anastomosis between the stomach and the je- After surgery
junum) • Watch for and report complications, such as
• Radiation therapy fistula, pancreatitis, fluid and electrolyte im-
balance, infection, hemorrhage, skin break-
Drug therapy down, nutritional deficiency, hepatic failure,
• Antineoplastic combinations: fluorouracil renal insufficiency, and diabetes, to ensure
(Adrucil), streptozocin (Zanosar), ifosfamide early detection and treatment of complications.
(Ifex), and doxorubicin (Adriamycin) • If the patient is receiving chemotherapy,
• Antibiotic: cefmetazole (Zefazone) to pre- treat adverse effects symptomatically to pro-
vent infection and relieve symptoms mote patient comfort and prevent complica-
• Anticholinergic: propantheline (Pro- tions.
Banthine) to decrease GI tract spasm and • Throughout the illness, provide meticulous
motility and reduce pain and secretions supportive care as follows:
• Histamine2-receptor antagonists: cimetidine – Monitor fluid balance, abdominal girth,
(Tagamet), ranitidine (Zantac), famotidine metabolic state, and weight daily to deter-
(Pepcid), nizatidine (Axid) mine fluid volume status.
• Diuretics: furosemide (Lasix) to mobilize – Replace nutrients I.V., orally, or by naso-
extracellular fluid from ascites gastric (NG) tube to combat weight loss.
• Insulin to provide adequate exogenous in- Maintain dietary restrictions such as a low-
sulin supply after pancreatic resection sodium or fluid retention diet as required to
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combat weight gain (due to ascites). Main- • Contacting local support groups and obtain-
tain a 2,500 calorie diet for the patient to ing hospice information
meet increased nutritional needs.
– Serve small, frequent, nutritious meals to
help the patient meet increased metabolic de- Thyroid cancer
mands.
– Administer an oral pancreatic enzyme at Thyroid cancer is a malignant, primary tumor
mealtimes, if needed, to aid digestion. of the thyroid. It may not affect thyroid hor-
– Administer laxatives, stool softeners, and mone secretion.
cathartics as required; modify diet; and in-
crease patient fluid intake to prevent consti- CAUSES
pation. • Chronic overstimulation of the pituitary
– Position the patient properly at mealtime gland
and help him walk when he can to increase • Chronic overstimulation of the thymus
GI motility. gland
– Administer pain medication, antibiotics, • Neck radiation
and antipyretics, as necessary to promote
comfort and treat infection. DATA COLLECTION FINDINGS
– Monitor blood glucose levels to detect ear- • Dysphagia
ly signs of hypoglycemia or hyperglycemia. • Dyspnea
– Watch for signs of hypoglycemia or hyper- • Enlarged thyroid gland
glycemia; administer glucose or an antidia- • Hoarseness
betic agent as necessary to prevent compli- • Painless, firm, irregular, and enlarged thy-
cations of hypoglycemia or hyperglycemia. roid nodule or mass
– Provide meticulous skin care to avoid pru- • Palpable cervical lymph nodes
ritus and necrosis.
– Watch for signs of upper GI bleeding; test DIAGNOSTIC FINDINGS
stools and vomitus for occult blood and • Blood chemistry shows increased calci-
keep a flow sheet of Hb values and HCT to tonin, serotonin, and prostaglandin levels.
prevent hemorrhage. • RAIU shows a “cold,” or nonfunctioning,
– Promote gastric vasoconstriction with pre- nodule.
scribed medication to control active bleed- • Thyroid biopsy shows cytology positive for
ing. cancer cells.
– Replace any fluid loss to prevent hypovole- • Thyroid function test result is normal.
mia.
– Ease discomfort from pyloric obstruction NURSING DIAGNOSES
with an NG tube to provide gastric decom- • Anxiety
pression. • Compromised family coping
– Apply antiembolism stockings and a se- • Acute and chronic pain
quential compression device and assist with
ROM exercises to prevent thrombosis. If TREATMENT
thrombosis occurs, elevate the patient’s • High-protein, high-carbohydrate, high-
legs to promote venous return and give an calorie diet with supplemental feedings
anticoagulant as ordered to decrease blood • Radiation therapy
viscosity and prevent further thrombosis. • Thyroidectomy (total or subtotal) with or
without radical neck excision
Teaching topics
• Knowing disease process and treatment op- Drug therapy
tions • Antiemetics: prochlorperazine (Compa-
• Contacting the American Cancer Society zine), ondansetron (Zofran)
920109.qxd 8/7/08 3:01 PM Page 298
• Chemotherapy: chlorambucil (Leukeran), CAUSES

doxorubicin (Adriamycin), vincristine (On- • Antibodies to thyroid antigens
covin) • Bacterial invasion
• Thyroid hormone replacements: levothy- • Mumps, influenza, coxsackievirus, or ade-
roxine (Synthroid), liothyronine (Cytomel), novirus infection
thyroglobulin (Proloid)
INTERVENTIONS AND RATIONALES • Thyroid enlargement
• Monitor respiratory status for signs of air- • Fever
way obstruction. A tracheotomy set should be • Pain
kept at the bedside because swelling may cause • Tenderness and reddened skin over the
airway obstruction. gland
• Evaluate ability to swallow to maintain a
patent airway. DIAGNOSTIC FINDINGS
• Provide postoperative thyroidectomy care • Precise diagnosis depends on the type of
to promote healing and prevent postoperative thyroiditis:
complications. – autoimmune—high titers of thyroglobulin
• Monitor and record vital signs, intake and and microsomal antibodies may be present
output, and laboratory studies to determine in serum
baseline and detect early changes that may oc- – subacute granulomatous—elevated ery-
cur with hemorrhage, airway obstruction, or throcyte sedimentation rate, increased thy-
hypocalcemia. roid hormone levels, decreased thyroidal
• Administer medications as prescribed to radioactive iodine uptake
maintain or improve the patient’s condition. – chronic infective and noninfective—varied
• Maintain the patient’s diet to improve nutri- findings, depending on underlying infection
tional status. or other disease.
• Encourage the patient to express feelings to
facilitate coping mechanisms. NURSING DIAGNOSES
• Provide postchemotherapy and postradia- • Risk for infection
tion nursing care to prevent and treat compli- • Acute pain
cations associated with therapy. • Disturbed body image
Teaching topics TREATMENT

• Recognizing the signs and symptoms of res- • Partial thyroidectomy to relieve tracheal or
piratory distress, infection, myxedema coma, esophageal compression in Riedel’s thyroidi-
and difficulty swallowing tis
• Contacting the American Cancer Society
Drug therapy
• Thyroid hormone replacement: levothyrox-
Thyroiditis ine (Synthroid) for accompanying hypothy-
roidism
Thyroiditis is inflammation of the thyroid • Analgesics and anti-inflammatory agents: in-
gland. It may occur in a variety of forms: domethacin (Indocin) for mild subacute gran-
autoimmune thyroiditis (long-term inflamma- ulomatous thyroiditis
tory disease; also known as Hashimoto’s thy- • Beta-adrenergic blocker: propranolol (In-
roiditis), subacute granulomatous thyroiditis deral) for transient thyrotoxicosis
(self-limiting inflammation), Riedel’s thyroidi-
tis (rare, invasive fibrotic process), and mis- INTERVENTIONS AND RATIONALES
cellaneous thyroiditis (acute suppurative, • Before treatment, obtain a patient history to
chronic infective, and chronic noninfective). identify underlying diseases that may cause thy-
920109.qxd 8/7/08 3:01 PM Page 299
roiditis, such as tuberculosis or a recent viral The airway may become obstructed because of
infection. postoperative edema.
• Check vital signs and examine the patient’s
neck for unusual swelling, enlargement, or Teaching topics
redness to detect disease progression and signs • Watching for and reporting signs of hypo-
of airway occlusion. thyroidism (lethargy, restlessness, sensitivity
• Obtain a consult for speech therapy to de- to cold, forgetfulness, dry skin)—especially if
termine the proper consistency of fluids if the he has Hashimoto’s thyroiditis, which com-
patient has difficulty swallowing, especially monly causes hypothyroidism
when due to fibrosis, to aid swallowing and • Understanding the need for lifelong thyroid
prevent aspiration. hormone replacement therapy if permanent
• If the neck is swollen, measure and record hypothyroidism occurs
the circumference daily to monitor progressive • Understanding the need to watch for signs
enlargement. of overdose, such as nervousness and palpita-
• Check for signs of thyrotoxicosis (nervous- tions
ness, tremor, weakness), which often occur in
subacute thyroiditis. Checking for early signs
avoids treatment delay.
After thyroidectomy
• Check vital signs every 15 to 30 minutes un-
til the patient’s condition stabilizes. Stay alert
for signs of tetany secondary to accidental
parathyroid injury during surgery. Keep 10%
calcium gluconate available for I.M. use if
needed. These measures help prevent serious
postoperative complications.
• Check dressings frequently for excessive
bleeding to detect signs of hemorrhage.
• Keep the head of the patient’s bed elevated.
• Watch for signs of airway obstruction, such
Pump up on practice
as difficulty talking and increased swallowing;
keep tracheotomy equipment handy to avoid
questions
treatment delay if airway becomes obstructed.
1. A client with a PTH deficiency would most
likely experience abnormal serum levels of:
After thyroidectomy, watch 1. sodium and chloride.
for signs of airway obstruction, 2. potassium and glucose.
such as difficulty talking and 3. urea and uric acid.
increased swallowing; keep 4. calcium and phosphorous.
tracheotomy equipment handy. Answer: 4. Because PTH regulates calcium
and phosphorous metabolism, a PTH deficien-
cy would affect calcium and phosphorous lev-
els. PTH doesn’t affect sodium, chloride,
potassium, glucose, urea, or uric acid.
integrity
logical adaptation
920109.qxd 8/7/08 3:01 PM Page 300
2. A 28-year-old woman is scheduled for a Client needs category: Health promo-

GTT. She asks the nurse what result indicates tion and maintenance
diabetes mellitus. The nurse should respond Client needs subcategory: None
that the minimum parameter for indication of Cognitive level: Comprehension
diabetes mellitus is a 2-hour blood glucose
level greater than:
1. 120 mg/dl.
2. 150 mg/dl.
3. 200 mg/dl.
4. 250 mg/dl.
Answer: 3. A GTT indicates a diagnosis of dia-
betes mellitus when the 2-hour blood glucose
level is greater than 200 mg/dl. Confirmation
occurs when at least one subsequent result is
greater than 200 mg/dl.
Client needs category: Health promo-
tion and maintenance
Client needs subcategory: None 4. A client is diagnosed with hyperthy-
Cognitive level: Comprehension roidism. The nurse should expect clinical
manifestations similar to:
1. hypovolemic shock.
2. adrenergic stimulation.
3. benzodiazepine overdose.
4. Addison’s disease.
Answer: 2. Hyperthyroidism is a hypermeta-
bolic state characterized by such signs as
tachycardia, systolic hypertension, and anxi-
ety—all seen in adrenergic (sympathetic)
stimulation. Manifestations of hypovolemic
shock, benzodiazepine overdose, and Addi-
son’s disease are more similar to a hypometa-
bolic state.
3. When interpreting a radioactive iodine up- Client needs category: Physiological
take test, the nurse should know that: integrity
1. uptake increases in hyperthyroidism Client needs subcategory: Physio-
and decreases in hypothyroidism. logical adaptation
2. uptake decreases in hyperthyroidism Cognitive level: Analysis
and increases in hypothyroidism.
3. uptake increases in both hyperthy- 5. A client with a history of mitral valve re-
roidism and hypothyroidism. placement and chronic warfarin (Coumadin)
4. uptake decreases in both hyperthy- usage is diagnosed with hypothyroidism and
roidism and hypothyroidism. prescribed levothyroxine (Synthroid). The
Answer: 1. Iodine is necessary for the synthe- nurse should expect the need for the war-
sis of thyroid hormones. In hyperthyroidism, farin:
more iodine is taken up by the thyroid so 1. dosage to be decreased.
more thyroid hormones may be synthesized. 2. dosage to be increased.
In hypothyroidism, less iodine is taken up be- 3. frequency to be decreased.
cause fewer thyroid hormones are synthe- 4. frequency to be increased.
sized.
920109.qxd 8/7/08 3:01 PM Page 301
Answer: 1. Levothyroxine enhances the ef- 7. A client with intractable asthma develops
fects of warfarin; therefore, the warfarin Cushing’s syndrome. Development of this
dosage would need to be decreased. complication can most likely be attributed to
Client needs category: Physiological chronic use of:
integrity 1. prednisone (Deltasone).
Client needs subcategory: Pharmaco- 2. theophylline (Theo-Dur).
logical therapies 3. metaproterenol (Alupent).
Cognitive level: Application 4. cromolyn (Intal).
Answer: 1. Cushing’s syndrome results from
excessive glucocorticoids. This can occur
from frequent or chronic use of cortico-
steroids such as prednisone. Theophylline,
metaproterenol, and cromolyn don’t cause
Cushing’s syndrome.
integrity
Client needs subcategory: Pharmaco-
logical therapies
6. A client with thyroid cancer undergoes a

thyroidectomy. After surgery, the client devel-
ops peripheral numbness and tingling and
muscle twitching and spasms. The nurse
should expect an order for which type of med-
ication?
1. Thyroid supplement
2. Antispasmodics
3. Barbiturates
4. Calcium
Answer: 4. Removal of the thyroid gland can
cause hyposecretion of PTH leading to calci- 8. During treatment of a client in adrenal cri-
um deficiency. Manifestations of calcium defi- sis (addisonian crisis), the nurse should ex-
ciency include numbness, tingling, and mus- pect a physician’s order for:
cle spasms. Treatment includes immediate 1. insulin.
administration of calcium. A thyroid supple- 2. normal saline solution.
ment will be necessary following thyroidecto- 3. dextrose 5% in half-normal saline solu-
my but isn’t specifically related to the identi- tion.
fied problem. An antispasmodic doesn’t treat 4. dextrose 5% in water.
the problem’s cause. A barbiturate isn’t indi- Answer: 2. A client in addisonian crisis has hy-
cated. ponatremia. It would be most appropriate to
Client needs category: Physiological administer normal saline solution. Hydrocor-
integrity tisone, glucose, and vasopressors are also
Client needs subcategory: Pharmaco- used to treat addisonian crisis. Administering
logical therapies dextrose 5% in half-normal saline solution,
Cognitive level: Application dextrose 5% in water, or insulin would be inap-
propriate for this client.
integrity
920109.qxd 8/7/08 3:01 PM Page 302
Client needs subcategory: Pharmaco- 10. Which nursing diagnosis is most likely
logical therapies for a client with an acute episode of diabetes
Cognitive level: Application insipidus?
1. Imbalanced nutrition
9. A client recently diagnosed with type 1 dia- 2. Deficient fluid volume
betes mellitus is learning foot care. The nurse 3. Impaired gas exchange
should include which of the following points 4. Ineffective tissue perfusion
in her teaching? Answer: 2. Diabetes insipidus causes a pro-
1. “It’s OK to go barefoot at home.” nounced loss of intravascular volume. The
2. “Trim your toenails with scissors regu- most prominent risk to the client is deficient
larly.” fluid volume. Nutrition, gas exchange, and tis-
3. “Wear tight-fitting shoes without sue perfusion are at risk because of diabetes
socks.” insipidus but this risk is a result of the fluid
4. “Wear cotton socks and apply foot pow- volume deficit caused by diabetes insipidus.
der to your feet to keep them dry.” Client needs category: Physiological
Answer: 4. The nurse should instruct the integrity
client to apply foot powder and to wear cotton Client needs subcategory: Reduction of
socks and properly fitting shoes. The nurse risk potential
should also instruct the client to avoid going Cognitive level: Application
barefoot to prevent injury and avoid using
scissors to trim his nails. The client should be
encouraged to see a podiatrist.
integrity
risk potential
Essentially, it’s
the end of the
endocrine chapter.
Good job!
920110.qxd 8/7/08 3:02 PM Page 303
10 Genitourinary
system
Here’s how urine is formed:
In this chapter,
you’ll review:
Brush up on key • Blood from the renal artery is filtered
across the glomerular capillary membrane in
✐ components of the
genitourinary system
concepts Bowman’s capsule.
• Blood filtration requires adequate intravas-
and their functions The genitourinary system performs various cular volume and adequate cardiac output.
✐ tests used to diag- excretory, regulatory, and secretory func- • Antidiuretic hormone and aldosterone con-
nose genitourinary tions. This system filters waste products from trol the tubular reabsorption of water and
disorders the body and expels them as urine. It does electrolytes.
✐ common genitouri- this by continuously exchanging water and • Composition of formed filtrate is similar to
nary disorders. solutes, such as hydrogen, potassium, chlo- blood plasma without proteins.
ride, bicarbonate, sulfate and phosphate, • Formed filtrate moves through the tubules
across cell membranes. of the nephron, which reabsorb and secrete
At any time, you can review the major points electrolytes, water, glucose, amino acids, am-
of this chapter by consulting the Cheat sheet monia, and bicarbonate.
on pages 304 to 309. • What’s left is excreted as urine.
Urine producers Transport tubule

The kidneys are two bean-shaped organs that The ureter, which transports urine from the
produce urine and maintain fluid and acid- kidney to the bladder, is a tubule that extends
base balance. To help maintain acid-base bal- from the renal pelvis to the bladder floor.
ance, the kidneys secrete hydrogen ions, re-
absorb sodium and bicarbonates, acidify Storage sac
phosphate salts, and produce ammonia. The bladder, a muscular, distendable sac,
The kidneys have four main components: can contain up to 1 L of urine at a single time.
• the cortex, which makes up the outer layer
of the kidney and contains the glomeruli, the Bagpipe
proximal tubules of the nephron, and the dis- The urethra is a tube extending from the
tal tubules of the nephron bladder to the urinary meatus that transports
• the medulla, which makes up the inner lay- urine from the bladder to the exterior of the
er of the kidney and contains the loops of body.
Henle and the collecting tubules
• the renal pelvis, which collects urine from Semen secretor
the calices The prostate gland surrounds the male ure-
• the nephron, which makes up the functional thra. It contains ducts that secrete the alka-
unit of the kidney and contains Bowman’s line portion of seminal fluid.
capsule, the glomerulus, and the renal tubule,
which consists of the proximal convoluted Blood pressure control
tubule and collecting segments. Regulation of fluid volume by the kidneys af-
fects blood pressure. The renin-angiotensin
Fluid facts system is activated by decreased blood pres-
Urine is produced by a complex process cen- sure and can be altered by renal disease.
tered in the kidneys. (Text continues on page 309.)
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304 Genitourinary system
et
heat she
C
Genitourinary refresher
ACUTE POSTSTREPTOCOCCAL Key test results
GLOMERULONEPHRITIS • Creatinine clearance is low.
Key signs and symptoms • Glomerular filtration rate is 20 to 40 ml/minute
• Azotemia (renal insufficiency); 10 to 20 ml/minute (renal fail-
• Fatigue ure); less than 10 ml/minute (end-stage renal dis-
• Oliguria ease).
• Edema Key treatments
Key test results • Continuous renal replacement therapy or he-
• Blood tests show elevated serum creatinine modialysis
and potassium levels. • Low-protein, high-carbohydrate, moderate-
• 24-hour urine sample shows low creatinine fat, and moderate-calorie diet with potassium,
clearance and impaired glomerular filtration. sodium, and phosphorus intake regulated ac-
• Urinalysis typically reveals proteinuria and cording to serum levels
hematuria. Red blood cells (RBCs), white blood • Inotropic agent: dopamine (Intropin) initially
cells, and mixed cell casts are common findings low-dose to improve renal perfusion
in urinary sediment. • Diuretics: furosemide (Lasix), metolazone
• Kidney-ureter-bladder (KUB) X-rays show bilat- (Zaroxolyn), bumetanide (Bumex)
eral kidney enlargement. Key interventions
Key treatments • Monitor fluid balance, respiratory, cardiovascu-
• Bed rest lar, and neurologic status.
• Diuretics: metolazone (Zaroxolyn), furosemide • Monitor and record vital signs, intake and out-
I cannot tell a (Lasix) put, and daily weight.
lie. When I am in a • Antihypertensive: hydralazine • Maintain the patient’s diet.
rush, I sometimes • Fluid restriction BENIGN PROSTATIC HYPERPLASIA
skip the chapter • High-calorie, low-sodium, low-potassium, low-
and just read the Key signs and symptoms
protein diet
Cheat sheet. • Decreased force and amount of urine
Key interventions
• Nocturia
• Check vital signs. Monitor intake and output • Urgency, frequency, and burning on urination
and daily weight. Watch for signs of acute renal
Key test results
failure (oliguria, azotemia, and acidosis).
• Provide good nutrition, use good hygienic tech- • Cystoscopy shows enlarged prostate gland, ob-
nique, and prevent contact with infected people. structed urine flow, and urinary stasis.
• Bed rest is necessary during the acute phase. • Digital rectal examination shows enlarged
Encourage the patient to gradually resume nor- prostate gland.
mal activities as symptoms subside. Key treatments
• Forcing fluids
ACUTE RENAL FAILURE • Transurethral resection of the prostate (TURP)
Key signs and symptoms or prostatectomy
• Urine output less than 400 ml/day for 1 to 2 Key interventions
weeks followed by diuresis (3 to 5 L/day) for 2 to 3 • Force fluids.
weeks • Provide postoperative care.
• Weight gain
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Genitourinary refresher (continued)

BLADDER CANCER Key interventions
Key signs and symptoms • Note the patient’s feelings about her illness, and determine
• Frequent urination what she knows about breast cancer and her expectations.
• Painless hematuria • Provide routine postoperative care.
• Urgency of urination • Perform comfort measures.
• Urinary obstruction • Administer analgesics as ordered, and monitor their effective-
• Urinary retention ness.
Key test results • Watch for treatment-related complications, such as nausea,
vomiting, anorexia, leukopenia, thrombocytopenia, GI ulceration,
• Biopsy and cytology examination are positive for malignant
and bleeding.
cells.
• Cystoscopy reveals a bladder mass. CERVICAL CANCER
Key treatment Key signs and symptoms
• Surgery, depending on the location and progress of the tumor • Preinvasive: absence of symptoms
Key interventions • Invasive: abnormal vaginal discharge (yellowish, blood-tinged,
• Provide postoperative care. (Closely monitor urine output; ob- and foul-smelling)
serve for hematuria [reddish tint to gross bloodiness] or infection • Postcoital pain and bleeding
[cloudy, foul smelling, with sediment]; maintain continuous blad- Key test results
der irrigation, if indicated; assist with turning, coughing, deep • Colposcopy determines the source of the abnormal cells seen
breathing, and incentive spirometry; apply a sequential compres- on Papanicolaou test.
sion device while the patient is on bedrest.) • Cone biopsy identifies malignant cells.
• Force fluids. Key treatments
BREAST CANCER • Preinvasive: cryosurgery
Key signs and symptoms • Invasive: radiation therapy (internal, external, or both), radical
hysterectomy
• Cervical, supraclavicular, or axillary lymph node lump or en-
largement on palpation Key interventions
• Painless lump or mass in the breast or thickening of breast tis- • Encourage the patient to use relaxation techniques.
sue • Watch for complications related to therapy.
• Skin changes of the breast • Provide postoperative care.
Key test results CHLAMYDIA
• Breast self-examination reveals a lump or mass in the breast Key signs and symptoms
or thickening of breast tissue. In women
• Fine-needle aspiration and excisional biopsy provide histologic • Dyspareunia
cells that confirm diagnosis. • Mucopurulent discharge
• Mammography and MRI detect a tumor. • Pelvic pain
Key treatments In men
• Bone marrow and peripheral stem cell therapy for advanced • Dysuria
breast cancer • Erythema
• Surgery: lumpectomy, skin-sparing mastectomy, partial mas- • Tenderness of the meatus
tectomy, total mastectomy, modified radical mastectomy, and • Urethral discharge
quandrantectomy • Urinary frequency
• Chemotherapy: cyclophosphamide (Cytoxan), methotrexate Key test result
(Folex), fluorouracil (Adrucil), doxorubicin (Adriamycin) • Antigen detection methods, including enzyme-linked immuno-
• Hormonal therapy: tamoxifen (Nolvadex), raloxifene (Evista), sorbent assay and direct fluorescent antibody test, are the diag-
fulvestrant (Faslodex), toremifene (Fareston), megestrol
(Megace) (continued)
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CHLAMYDIA (continued) Key test result
nostic tests of choice for identifying chlamydial infection, al- • Blood chemistry shows increased BUN, creatinine, potassium,
though tissue cell cultures are more sensitive and specific. phosphorus and lipid levels and decreased calcium, carbon
Key treatments dioxide, and albumin levels.
• Antibiotics: doxycycline (Vibramycin), azithromycin (Zithromax) Key treatments
• For pregnant women with chlamydial infections, azithromycin, • Limited fluids
in a single 1-g dose • Low-protein, low-sodium, low-potassium, low-phosphorus,
Key interventions high-calorie, and high-carbohydrate diet
• Practice standard and contact precautions when caring for a • Peritoneal dialysis or hemodialysis
patient with a chlamydial infection. • Antacid: aluminum hydroxide gel (AlternaGEL)
• Make sure that the patient fully understands the dosage re- • Antiemetic: prochlorperazine (Compazine), metoclopramide
quirements of any prescribed medications for this infection. (Reglan)
• Obtain appropriate specimens for diagnostic testing. • Calcium supplement: calcium carbonate (Os-Cal)
• Cation exchange resin: sodium polystyrene sulfonate (Kayex-
CHRONIC GLOMERULONEPHRITIS alate)
Key signs and symptoms • Diuretics: furosemide (Lasix), bumetanide (Bumex)
• Edema Key interventions
• Hematuria • Monitor renal, respiratory, and cardiovascular status and fluid
• Hypertension balance.
Key test results • Check dialysis access for bruit and thrill.
• Kidney biopsy identifies the underlying disease and provides • Follow standard precautions.
data needed to guide therapy. • Restrict fluids.
• Blood studies reveal rising blood urea nitrogen (BUN) and
CYSTITIS
serum creatinine levels, which indicate advanced renal insuffi-
ciency. Key signs and symptoms
• Urinalysis reveals proteinuria, hematuria, cylindruria, and RBC • Dark, odoriferous urine
casts. • Frequency of urination
• Urgency of urination
Key treatments
• Dialysis Key test result
• Kidney transplant • Urine culture and sensitivity positively identifies organisms (Es-
cherichia coli, Proteus vulgaris, and Streptococcus faecalis).
Key interventions
• Understand that patient care is primarily supportive, focusing Key treatment
on continual observation and sound patient teaching. • Diet: increased intake of fluids and vitamin C
• Accurately monitor vital signs, intake and output, and daily Key interventions
weight. • Monitor vital signs and intake and output.
• Observe for signs of fluid, and electrolyte imbalances. • Force fluids (cranberry or orange juice) to 3 qt (3 L)/day.
• Administer medications. • Instruct the patient to decrease his intake of carbonated bev-
• Provide good skin care. erages and to avoid coffee, tea, and alcohol.
CHRONIC RENAL FAILURE GONORRHEA
• Azotemia • Dysuria
• Decreased urine output • Purulent urethral or cervical discharge
• Indications of heart failure • Itching, burning, and pain
• Lethargy
• Pruritus
• Weight gain
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GONORRHEA (continued) Key treatment
Key test result • Indwelling urinary catheter insertion (including teaching the
• A culture from the site of infection (urethra, cervix, rectum, or patient self-catheterization techniques)
pharynx), is used to establish the diagnosis by isolating the or- Key interventions
ganism. • Use strict sterile technique during insertion of an indwelling
Key treatments urinary catheter (a temporary measure to drain the incontinent
• Antibiotics: ceftriaxone (Rocephin), doxycycline (Vibramycin), patient’s bladder). Don’t interrupt the closed drainage system for
erythromycin (E-mycin) any reason.
• Prophylactic antibiotic: 1% silver nitrate or erythromycin • Clean the catheter insertion site with soap and water at least
(EryPed) eye drops to prevent infection in neonates twice a day.
Key interventions • Clamp the tubing or empty the catheter bag before transferring
• Before treatment, establish whether the patient has any drug the patient to a wheelchair or stretcher.
sensitivities. • Watch for signs of infection (fever, cloudy or foul-smelling
• Follow standard and contact precautions. urine).
HERPES SIMPLEX OVARIAN CANCER

• Blisters, which may form on any part of the mouth • Abdominal distention
• Dysuria (in genital herpes) • Pelvic discomfort
• Erythema • Urinary frequency
• Flulike symptoms • Weight loss
• Fluid-filled blisters (genital herpes) Key test result
Key test result • Abdominal ultrasonography, computed tomography scan, or
• Confirmation requires isolation of the virus from local lesions X-ray may delineate tumor size.
and a histologic biopsy. Key treatments
Key treatments • Resection of the involved ovary
• Antiviral agents: idoxuridine (Herplex Liquifilm), trifluridine (Vi- • Total abdominal hysterectomy and bilateral salpingo-oopho-
roptic), or vidarabine (Vira-A) rectomy with tumor resection, omentectomy, and appendectomy
• 5% acyclovir (Zovirax) ointment (possible relief to patients with • Antineoplastics: carboplatin (Paraplatin), chlorambucil (Leuk-
genital herpes or to immunosuppressed patients with Herpes- eran), cyclophosphamide (Cytoxan), dactinomycin (Cosmegen),
virus hominis skin infections; I.V. acyclovir to help treat more se- doxorubicin (Rubex), fluorouracil (Adrucil), cisplatin (Platinol),
vere infections) paclitaxel (Taxol), topotecan (Hycamtin)
• Analgesics: morphine, fentanyl (Duragesic-25)
Key interventions
Key interventions
• Follow standard and contact precautions. For patients with ex-
tensive cutaneous, oral, or genital lesions, institute contact pre- Before surgery
cautions. • Thoroughly explain all preoperative tests, the expected course
• Administer pain medication and prescribed antiviral agents as of treatment, and surgical and postoperative procedures.
ordered. After surgery
• Provide supportive care, as indicated, such as oral hygiene, • Monitor vital signs frequently.
nutritional supplementation, and antipyretics for fever. • Monitor intake and output while maintaining good catheter
care.
NEUROGENIC BLADDER • Check the dressing regularly for excessive drainage or bleed-
Key symptom ing, and watch for signs of infection.
• Altered micturition • Encourage coughing, deep breathing, and incentive spirometry
Key test result hourly during the waking hours.
• Reposition the patient often, and encourage her to walk shortly
• Voiding cystourethrography evaluates bladder neck function,
after surgery.
vesicoureteral reflux, and continence.
(continued)
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PROSTATE CANCER • If surgery was performed, check dressings regularly for bloody
Key signs and symptoms drainage and report excessive amounts of bloody drainage to
• Decreased size and force of urinary stream the doctor; use sterile technique to change the dressing; main-
• Difficulty and frequency of urination tain nephrostomy tube or indwelling urinary catheter if indicated;
• Hematuria and monitor the incision site for signs of infection.
• Urine retention SYPHILIS
• Carcinoembryonic antigen is elevated. Primary syphilis
• Digital rectal examination reveals palpable firm nodule in gland • Chancres on the genitalia, anus, fingers, lips, tongue, nipples,
or diffuse induration in posterior lobe. tonsils, or eyelids
• Prostatic-specific antigen is increased. Secondary syphilis
Key treatments • Symmetrical mucocutaneous lesions
• Radiation implant • Malaise
• Radical prostatectomy (for localized tumors without metasta- • Anorexia
sis) or TURP (to relieve obstruction in metastatic disease) • Weight loss
• Luteinizing hormone-releasing hormone agonists: goserelin ac- • Slight fever
etate (Zoladex) and leuprolide acetate (Lupron) Key test results
• Estrogen therapy: diethylstilbestrol • Fluorescent treponemal antibody-absorption test identifies
Key interventions antigens of T. pallidum in tissue, ocular fluid, cerebrospinal fluid,
• Monitor and record vital signs and intake and output. tracheobronchial secretions, and exudates from lesions. This is
• Check for signs of infection. the most sensitive test available for detecting syphilis in all
• Monitor the patient’s pain and note the effectiveness of anal- stages. Once reactive, it remains so permanently.
gesia. • Venereal Disease Research Laboratory (VDRL) slide test and
• Maintain the patient’s diet. rapid plasma reagin test detect nonspecific antibodies. Both
• Maintain the patency of the urinary catheter and note tests, if positive, become reactive within 1 to 2 weeks after the
drainage. primary lesion appears or 4 to 5 weeks after the infection begins.
RENAL CALCULI Key treatment
• Antibiotics: penicillin G benzathine (Permapen); if allergic to
Key sign
penicillin, erythromycin (Erythrocin) or tetracycline (Panmycin)
• Flank pain
Key interventions
Key test results
• Check for a history of drug sensitivity before administering the
• Excretory urography reveals stones.
first dose of penicillin.
• KUB X-rays reveal stones.
• Urge the patient to seek VDRL testing after 3, 6, 12, and 24
Key treatments months. A patient treated for latent or late syphilis should re-
• Diet: for calcium stones, acid-ash with limited intake of calcium ceive blood tests at 6-month intervals for 2 years.
and milk products; for oxalate stones, alkaline-ash with limited
intake of foods high in oxalate (cola, tea); for uric acid stones, TESTICULAR CANCER
alkaline-ash with limited intake of foods high in purine Key signs and symptoms
• Extracorporeal shock wave lithotripsy • Firm, painless, smooth testicular mass, varying in size and
• Surgery to remove the stone if other measures aren’t effective sometimes producing a sense of testicular heaviness
(type of surgery dependent on location of the stone) In advanced stages
Key interventions • Ureteral obstruction
• Monitor the patient’s urine for evidence of renal calculi. Strain • Abdominal mass
all urine and save all solid material for analysis. • Weight loss
• Force fluids to 3 qt (3 L)/day. • Fatigue
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TESTICULAR CANCER (continued) (VePesid), ifosfamide (Ifex), plicamycin (Mithracin), vinblastine
• Back pain (Velban)
• Pallor • Analgesics: morphine, fentanyl (Duragesic-25)
Key test results • Antiemetics: trimethobenzamide (Tigan), metoclopramide
• Regular self-examinations and testicular palpation during a (Reglan), ondansetron (Zofran)
routine physical examination may detect testicular tumors. Key interventions
• Surgical excision and biopsy of the tumor and testes permits • Develop a treatment plan that addresses the patient’s psycho-
histologic verification of the tumor cell types. logical and physical needs.
Key treatments After orchiectomy
• Surgery: orchiectomy (testicle removal; most surgeons remove • For the first day after surgery, apply an ice pack to the scrotum
the testicle but not the scrotum to allow for a prosthetic implant) and provide an analgesic.
• High-calorie diet provided in small frequent feedings • Check for excessive bleeding, swelling, and signs of infection.
• I.V. fluid therapy • Give an antiemetic, as needed.
• Antineoplastics: bleomycin (Blenoxane), carboplatin (Para- • Encourage small, frequent meals.
platin), cisplatin (Platinol), dactinomycin (Cosmegen), etoposide
Female and male and sweat glands, nonstriated muscle fibers,

nerve endings, and blood vessels. They unite
reproductive systems to form the fourchette (the vaginal vestibule)
and serve to lubricate the vulva, which adds
The genitourinary system also encompasses to sexual pleasure and fights bacteria.
the female and male reproductive systems.
Here’s a brief review of the female and male Pleasure center
reproductive systems, including external and The clitoris—located in the anterior portion
internal genitalia. of the vulva above the urethral opening—is
made up of erectile tissue, nerves, and blood
FEMALE EXTERNAL GENITALIA vessels and provides sexual pleasure. The cli-
Here’s a look at the external female genitalia. toris consists of:
• the glans
Pelvic protection • the body
The mons pubis provides an adipose cush- • two crura.
ion over the anterior symphysis pubis, pro-
tects the pelvic bones, and contributes to the The vestibule
rounded contour of the female body. The vaginal vestibule extends from the cli-
toris to the posterior fourchette and consists
Vulval cleft protection of:
The labia majora are two folds that converge • the vaginal orifice
at the mons pubis and extend to the posterior • the hymen—a thin, vascularized mucous
commissure. They consist of connective tis- membrane at the vaginal orifice
sue, elastic fibers, veins, and sebaceous • the fossa navicularis—a depressed area be-
glands, and protect components of the vulval tween the hymen and fourchette
cleft. • Bartholin’s glands—two bean-shaped
glands on either side of the vagina that se-
Lubricating the vulva crete mucus during sexual stimulation.
The labia minora are within the labia majora
and consist of connective tissue, sebaceous
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Episiotomy site gesterone, androgen) and serve as the site of

The perineal body (the area between the ovulation.
vagina and the anus) is the site of episiotomy
during childbirth. Food for thought
Although not part of the female internal or ex-
Urine passage ternal genitalia, the breasts are affected by
The urethral meatus is located 3⁄8⬙ to 1⬙ (1 to the genitourinary system. They consist of
2.5 cm) below the clitoris. glandular, fibrous, and adipose tissue. Stimu-
lated by secretions from the hypothalamus,
Grease monkeys anterior pituitary, and ovaries, they provide
The paraurethral glands (Skene’s glands) nourishment to an infant, transfer maternal
are located on both sides of the urethral open- antibodies during breast-feeding.
ing. Their function is to produce mucus.
MALE EXTERNAL GENITALIA
FEMALE INTERNAL GENITALIA External male genitalia include the penis and
Here’s a brief review of internal female geni- the scrotum.
talia.
Upstanding members
Copulatory and birth passage The penis, consisting of the body (shaft) and
The vagina is a vascularized musculomem- glans, has three layers of erectile tissue—two
branous tube extending from the external corpora cavernosa and one corpus spongio-
genitals to the uterus. sum. The penis deposits spermatozoa in the
female reproductive tract during sexual inter-
Womb for more course.
Hollow and pear-shaped, the uterus is a mus-
cular organ divided by a slight constriction Protective pouch
(isthmus) into an upper portion (body or cor- The scrotum is a pouchlike structure com-
pus) and a lower portion (cervix); the body or posed of skin, fascial connective tissue, and
corpus has three layers (perimetrium, myo- smooth muscle fibers that houses the testes
metrium, and endometrium). The uterus re- and protects spermatozoa from high body
ceives support from broad, round, uterosacral temperature.
ligaments and provides an environment for fe-
tal growth and development. MALE INTERNAL GENITALIA
Internal male genitalia, which are discussed
Fertilization site here, produce and transport semen and semi-
The fallopian tubes are about 41⁄2⬙ (11.5 cm) nal fluid.
long and consist of four layers (peritoneal,
subserous, muscular, mucous) divided into Sperm producers
four portions (interstitial, isthmus, ampulla, The testes or testicles, two oval-shaped glan-
fimbria). The fallopian tubes: dular organs inside the scrotum, function to
• transport ovum from the ovary to the produce spermatozoa and testosterone.
uterus
• provide a nourishing environment for zy- Sperm storage
gotes The epididymides serve as the initial section
• serve as the site of fertilization. of the testes’ excretory duct system and store
spermatozoa as they mature and become
Ovulation site motile.
The ovaries are two almond-shaped glandu-
lar structures resting below and behind the Sperm conduit
fallopian tubes on either side of the uterus. The vas deferens, which connects the epi-
They produce sex hormones (estrogen, pro- didymal lumen and the prostatic urethra,
serves as a conduit for spermatozoa.
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Seminal passage Urine sample study 2 Maintain a sense

The ejaculator y ducts—located between the A urine culture and sensitivity test in- of accomplishment
seminal vesicles and the urethra—serve as volves examination of a urine specimen for while studying. Make a
passageways for semen and seminal fluid. the presence of bacteria. list of chapters to
review this week and
Exit strategy Nursing actions then cross them off
The urethra, which extends from the bladder • Clean the perineal area and urinary meatus one by one. That’s
through the penis to the external urethral with bacteriostatic solution. satisfying!
opening, serves as the excretory duct for • Collect a midstream sample in a sterile con-
urine and semen. tainer.
Motility aids All in a day’s work

The seminal vesicles are two pouchlike A 24-hour urine collection is used to ana-
structures between the bladder and the rec- lyze urine specimens collected over 24 hours
tum that secrete a viscous fluid that aids in to evaluate kidney function.
spermatozoa motility and metabolism.
Nursing actions
Lubricating gland • Instruct the patient to void. Sample collec-
The prostate gland, located just below the tion starts the next time the patient voids;
bladder, is considered homologous to Skene’s note this time.
glands in females. It produces an alkaline flu- • Place the urine container on ice, if indicat-
id that enhances spermatozoa motility and lu- ed.
bricates the urethra during sexual activity. • Measure each voided urine specimen and
place in the collection container.
Peas in a pod • Instruct the patient to void at the end of the
The bulbourethral glands (or Cowper’s 24-hour period.
glands) are two pea-sized glands opening into
the posterior portion of the urethra. They se- Blood study 1
crete a thick alkaline fluid that neutralizes Blood chemistr y tests analyze blood sam-
acidic secretions in the female reproductive ples for potassium, sodium, calcium, phospho-
tract, thus prolonging spermatozoa survival. rus, glucose, bicarbonate, blood urea nitro-
gen (BUN), creatinine, protein, albumin, os-
molality, magnesium, uric acid, and carbon
dioxide (CO2) levels.
diagnostic tests • Withhold food and fluids before the proce-
dure, as directed.
Here are some diagnostic tests to help identi- • Monitor the venipuncture site for bleeding.
fy genitourinary disorders as well as common
nursing actions associated with each test. Blood study 2
A hematologic study involves analysis of a
Urine sample study 1 blood sample for WBCs, RBCs, erythrocyte
Urinalysis involves an examination of urine sedimentation rate, platelets, hemoglobin
for color, appearance, pH, urine specific gravi- (Hb) level, and hematocrit (HCT).
ty, protein, glucose, ketones, red blood cells
(RBCs), white blood cells (WBCs), and casts. Nursing actions
• Explain the purpose of the procedure.
Nursing actions • Check the venipuncture site for bleeding.
• Wash the perineal area.
• Obtain first morning urine specimen.
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Blood study 3 • Make sure that written, informed consent

A coagulation study involves analysis of a has been obtained.
blood sample for prothrombin time (PT), in- • Administer enemas and medications, as pre-
ternational normalized ratio, and partial scribed.
thromboplastin time (PTT). After the procedure
• Monitor vital signs and intake and output.
Nursing actions • Administer an analgesic and sitz baths, as
• Explain the purpose of the procedure. prescribed.
• Check the medication list and note any that • Check the patient’s urine for blood clots.
may alter test results. • Encourage fluids.
Examining arteries
Picture this Renal angiography is a radiographic exami-
A kidney-ureter-bladder (KUB) X-ray pronation of the renal arterial supply.
vides a radiographic picture of the kidneys,
ureters, and bladder. Nursing actions
Nursing actions • Note any allergies to iodine, seafood, and
• Schedule the X-ray before other examina- radiopaque dyes.
tions requiring contrast medium. • Make sure that written, informed consent
• Make sure that the patient removes metallic has been obtained.
belts. • Withhold food and fluids after midnight.
• Instruct the patient to void immediately be-
Scope the whole system fore the procedure.
Excretor y urography is a fluoroscopic ex- • Administer enemas, as prescribed.
amination of the kidneys, ureters, and blad- After the procedure
der. • Monitor vital signs and pulses below the
catheter insertion site.
Nursing actions • Inspect the catheter insertion site for bleed-
Before the procedure ing or hematoma formation.
Remember that • Note any allergies to iodine, seafood, and • Force fluids.
after many radiopaque dyes.
genitourinary tests, • Withhold food and fluids after midnight. Go with the blood flow
such as excretory • Administer a laxative, as prescribed. A renal scan permits visual imaging of blood
urography,
• Make sure that written, informed consent flow distribution to the kidneys.
cytoscopy, and renal
angiography, you has been obtained.
need to encourage • Inform the patient that he may experience a Nursing actions
fluids. transient burning sensation and metallic taste Before the procedure
when the contrast is injected. • Note any allergies.
After the procedure • Make sure that written, informed consent
• Instruct the patient to drink at least 1 qt has been obtained.
(1 L) of fluids. After the procedure
• Monitor the patient for signs of delayed al-
Bladder inspection lergic reaction, such as itching and hives.
With cystoscopy, a cystoscope is used to di- • Wear gloves when caring for incontinent pa-
rectly visualize the bladder. During the proce- tients and double-bag linens.
dure, the bladder is usually distended with
fluid to enhance visualization. Taking kidney tissue
A renal biopsy is the percutaneous removal
Nursing actions of a small amount of renal tissue for histologic
Before the procedure evaluation.
• Withhold food and fluids.
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Nursing actions Acute poststreptococcal I’m not very

• Record baseline vital signs. glomerulonephritis good at winning
contests. I prefer
• Withhold food and fluids after midnight. to ignore the rule:
• Make sure that written, informed consent Also called acute glomerulonephritis, APSGN void where
has been obtained. is a relatively common bilateral inflammation prohibited.
After the procedure of the glomeruli, the kidney’s blood vessels. It
• Monitor and record vital signs, Hb level, follows a streptococcal infection of the respi-
and HCT. ratory tract or, less often, a skin infection
• Check the biopsy site for bleeding. such as impetigo.
Dye and shoot CAUSES

For cystourethrography, a radiopaque dye • Trapped antigen-antibody complexes
and an X-ray are used to provide visualization (produced as an immunologic mechanism in
of the bladder and ureters. response to streptococci) in the glomerular
capillary membranes, induce inflammatory
Nursing actions damage and impede glomerular function
Before the procedure • Untreated pharyngitis (inflammation of the
• Note any allergies to iodine, seafood, and pharynx)
radiopaque dyes.
• Make sure that written, informed consent DATA COLLECTION FINDINGS
has been obtained. • Azotemia
• Advise the patient about voiding require- • Edema
ments during the procedure. • Fatigue
After the procedure • Flank pain
• Monitor voiding. • Hematuria
• Hypertension
Bladder pressure measure • Oliguria
Cystometrogram (CMG) graphs the pres- • Proteinuria
sure exerted while the bladder fills.
DIAGNOSTIC FINDINGS I get it! Acute
Nursing actions • Blood tests show elevated serum creatinine poststreptococcal
glomerulonephritis is a
• Advise the patient about voiding require- and potassium levels.
relatively common
ments during the procedure. • 24-hour urine sample shows low creatinine inflammation of my
• Monitor voiding after the procedure. clearance and impaired glomerular filtration. blood vessels.
• Elevated antistreptolysin-O titers (in 80%
of patients), elevated streptozyme and anti-
DNase B titers, and low serum complement
Polish up on patient levels verify recent streptococcal infection.
• Renal biopsy may confirm the diagnosis in a
care patient with APSGN or may be used to assess
renal tissue status.
Major genitourinary disorders include acute • Renal ultrasonography may show a normal
poststreptococcal glomerulonephritis (APS- or slightly enlarged kidney.
GN), acute renal failure, benign prostatic hy- • Throat culture may show group A beta-
perplasia (BPH), bladder cancer, breast can- hemolytic streptococci.
cer, cervical cancer, chlamydia, chronic • Urinalysis typically reveals proteinuria and
glomerulonephritis, chronic renal failure, cys- hematuria. RBCs, WBCs, and mixed cell casts
titis, gonorrhea, herpes simplex, neurogenic are common findings in urinary sediment.
bladder, ovarian cancer, prostate cancer, renal • KUB X-rays show bilateral kidney enlarge-
calculi, syphilis, and testicular cancer. ment.
920110.qxd 8/7/08 3:02 PM Page 314
Encourage
NURSING DIAGNOSES • Knowing what to expect (after APSGN,
pregnant women with • Impaired urinary elimination gross hematuria may recur during nonspecif-
a history of APSGN • Excess fluid volume ic viral infections; abnormal urinary findings
to have frequent • Risk for injury may persist for years)
medical evaluations • Understanding the possibility of orthostatic
because they’re at TREATMENT hypotension when taking a diuretic and the
increased risk for • Bed rest need to change position slowly
chronic renal failure. • Fluid restriction • Knowing the need for frequent medical
• High-calorie, low-sodium, low-potassium, evaluations in pregnant patients with a history
low-protein diet of APSGN (pregnancy further stresses the
• Dialysis (occasionally necessary) kidneys, increasing the risk of chronic renal
failure)
Drug therapy
• Diuretics: metolazone (Zaroxolyn),
furosemide (Lasix) Acute renal failure
• Antihypertensive: hydralazine
Acute renal failure is a sudden interruption of
INTERVENTIONS AND RATIONALES renal function resulting from obstruction,
• Check vital signs. Monitor fluid intake and poor circulation, or kidney disease. With
output and daily weight. Watch for signs of treatment, this condition is usually reversible;
acute renal failure (oliguria, azotemia, acido- however, if left untreated, it may progress to
sis). These measures detect early signs of com- end-stage renal disease or death.
plications and help guide the treatment plan. Acute renal failure is classified as prerenal
• Consult the dietitian to provide a diet high in (results from conditions that diminish blood
calories and low in protein, sodium, potassium, flow to the kidneys), intrarenal (results from
and fluids. damage to the kidneys, usually from acute
With treatment, • Provide good nutrition, use good hygienic tubular necrosis), or postrenal (results from
acute renal failure is technique, and prevent contact with infected obstruction of urine flow).
usually reversible. people to protect the debilitated patient from
Untreated, it may secondary infection. CAUSES
progress to end-stage • Stress bed rest during the acute phase. En- • Acute glomerulonephritis
renal disease or courage the patient to gradually resume nor- • Acute tubular necrosis
death. mal activities as symptoms subside to prevent • Anaphylaxis
fatigue. • BPH
• Provide emotional support for the patient • Blood transfusion reaction
and family. If the patient is on dialysis, explain • Burns
the procedure fully. These measures may help • Cardiopulmonary bypass
ease the patient’s anxiety. • Collagen diseases
• Congenital deformity
Teaching topics • Dehydration
• Knowing the importance of immediately re- • Diabetes mellitus
porting signs of infection, such as fever and • Heart failure, cardiogenic shock, endocardi-
sore throat (for the patient with a history of tis, malignant hypertension
chronic upper respiratory tract infections) • Hemorrhage
• Understanding the importance of follow-up • Nephrotoxins: antibiotics, X-ray dyes, pesti-
examinations to detect chronic renal failure cides, anesthetics
• Understanding the need for regular blood • Renal calculi
pressure, urinary protein, and renal function • Septicemia
assessments during the convalescent months • Trauma
to detect recurrence • Tumor
920110.qxd 8/7/08 3:02 PM Page 315
DATA COLLECTION FINDINGS sodium, and phosphorus intake regulated ac-

Everyone depends
• Anorexia, nausea, and vomiting cording to serum levels on me. If I fail to
• Circumoral numbness, tingling extremities • Fluid intake restricted to amount needed to function, it can
• Costovertebral pain replace fluid loss threaten many body
• Diarrhea or constipation • Transfusion therapy with packed RBCs ad- systems. Just call me
• Epistaxis ministered over 1 to 3 hours as needed Mr. Dependable.
• Headache
• Irritability, restlessness Drug therapy
• Lethargy, drowsiness, stupor, coma • Alkalinizing agent: sodium bicarbonate
• Pallor, ecchymosis • Antacid: aluminum hydroxide gel (Alter-
• Stomatitis naGEL)
• Thick, tenacious sputum • Antibiotic: cefazolin (Ancef)
• Urine output less than 400 ml/day for 1 to 2 • Anticonvulsant: phenytoin (Dilantin)
weeks followed by diuresis (3 to 5 L/day) for • Antiemetic: prochlorperazine (Compazine)
2 to 3 weeks • Antipyretic: acetaminophen (Tylenol)
• Weight gain • Inotropic agent: dopamine (Intropin) initial-
ly low-dose to improve renal perfusion
DIAGNOSTIC FINDINGS • Cation exchange resin: sodium polystyrene
• Arterial blood gas (ABG) analysis shows sulfonate (Kayexalate)
metabolic acidosis. • Diuretics: furosemide (Lasix), metolazone
• Blood chemistry shows increased potassi- (Zaroxolyn), bumetanide (Bumex)
um, phosphorus, magnesium, BUN, creati-
nine, and uric acid levels and decreased calci- INTERVENTIONS AND RATIONALES
um, CO2, and sodium levels. • Monitor fluid balance, respiratory, cardio-
• Creatinine clearance is low. vascular, and neurologic status to detect fluid
• Excretory urography shows decreased re- overload, a complication of acute renal failure.
nal perfusion and function. • Monitor and record vital signs, intake and
• Glomerular filtration rate is 20 to 40 ml/ output, and daily weight to detect early signs of
minute (renal insufficiency); 10 to 20 ml/ fluid overload.
minute (renal failure); less than 10 ml/minute • Observe for the presence of dependent ede-
(end-stage renal disease). ma, which may indicate fluid overload.
• Hematology shows decreased Hb level, • Restrict fluids to prevent fluid volume excess.
HCT, and erythrocytes. • Maintain I.V. fluids to correct electrolyte im- If conservative
• Coagulation studies show increased PT and balance and maintain hydration. measures fail to
PTT. • Place the patient in semi-Fowler’s position reverse renal failure,
• Urine chemistry shows albuminuria, pro- to facilitate lung expansion. continuous renal
teinuria, and increased sodium level; casts, • Maintain the patient’s diet to promote nutri- replacement therapy
RBCs, and WBCs; and urine specific gravity tional status. or hemodialysis may
greater than 1.025, then fixed at less than • Monitor total parenteral nutrition or enteral be necessary.
1.010. nutrition, if indicated, to promote nutritional
status.
NURSING DIAGNOSES • Administer medications, as prescribed, to
• Decreased cardiac output maintain or improve the patient’s condition.
• Excess fluid volume • Encourage the patient to express feelings
• Ineffective tissue perfusion: Renal about changes in body image to facilitate
coping mechanisms.
TREATMENT • Maintain a quiet environment to reduce
• Continuous renal replacement therapy, or metabolic demands.
hemodialysis • Assist the patient with turning, coughing,
• Low-protein, high-carbohydrate, moderate- and deep breathing to mobilize secretions and
fat, and moderate-calorie diet with potassium, promote lung expansion.
920110.qxd 8/7/08 3:02 PM Page 316
• Provide skin and mouth care using plain wa- NURSING DIAGNOSES
ter to promote comfort and prevent tissue • Sexual dysfunction
breakdown. • Impaired urinary elimination
• Urinary retention
Teaching topics
• Avoiding over-the-counter medications TREATMENT
• Understanding dietary modifications • Encouraging fluids
• Maintaining a quiet environment • Transurethral resection of the prostate
(TURP) or prostatectomy
Benign prostatic hyperplasia Drug therapy

• Alpha-adrenergic antagonists: prazosin
With BPH, the prostate gland enlarges and (Minipress), tamsulosin (Flomax), terazosin
compresses the urethra, causing urinary ob- (Hytrin)
struction. • Alpha-adrenergic blockers: doxazosin (Car-
dura), phenoxybenzamine (Dibenzyline)
Relate data
CAUSES • Analgesics: oxycodone and acetaminophen
collection findings to • Hormonal (Tylox)
how the disorder • Unknown • Antianxiety: oxazepam (Serax)
affects the body. BPH • Antibiotic: co-trimoxazole (Bactrim)
can compress the DATA COLLECTION FINDINGS • Urinary antiseptic: phenazopyridine (Pyridi-
urethra. Decreased • Decreased force and amount of urine um)
force and amount of • Dribbling of urine
urine are key signs. • Dysuria INTERVENTIONS AND RATIONALES
• Hesitancy in voiding • Monitor and record vital signs and intake
• History of urinary tract infection (UTI) and output. Accurate intake and output are es-
• Nocturia sential to detect urine retention if the patient
• Urgency, frequency, and burning on urina- doesn’t have an indwelling urinary catheter in
tion place.
• Urine retention • Monitor for UTI to assess for complications.
• Force fluids to improve hydration.
DIAGNOSTIC FINDINGS • Administer medications, as prescribed, to
• Blood chemistry shows increased BUN and maintain or improve the patient’s condition.
creatinine levels. • Encourage the patient to express feelings
• CMG shows abnormal pressure recordings. about changes in body image and fear of sex-
• Cystoscopy shows enlarged prostate gland, ual dysfunction to help pinpoint fears, establish
obstructed urine flow, and urinary stasis. trust, and facilitate coping.
• Digital rectal examination reveals enlarged • Maintain the position and patency of the in-
prostate gland. dwelling urinary catheter to straight drainage
• Excretory urography shows urethral ob- to avoid urine reflux. (See Inserting an in-
struction and hydronephrosis. dwelling urinary catheter.)
• In many cases, prostate-specific antigen • Maintain activity as tolerated to promote in-
(PSA) levels are low. dependence.
• Urinary flow rate determination shows • Provide routine postoperative care to pre-
small volume, prolonged flow pattern, and low vent complications.
peak flow.
• Urine chemistry shows bacteria, hematuria, Teaching topics
alkaline pH, and increased urine specific grav- • Recognizing the signs and symptoms of
ity. urine retention
• Adhering to medical follow-up
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Stepping up
Inserting an indwelling urinary catheter

WHY YOU DO IT with another sterile cotton ball in the same way. Then wipe di-
A urinary catheter, which is inserted through the urethra into rectly over the meatus with still another cotton ball. For the
the urinary bladder, can be used to empty the bladder before male patient, clean the glans with a sterile cotton ball held in
surgery, treat urine retention, obtain a sterile urine specimen, the forceps. Clean in a circular motion, starting at the urinary
determine the amount of residual urine, or monitor urine output meatus and working outward. Repeat the procedure, using an-
continuously in a seriously ill patient. other cotton ball and taking care not to contaminate your sterile
glove.
HOW YOU DO IT
• Using the dominant hand, insert the catheter into the meatus
• Explain the procedure to the patient, provide privacy, and
until urine flows; for a female, insert the indwelling catheter 3⬙
arrange for good lighting.
to 4⬙ (7.5 to 10 cm); for a male, 7⬙ to 9⬙ (17.5 to 23 cm). Don’t use
• Place the female patient in the dorsal recumbent position with
force when advancing the catheter. If you meet resistance, ro-
knees flexed and feet positioned about 2⬘ (61 cm) apart. Place
tate the catheter slightly (for a male, exert slight upward tension
the male patient in the supine position.
on the penis). Note the flow of urine from the catheter.
• After placing a waterproof pad under the patient, clean the
• Inflate the balloon with sterile water; then tug gently on the
genital area with soap and water and then dry it.
catheter to check placement.
• Open the supplies, put on sterile gloves, and set up sterile
• Attach the catheter to the drainage system (if not connected
supplies.
already). Position the collection bag on the bed frame. Secure
• Spread the labia or position the penis with your nondominant
the catheter to the female patient’s thigh or to the male patient’s
hand. Identify the meatus (in an uncircumcised male, retract
abdomen or thigh, allowing sufficient slack for leg movement.
the foreskin). Using cotton balls held by forceps, clean the area
• Document the date and time of the catheter insertion, the
with antiseptic (use each cotton ball only once). For the female
amount of urine initially obtained, urine characteristics, the size
patient, wipe one side of the urinary meatus with a sterile cot-
of the catheter, and the patient’s response to the procedure.
ton ball using a single downward motion. Wipe the other side
Bladder cancer DATA COLLECTION FINDINGS

• Anuria
Bladder cancer is a malignant tumor that in- • Chills
vades the mucosal lining of the bladder. It • Dysuria
may metastasize to the ureters, prostate • Fever
gland, vagina, rectum, and periaortic lymph • Flank or pelvic pain
nodes. • Frequent urination
• Painless hematuria
CAUSES • Peripheral edema
• Chronic bladder irritation • Urgency of urination
• Cigarette smoking • Urinary obstruction
• Drug-induced from cyclophosphamide (Cy- • Urinary retention
toxan)
• Excessive intake of coffee, phenacetin, sac- DIAGNOSTIC FINDINGS
charin, sodium cyclamate • Biopsy and cytologic examination are posi-
• Exposure to industrial chemicals tive for malignant cells.
• Radiation • Cystoscopy reveals a bladder mass.
• Excretory urography shows a mass or an
obstruction.
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Bladder cancer treatment options

Treatment options for bladder cancer depend on when tumors are in several sites). This treatment
the patient’s lifestyle, other health problems, and washes the bladder with drugs that fight cancer,
mental outlook. usually thiotepa, doxorubicin, and mitomycin.
TUMOR THAT HASN’T INVADED MUSCLE INFILTRATING TUMOR
With transurethral resection, superficial bladder Radical cystectomy is the treatment choice for
tumors are removed cystoscopically by trans- infiltrating bladder tumors. In this procedure, the
urethral resection and electrically by fulguration. bladder is removed and a urinary diversion is
The procedure is only effective if the tumor created.
hasn’t invaded muscle. Additional tumors may
REMOVAL OF A SECTION
develop, and fulguration may need repeating
Segmental bladder resection removes a full-
every 3 months for years.
thickness section of the bladder. It’s only used if
SUPERFICIAL TUMOR the tumor isn’t located near the bladder neck or
Intravesical chemotherapy is commonly used to ureteral orifices.
treat superficial bladder tumors (especially
• Hematology shows decreased RBC count, dish tint to gross bloodiness] or infection
Hb level, and HCT. [cloudy, foul smelling, with sediment]; main-
• KUB X-ray shows mass or obstruction. tain continuous bladder irrigation, if indicat-
• Urinalysis shows hematuria. ed; assist with turning, coughing, deep
breathing, and incentive spirometry. Apply se-
NURSING DIAGNOSES quential compression stockings while the pa-
• Functional urinary incontinence tient is on bedrest to prevent blood clot forma-
• Chronic pain tion.)
Postoperative • Impaired urinary elimination • Maintain the patient’s diet to improve nutri-
pointer: With bladder tion and meet metabolic demands.
cancer patients, be TREATMENT • Force fluids to prevent dehydration.
sure to monitor urine
• Transfusion therapy with packed RBCs • Monitor I.V. fluids to maintain hydration.
for signs of hematuria
or infection. • Surgery, depending on the location and • Administer medications, as prescribed, to
progress of the tumor (see Bladder cancer maintain or improve the patient’s condition.
treatment options) • Encourage the patient to express feelings
about a fear of dying to encourage adequate
Drug therapy coping mechanisms.
• Analgesics: morphine, hydromorphone (Di-
laudid) Teaching topics
• Antispasmodic: phenazopyridine (Pyridium) • Contacting the American Cancer Society
• Sedative: oxazepam (Serax) • Contacting community agencies and re-
sources for supportive services
INTERVENTIONS AND RATIONALES • Providing skin care after radiation therapy
• Monitor and record vital signs and intake such as avoiding cold packs to area
and output. Accurate intake and output are es-
sential for correct fluid replacement therapy.
• Provide postoperative care to promote heal-
ing and prevent complications. (Closely moni-
tor urine output; observe for hematuria [red-
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Breast cancer • Chest X-rays can be used to pinpoint metas-

tasis.
Breast cancer is the most common cancer in • Fine-needle aspiration and excisional biopsy
women and the second leading cause of can- provide histologic cells that confirm the diag-
cer deaths in women ages 35 to 54. Breast nosis.
cancer can also occur in men but the inci- • Hormonal receptor assay pinpoints whether
dence is rare. Breast cancer is more common- the tumor is estrogen- or progesterone-
ly found in the left breast than the right. It’s dependent.
also more common in the upper outer quad- • Mammography and MRI show the location
rant. Growth rates vary. Breast cancer of a tumor.
spreads via the lymphatic system and blood- • Scans of the bone, brain, liver, and other or-
stream through the right side of the heart to gans can reveal distant metastasis.
the lungs and, eventually, to the other breast, • Ultrasonography distinguishes a fluid-filled
chest wall, liver, bone, and brain. cyst from a solid mass.
CAUSES AND CONTRIBUTING FACTORS NURSING DIAGNOSES

• Alcohol and tobacco use • Disturbed body image
• Antihypertensive therapy • Fear
• Being a premenopausal woman over age 40 • Chronic pain
• Benign breast disease
• Early onset menses or late menopause TREATMENT
• Endometrial or ovarian cancer • High-protein diet
• Estrogen therapy • Bone marrow and peripheral stem cell ther-
• Exact cause unknown apy for advanced breast cancer
• Family history of breast cancer (scientists • Radiation therapy
have discovered specific genes linked to • Surgery; options include lumpectomy, skin-
breast cancer, which confirms that the dis- sparing mastectomy, partial mastectomy, total
ease can be inherited from a person’s mother mastectomy, modified radical mastectomy,
or father) and quandrantectomy
• First pregnancy after age 35 • Transfusion therapy, if needed
• High-fat diet
• Nulligravida (never pregnant) Drug therapy
• Obesity • Analgesic: morphine
• Radiation exposure • Antiemetics: trimethobenzamide (Tigan),
prochlorperazine (Compazine)
DATA COLLECTION FINDINGS • Chemotherapy: cyclophosphamide (Cytox-
• Cervical, supraclavicular, or axillary lymph an), methotrexate (Folex), fluorouracil (Adru-
node lump or enlargement on palpation cil), doxorubicin (Adriamycin)
• Clear, milky, or bloody nipple discharge • Hormonal therapy: tamoxifen (Nolvadex),
• Edema in the affected arm raloxifene (Evista), fulvestrant (Faslodex),
• Erythema toremifene (Fareston), megestrol (Megace)
• Nipple retraction • Aromatase inhibitors: letrozole (Femara),
• Painless lump or mass in the breast or anastrozole (Arimidex), exemestane (Aro-
thickening of breast tissue masin)
• Skin changes of the breast
DIAGNOSTIC FINDINGS • Explore the patient’s feelings about her ill-
• Breast self-examination may be used to find ness, and determine what she knows about
a lump or mass in the breast or thickening of breast cancer and what her expectations are
breast tissue. to help identify her needs and aid in developing
a care plan.
920110.qxd 8/7/08 3:02 PM Page 320
• Encourage the patient to ask questions • History of human papillomavirus or other

about her illness and treatment options to re- bacterial or viral venereal infections
duce anxiety and promote autonomy. • Multiple pregnancies
• Provide routine postoperative care to pre- • Multiple sex partners
vent postoperative complications. • Untreated chronic cervicitis
• Perform comfort measures to promote relax-
ation and relieve anxiety. DATA COLLECTION FINDINGS
• Administer analgesics as ordered, and mon- Preinvasive
itor their effectiveness to promote patient com- • Absence of symptoms
fort.
• Watch for treatment-related complications, Invasive
such as nausea, vomiting, anorexia, leuko- • Abnormal vaginal discharge (yellowish,
penia, thrombocytopenia, GI ulceration, and blood-tinged, and foul-smelling)
bleeding, to ensure that measures are taken to • Gradually increasing flank pain
prevent further complications. • Leakage of feces (with metastasis to the rec-
• Monitor the patient’s weight and nutritional tum with fistula development)
intake to detect evidence of malnutrition. En- • Leakage of urine (with metastasis into the
courage a high-protein diet. Dietary supple- bladder with formation of a fistula)
ments may be necessary to meet increased • Postcoital pain and bleeding
metabolic demands.
• Observe the patient’s and family’s ability to DIAGNOSTIC FINDINGS
cope, especially if the cancer is terminal. • Colposcopy is used to determine the source
Counseling may be necessary to help them cope of the abnormal cells seen on the Papanico-
with the fear of death and dying. laou (Pap) test.
• Cone biopsy identifies malignant cells.
Teaching topics • Lymphangiograpy, cystography, and major
• Managing adverse reactions to treatment organ and bone scans can be used to detect
• Knowing importance of immediately report- metastasis.
ing signs of infection to the doctor
• Performing breast self-examinations NURSING DIAGNOSES
monthly • Fear
• Understanding community support services • Impaired tissue integrity
• Contacting the American Cancer Society • Chronic pain
TREATMENT
Cervical cancer Preinvasive
• Cryosurgery
The third most common cancer of the female • Hysterectomy (rare)
reproductive system, cervical cancer is classi- • Laser destruction
fied as either preinvasive or invasive. Pre- • Total excisional biopsy
invasive cancers range from minimal cervical
dysplasia, in which the lower one-third of the Invasive
epithelium contains abnormal cells, to carci- • Pelvic exenteration (rare)
noma in situ, in which the full thickness of the • Radiation therapy (internal, external, or
epithelium contains abnormally proliferating both)
cells. • Radical hysterectomy
CAUSES AND CONTRIBUTING FACTORS Drug therapy

• Frequent intercourse at a young age (under Chemotherapy is usually ineffective in treat-
age 16) ing cervical cancer. When used, it consists of
920110.qxd 8/7/08 3:02 PM Page 321
hydroxyurea (Hydrea) in combination with In men

Because signs of
radiation treatment. • Dysuria chlamydial infection
• Erythema occur late in the
INTERVENTIONS AND RATIONALES • Pruritus course of illness,
• Encourage the patient to use relaxation • Tenderness of the meatus transmission usually
techniques to promote comfort during diagnos- • Urethral discharge occurs unknowingly.
tic procedures. • Urinary frequency
• Watch for complications related to therapy
to ensure that measures can be instituted to pre- DIAGNOSTIC FINDINGS
vent or alleviate complications. • A swab from the site of infection (urethra,
• Administer pain medication, as needed, and cervix, or rectum) is used to establish a diag-
note its effectiveness. If pain relief isn’t nosis of urethritis, cervicitis, salpingitis, en-
achieved, an alternative dose or medication dometritis, or proctitis.
may be required to promote comfort. • A culture of aspirated material is used to es-
• Provide postoperative care to prevent com- tablish a diagnosis of epididymitis.
plications. • Antigen detection methods, including
enzyme-linked immunosorbent assay and di-
Teaching topics rect fluorescent antibody test, are the diag-
• Understanding postexcisional biopsy care nostic tests of choice for identifying chlamydi-
(expecting discharge or spotting for about 1 al infection, although tissue cell cultures are
week; avoiding douching, using tampons, or more sensitive and specific.
engaging in sexual intercourse during this
time; reporting signs of infection) NURSING DIAGNOSES
• Knowing the importance of follow-up Pap • Impaired urinary elimination
tests and pelvic examinations • Chronic pain
• Deficient knowledge (disease transmission)
Chlamydia TREATMENT
The only treatment available for chlamydial
Chlamydia refers to a group of bacterial infec- infection is drug therapy.
tions linked to one organism: Chlamydia tra-
chomatis. Chlamydia infection causes urethri- Drug therapy
tis in men and urethritis and cervicitis in • Antibiotics: doxycycline (Vibramycin), What one little
women. Untreated, chlamydial infections can azithromycin (Zithromax) microorganism can do!
Chlamydia is a group
lead to such complications as acute epididymi- • For pregnant women with chlamydial infec-
of infections linked to
tis, salpingitis, pelvic inflammatory disease tions, azithromycin, in a single 1-g dose the bacterium
(PID) and, eventually, sterility. Chlamydial in- Chlamydia
fections are the most common sexually trans- INTERVENTIONS AND RATIONALES trachomatis.
mitted diseases (STDs) in the United States. • Practice standard and contact precautions
when caring for a patient with a chlamydial in-
CAUSES AND CONTRIBUTING FACTORS fection to prevent the spread of infection.
• Exposure to C. trachomatis through sexual • Make sure that the patient understands the
contact dosage requirements of any prescribed med-
ications for this infection to ensure compliance
DATA COLLECTION FINDINGS with the treatment regimen.
In women • Suggest that the patient and his sexual part-
• Dyspareunia ners receive testing for human immunodefi-
• Mucopurulent discharge ciency virus (HIV). Unsafe sex practices which
• Pelvic pain lead to chlamydial infection also place the pa-
tient at risk for contracting HIV.
920110.qxd 8/7/08 3:02 PM Page 322
• Obtain appropriate specimens for diagnostic • Urinalysis reveals proteinuria, hematuria,

testing to confirm the diagnosis of chlamydial cylindruria, and RBC casts.
infection. • X-ray or ultrasonography shows small kid-
neys.
Teaching topics
• Practicing safer sex NURSING DIAGNOSES
• Understanding the importance of taking the • Impaired urinary elimination
full course of medication, even after symp- • Excess fluid volume
toms subside • Risk for injury
• Avoiding contact with eyes after touching
discharge TREATMENT
• Washing hands using proper technique • Dialysis
• Knowing the importance of follow-up med- • Low-sodium, high-calorie diet with adequate
ical care protein
• Kidney transplant
Chronic glomerulonephritis Drug therapy

• Antibiotic (for symptomatic UTIs)
A slowly progressive disease, chronic glomer- • Antihypertensive: metoprolol (Lopressor)
ulonephritis is characterized by inflammation • Diuretic: furosemide (Lasix)
of the glomeruli (the kidney’s blood vessels),
which results in sclerosis, scarring and, even- INTERVENTIONS AND RATIONALES
tually, renal failure. • Understand that patient care is primarily
By the time it produces symptoms, chronic supportive, focusing on continual observation
glomerulonephritis is usually irreversible. and sound patient teaching. Supportive mea-
sures encourage the patient to cope with chron-
CAUSES ic disease.
• Burns • Accurately monitor vital signs, intake and
• Hemolytic transfusion reaction output, and daily weight to evaluate fluid re-
• Nephrotoxic drugs tention.
• Renal disorders • Observe for signs of fluid and electrolyte
By the time • Septicemia imbalances to detect early changes in the pa-
chronic • Systemic disorders (lupus erythematosus, tient’s condition.
glomerulonephritis is
Goodpasture’s syndrome, and diabetes melli- • Consult a dietitian to plan low-sodium,
diagnosed, the patient
usually can’t be cured tus) high-calorie meals with adequate protein.
and must rely on • Administer medications and provide good
dialysis or a kidney DATA COLLECTION FINDINGS skin care to combat pruritus and edema.
transplant. • Edema • Provide good oral hygiene to prevent break-
• Hematuria down of the oral mucosa.
• Hypertension
• Signs of fluid overload Teaching topics
• Uremic symptoms (in the late stages of the • Continuing prescribed antihypertensives as
disease) scheduled, and reporting any adverse effects
• Reporting signs of infection, particularly
DIAGNOSTIC FINDINGS UTI, and avoiding contact with people who
• Kidney biopsy is used to identify underlying have infections
disease and obtain data needed to guide ther- • Knowing the importance of follow-up exami-
apy. nations to assess renal function
• Blood studies reveal rising BUN and serum • Understanding dietary modifications
creatinine levels, which indicate advanced re-
nal insufficiency.
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Chronic renal failure TREATMENT

• Limited fluids
Chronic renal failure is progressive, irre- • Low-protein, low-sodium, low-potassium,
versible destruction of the kidneys, leading to low-phosphorus, high-calorie, and high-
loss of renal function. It may result from a carbohydrate diet
rapidly progressing disease of sudden onset • Peritoneal dialysis or hemodialysis (see
that destroys the nephrons and causes irre- Types of dialysis, page 324)
versible kidney damage. • Transfusion therapy with packed RBCs and
platelets, as indicated
CAUSES
• Congenital abnormalities Drug therapy
• Dehydration • Antacid: aluminum hydroxide gel (Alter-
• Diabetes mellitus naGEL)
• Exacerbations of nephritis • Antianemics: ferrous sulfate (Feosol), iron
• Hypertension dextran (InFeD), epoetin alfa (recombinant
• Nephrotoxins human erythropoietin, Epogen)
• Recurrent UTI • Antiemetics: prochlorperazine (Com-
• Systemic lupus erythematosus (SLE) pazine), metoclopramide (Reglan)
• Urinary tract obstructions • Calcium supplement: calcium carbonate
(Os-Cal)
DATA COLLECTION FINDINGS • Cation exchange resin: sodium polystyrene Yikes! Chronic
• Azotemia sulfonate (Kayexalate) renal failure
• Bone pain • Cardiac glycoside: digoxin (Lanoxin) produces major
• Brittle nails and hair • Diuretics: furosemide (Lasix), bumetanide changes in all of the
• Decreased urine output (Bumex) patient’s body
• Ecchymosis • Histamine2-receptor antagonists: cimetidine systems.
• Lethargy (Tagamet), ranitidine (Zantac), famotidine
• Muscle twitching (Pepcid), nizatidine (Axid)
• Paresthesia • Stool softener: docusate (Colace)
• Pruritus • Vitamins: pyridoxine (vitamin B6), ascorbic
• Seizures acid (vitamin C)
• Signs and symptoms of heart failure
• Stomatitis INTERVENTIONS AND RATIONALES
• Weight gain • Monitor renal, respiratory, and cardiovascu-
lar status and fluid balance. An increase in he-
DIAGNOSTIC FINDINGS modynamic values and vital signs may indicate
• ABG analysis shows metabolic acidosis. fluid overload caused by lack of kidney function.
• Blood chemistry shows increased BUN, • Restrict fluids to prevent fluid overload.
creatinine, potassium, phosphorus, and lipid • Check dialysis access for bruit and thrill to
levels and decreased calcium, CO2, and albu- ensure patency and detect complications.
min levels. • Monitor and record vital signs, intake and
• Hematology shows decreased Hb level, output, daily weight, and stools for occult
HCT, and platelet count. blood to detect early changes in the patient’s
• Urine chemistry shows proteinuria, in- condition.
creased WBC count, sodium level, and de- • Monitor for ecchymosis and GI bleeding
creased and then fixed urine specific gravity. because blood clotting mechanism may be
affected.
NURSING DIAGNOSES • Follow standard precautions to prevent the
• Decreased cardiac output spread of infection.
• Excess fluid volume • Maintain the patient’s diet to promote nutri-
• Ineffective tissue perfusion: Renal tional status.
920110.qxd 8/7/08 3:02 PM Page 324
Types of dialysis
The two types of dialysis used to treat chronic renal failure are hemodialysis and peritoneal dialysis.
HEMODIALYSIS
Hemodialysis removes toxic wastes and other impurities from the blood. Blood is removed from the
body through a surgically created access site, pumped through a filtration unit to remove toxins and
fluid, and then returned to the body. The extracorporeal dialyzer works through osmosis, diffusion,
and filtration. Hemodialysis is performed by specially trained nurses or technicians.
Nursing actions
• Monitor the venous access site for bleeding. If bleeding is excessive, maintain pressure on the
site.
• Don’t use the access site arm for blood pressure monitoring, I.V. catheter insertion, or venipunc-
ture.
• At least four times daily, auscultate the access site for a bruit and palpate for thrills.
PERITONEAL DIALYSIS
Peritoneal dialysis removes toxins from the blood but, unlike hemodialysis, it uses the patient’s peri-
toneal membrane as a semipermeable dialyzing membrane. Hypertonic dialyzing solution is instilled
through a catheter inserted into the peritoneal cavity. Then by diffusion, excessive concentrations of
electrolytes and uremic toxins in the blood move across the peritoneal membrane and into the dialy-
sis solution. Next, by osmosis, excessive water in the blood does the same.
After appropriate dwelling time, the dialysis solution is drained, taking toxins, wastes, and fluids
with it. The patient is trained to perform this procedure.
Nursing actions
• Check the patient’s weight daily, and report any gain.
• Using aseptic technique, change the catheter dressing every 24 hours and whenever it becomes
wet or soiled.
• Calculate the patient’s fluid balance at the end of each dialysis session or after 8 hours in a longer
session. Include oral and I.V. fluid intake as well as urine output and wound drainage. Record and re-
port any significant imbalance, either positive or negative.
Advise the
patient to take
diuretics in the • Administer medications, as prescribed, to • Completing skin and mouth care daily
morning so he won’t improve or maintain patient’s condition. • Caring for the dialysis access site
have to disrupt his • Encourage the patient to express feelings
sleep to void. about chronicity of illness to encourage coping.
• Provide tepid baths to promote comfort and Cystitis
reduce skin irritation.
• Maintain a cool and quiet environment to re- Cystitis is inflammation of the urinary blad-
duce metabolic demands. der. It’s usually related to a superficial infec-
• Provide skin and mouth care using plain wa- tion that doesn’t extend to the bladder mu-
ter to promote comfort. cosa.
• Avoid giving the patient I.M. injections to
prevent bleeding from the injection site. CAUSES
• Diabetes mellitus
Teaching topics • Incorrect sterile technique during urinary
• Maintaining a quiet environment catheterization
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• Incorrect perineal care • Force fluids (cranberry or orange juice) to

Think vitamin C
• Kidney infection 3 qt (3 L)/day because dilute urine lessens the for cystitis.
• Obstruction of the urethra irritation to the bladder mucosa and lowering Patients with this
• Pregnancy urine pH with orange juice and cranberry juice disorder will benefit
• Radiation consumption helps diminish bacterial growth. from drinking
• Sexual intercourse • Administer medications, as prescribed, to orange or
• Stagnation of urine in the bladder maintain or improve the patient’s condition. cranberry juice.
• Encourage voiding every 2 to 3 hours. Fre-
DATA COLLECTION FINDINGS quent bladder emptying decreases bladder irri-
• Burning or pain on urination tation and prevents stasis of urine.
• Dark, odoriferous urine
• Dribbling of urine Teaching topics
• Dysuria • Avoiding coffee, tea, alcohol, and carbonat-
• Flank tenderness or suprapubic pain ed beverages
• Lower abdominal discomfort • Increasing fluid intake to 3 qt/day
• Low-grade fever • Voiding every 2 to 3 hours and after inter-
• Nocturia course
• Urge to bear down on urination • Performing perineal care correctly
• Urinary frequency • Avoiding bubble baths, vaginal deodorants,
• Urinary urgency and tub baths
• Recognizing that urine may be orange while
DIAGNOSTIC FINDINGS taking phenazopyridine
• Cystoscopy shows obstruction or deformity.
• Urinalysis shows hematuria, pyuria, and in-
creased protein, leukocytes, and urine specif- Gonorrhea
ic gravity.
• Urine culture and sensitivity positively iden- A common STD, gonorrhea is a viral infection
tifies organisms (Escherichia coli, Proteus vul- of the genitourinary tract (especially the ure-
garis, or Streptococcus faecalis). thra and cervix) and, occasionally, the rec-
tum, pharynx, and eyes. Untreated gonorrhea
NURSING DIAGNOSES can spread through the blood to the joints,
• Impaired urinary elimination tendons, meninges, and endocardium; in fe-
• Urge urinary incontinence males, it can also lead to chronic PID and
• Acute pain sterility.
After adequate treatment, the prognosis in
TREATMENT both males and females is excellent, although
• Diet: increased intake of fluids and reinfection is common. Gonorrhea is especial-
vitamin C ly prevalent among young people and people
with multiple partners, particularly those be-
Drug therapy tween ages 19 and 25.
• Antibiotics: co-trimoxazole (Bactrim), levo-
floxacin (Levaquin), ciprofloxacin (Cipro) CAUSES
• Antipyretic: acetaminophen (Tylenol) • Exposure to Neisseria gonorrhoeae through
• Urinary antiseptic: phenazopyridine (Pyridi- sexual contact
um)
INTERVENTIONS AND RATIONALES • Dysuria
• Monitor and record vital signs and intake • Itching, burning, and pain
and output to detect early complications. • Purulent urethral or cervical discharge
• Maintain the patient’s diet to promote nutri- • Redness and swelling
tion.
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Emphasize to the DIAGNOSTIC FINDINGS • Understanding the importance of continu-

patient with • A culture from the site of infection (urethra, ing antibiotic therapy for the duration pre-
gonorrhea that he cervix, rectum, or pharynx) is used to estab- scribed
may be infectious even lish the diagnosis by isolating the organism.
if no symptoms of the • A Gram stain showing gram-negative diplo-
disease are present.
cocci supports the diagnosis and may be suffi- Herpes simplex
cient to confirm gonorrhea in males.
A recurrent viral infection, herpes simplex is
NURSING DIAGNOSES caused by two types of Herpesvirus hominis
• Risk for infection (HSV), a widespread infectious agent:
• Chronic pain • Herpes virus type 1, which is transmitted by
• Ineffective sexuality patterns oral and respiratory secretions, affects the
skin and mucous membranes and commonly
TREATMENT produces cold sores and fever blisters.
• Moist heat to affected joints, if gonococcal • Herpes virus type 2 primarily affects the
arthritis is present genital area and is transmitted by sexual con-
tact. Cross-infection may result from orogeni-
Drug therapy tal sex.
• Antibiotics: ceftriaxone (Rocephin), doxycy-
cline (Vibramycin), erythromycin (E-mycin) CAUSES
• Prophylactic antibiotic: 1% silver nitrate or • Exposure to herpes virus type 2 through
erythromycin (EryPed) eye drops to prevent sexual contact
infection in neonates • Contact with herpes virus type 1 through
oral or respiratory secretions
• Before treatment, establish whether the pa- DATA COLLECTION FINDINGS
tient has any drug sensitivities to prevent se- • Appetite loss
vere adverse reactions. • Blisters on any part of the mouth accompa-
• Warn the patient that, until cultures prove nied by erythema and edema
negative, he’s still infectious and can transmit • Conjunctivitis (herpetic keratoconjunctivitis
gonococcal infection to prevent the spread of or herpes of the eye)
infection to others. • Fever
After the first • Follow standard and contact precautions to • Increased salivation
infection with HSV, the
prevent the spread of infection. • Swelling of the lymph nodes under the jaw
person carries the
virus permanently and • For the patient with gonococcal arthritis,
is vulnerable to apply moist heat to ease pain in affected joints. Genital herpes
recurrent herpes • Urge the patient to inform sexual contacts • Fever, swollen lymph nodes
infection. of his infection so that they can seek treatment, • Fluid-filled blisters
even if cultures are negative. They should be • Flulike symptoms
advised to avoid sexual intercourse until treat- • Painful urination
ment is complete to prevent the spread of infec-
tion. DIAGNOSTIC FINDINGS
• Confirmation requires isolation of the virus
Teaching topics from local lesions and a histologic biopsy.
• Using condoms during intercourse, wash- • Blood studies reveal a rise in antibodies and
ing genitalia with soap and water before and moderate leukocytosis.
after intercourse, and avoiding sharing wash-
cloths or douche equipment NURSING DIAGNOSES
• Impaired urinary elimination
• Chronic pain
• Impaired oral mucous membrane
920110.qxd 8/7/08 3:02 PM Page 327
TREATMENT neuron lesion) or flaccid (resulting from a

Symptomatic and supportive treatment lower motor neuron lesion).
This disorder is also known as neuromuscu-
Drug therapy lar dysfunction of the lower urinary tract, neu-
• Analgesic-antipyretic agent: acetaminophen rologic bladder dysfunction, and neuropathic
(Tylenol) bladder.
• Antiviral agents: idoxuridine (Herplex
Liquifilm), trifluridine (Viroptic), or vidara- CAUSES
bine (Vira-A) • Acute infectious diseases such as Guillain-
• 5% acyclovir (Zovirax) ointment (possible Barré syndrome
relief to patients with genital herpes or to im- • Cerebral disorder (stroke, brain tumor
munosuppressed patients with HSV skin in- [meningioma and glioma], Parkinson’s dis-
fections; I.V. acyclovir to help treat more se- ease, multiple sclerosis, dementia)
vere infections) • Chronic alcoholism
• Collagen diseases such as SLE
INTERVENTIONS AND RATIONALES • Disorders of peripheral innervation
• Follow standard and contact precautions. • Distant effects of cancer such as primary
For patients with extensive cutaneous, oral, or oat cell carcinoma of the lung
genital lesions, institute contact precautions to • Heavy metal toxicity
prevent the spread of infection. • Herpes zoster
• Administer pain medication and prescribed • Metabolic disturbances (hypothyroidism,
antiviral agent as ordered to relieve pain and porphyria, or uremia)
treat infection. • Sacral agenesis
• Provide supportive care, as indicated, such • Spinal cord disease or trauma
as oral hygiene, nutritional supplementation, • Vascular diseases such as atherosclerosis
and antipyretics for fever. These measures en-
hance the patient’s well-being. DATA COLLECTION FINDINGS
• Abstain from direct patient care if you have • Altered micturition
herpetic whitlow (an HSV finger infection that • Flaccid neurogenic bladder: Overflow incon-
sometimes affects health care workers) to tinence, diminished anal sphincter tone,
prevent the spread of infection. greatly distended bladder with an accompany-
ing feeling of bladder fullness Has the patient
Teaching topics • Incontinence lost his nerve?
• Caring for themselves during an outbreak • Spastic neurogenic bladder: involuntary or Neurogenic bladder
of HSV and how to avoid infecting others frequent scanty urination without a feeling of refers to bladder
• Having annual Pap test (women with genital bladder fullness, possible spontaneous problems caused by
herpes) spasms of the arms and legs, increased anal disruption of normal
• Avoiding kissing infants and people with sphincter tone nerve impulses to the
eczema if a cold sore is present bladder.
DIAGNOSTIC FINDINGS
• Voiding cystourethrography evaluates blad-
Neurogenic bladder der neck function, vesicoureteral reflux, and
continence.
Neurogenic bladder refers to bladder dys- • Urodynamic studies help evaluate how
function caused by an interruption of normal urine is stored in the bladder, how well the
bladder innervation. Subsequent complica- bladder empties, and the rate of movement of
tions include incontinence, residual urine re- urine out of the bladder during voiding.
tention, UTI, stone formation, and renal fail- • Retrograde urethrography reveals the pres-
ure. A neurogenic bladder may be described ence of strictures and diverticula.
as spastic (resulting from an upper motor
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NURSING DIAGNOSES • Try to keep the patient as mobile as possi-

• Impaired urinary elimination ble. Perform passive range-of-motion exercise
• Urge urinary incontinence if necessary. These measures prevent complica-
• Urinary retention tions of immobility.

• Credé’s maneuver (application of manual • Using evacuation techniques as necessary
pressure over the lower abdomen) to evacu- (Credé’s method, intermittent self-
ate the bladder catheterization techniques)
• Valsalva’s maneuver to promote complete • Preventing and identifying infection
emptying of the bladder
• Indwelling urinary catheter insertion,
including teaching the patient self- Ovarian cancer
catheterization techniques
• Surgical repair if the patient has structural Ovarian cancer attacks the ovaries, the female
impairment organs that produce the hormones estrogen
• Surgical insertion of an artificial urinary and progesterone. After lung and bronchus,
sphincter breast, colorectal, and pancreatic cancers, pri-
mary ovarian cancer ranks as the most com-
Drug therapy mon cause of cancer deaths among American
• Urinary tract stimulants: bethanechol (Ure- women. In women with previously treated
choline) and phenoxybenzamine breast cancer, metastatic ovarian cancer is
• Antimuscarinic agents: propantheline (Pro- more common than cancer at any other site.
Banthine), flavoxate (Urispas), and dicyclo- The prognosis varies with the histologic
mine (Antispas) type and stage of the disease but is generally
poor because ovarian tumors produce few ear-
INTERVENTIONS AND RATIONALES ly signs and are usually advanced at diagno-
• Use strict sterile technique during in- sis. About 40% of women with ovarian cancer
dwelling urinary catheter insertion (a tempo- survive for 5 years.
rary measure to drain the incontinent pa-
tient’s bladder). Don’t interrupt the closed CONTRIBUTING FACTORS
drainage system for any reason to prevent in- • Age at menopause
fection. • Celibacy
• Obtain urine specimens with a syringe and • Exposure to asbestos, talc, and industrial
smallbore needle inserted through the aspi- pollutants
rating port of the catheter itself (below the • Familial tendency and history of breast or
junction of the balloon instillation site). Irri- uterine cancer
gate in the same manner if necessary to pre- • Fertility drugs
vent infection. • High-fat diet
• Clean the catheter insertion site with soap • Incidence is highest in women of upper so-
and water at least twice a day to prevent infec- cioeconomic levels between ages 20 and 54
tion. • Infertility
• Keep the drainage bag below the tubing,
and don’t raise the bag above the level of the DATA COLLECTION FINDINGS
bladder to prevent urine reflux and infection. • Abdominal discomfort, dyspepsia, and other
• Clamp the tubing or empty the catheter bag mild GI disturbances
before transferring the patient to a wheelchair • Abdominal distention
or stretcher to prevent accidental urine reflux. • Constipation
• Watch for signs of infection (fever, cloudy or • Pelvic discomfort
foul-smelling urine) to ensure early treatment • Pelvic mass
intervention and prevent complications.
920110.qxd 8/7/08 3:02 PM Page 329
• Urinary frequency • peritoneal washings for cytologic examina-

• Weight loss tion of pelvic fluid
• careful follow-up, including periodic chest
DIAGNOSTIC FINDINGS X-rays to rule out lung metastasis.
Diagnosis requires clinical evaluation, a com-
plete patient history, surgical exploration, and Aggressive treatment
histologic studies. Preoperative evaluation in- Ovarian cancer usually requires more aggres-
cludes a complete physical examination, in- sive treatment, including:
cluding pelvic examination with Pap smear • Total abdominal hysterectomy and bilateral
(positive in only a small number of women salpingo-oophorectomy with tumor resection,
with ovarian cancer) and the following special omentectomy, and appendectomy
tests: • Lymph node biopsies with lymphade-
• Abdominal ultrasonography, computed to- nectomy, tissue biopsies, and peritoneal wash-
mography (CT) scan, or X-ray may delineate ings.
tumor size.
• Chest X-ray may reveal distant metastasis Drug therapy
and pleural effusions. • Antineoplastics: carboplatin (Paraplatin),
• Barium enema (especially in patients with chlorambucil (Leukeran), cyclophosphamide
GI symptoms) may reveal obstruction and (Cytoxan), dactinomycin (Cosmegen), dox-
size of tumor. orubicin (Rubex), fluorouracil (Adrucil), cis-
• Lymphangiography may show lymph node platin (Platinol), paclitaxel (Taxol), topotecan
involvement. (Hycamtin)
• Mammography may rule out primary • Analgesics: morphine, fentanyl (Duragesic-
breast cancer. 25)
• Liver scan in patients with ascites may rule • Antipyretics: aspirin, acetaminophen
out liver metastasis. (Tylenol)
• Blood tests, such as ovarian carcinoma anti- • Immunotherapy: bacille Calmette-Guérin
gen, carcinoembryonic antigen (CEA), and vaccine
human chorionic gonadotropin, reveal pres-
ence of cancer. INTERVENTIONS AND RATIONALES
Despite extensive testing, accurate diagno- Before surgery
sis and staging are only possible with ex- • Thoroughly explain all preoperative tests, Bilateral
ploratory laparotomy, including lymph node the expected course of treatment, and surgi- oophorectomy
evaluation and tumor resection. cal and postoperative procedures to allay anx- artificially induces
iety. early menopause in
NURSING DIAGNOSES • In premenopausal women, explain that bilat- premenopausal
• Fear eral oophorectomy artificially induces early women, possibly
causing headaches,
• Excess fluid volume menopause, so they may experience hot flash-
insomnia, and hot
• Imbalanced nutrition: Less than body re- es, headaches, palpitations, insomnia, depres- flashes. Whew!
quirements sion, and excessive perspiration to help the pa-
tient cope with changes in body image that oc-
TREATMENT cur as a result of surgery.
Conservative treatment
Occasionally, in girls or young women with a After surgery
unilateral encapsulated tumor who wish to • Monitor vital signs frequently to detect early
maintain fertility, the following conservative signs of postoperative complications, such as
approach may be appropriate: fluid volume deficit.
• resection of the involved ovary • Monitor fluid intake and output to detect flu-
• biopsies of the omentum and the unin- id volume excess or deficit, while maintaining
volved ovary good catheter care to prevent infection.
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• Check the dressing regularly for excessive • Hematuria

Encourage
ambulation after drainage or bleeding, and watch for signs of • Urine retention
surgery for ovarian infection. These measures detect early signs of
cancer to help prevent complications and prevent treatment delay. DIAGNOSTIC FINDINGS
complications from • Provide abdominal support to promote com- • CEA is elevated.
immobility. fort. • Digital rectal examination reveals a palpable
• Watch for abdominal distention, which may firm nodule in gland or diffuse induration in
indicate the presence of ascites. posterior lobe.
• Encourage coughing, deep breathing, and • Serum acid phosphatase level is increased.
incentive spirometry hourly during the wak- • Radioimmunoassay for acid phosphatase is
ing hours to mobilize secretions and prevent increased.
postoperative pneumonia. • PSA is increased.
• Reposition the patient often to prevent skin • Transurethral ultrasound studies show
breakdown. mass or obstruction.
• Encourage ambulation after surgery to pre- • Prostate biopsy has cytology positive for
vent complications of immobility. cancer cells.
• Apply sequential compression stocking to • Excretory urogram shows mass or obstruc-
prevent blood clot formation while the patient tion.
is on bedrest.
• Monitor and treat adverse effects of radia- NURSING DIAGNOSES
tion and chemotherapy to prevent complica- • Chronic pain
tions. • Sexual dysfunction
• Enlist the help of a social worker, chaplain, • Impaired urinary elimination
and other members of the health care team to
provide additional supportive care. TREATMENT
• High-protein diet with restrictions on caf-
Teaching topics feine and spicy foods
• Knowing the disease process and treatment • Radiation implant
options • Radical prostatectomy (for localized tumors
• Preventing and reporting infection without metastasis) or TURP (transurethral
• Managing adverse reactions to chemo- resection to relieve obstruction in metastatic
therapy disease)
Because prostate
cancer can lead to
Drug therapy
sexual dysfunction,
patient care may Prostate cancer • Analgesics: oxycodone and acetaminophen
include providing (Tylox), morphine
information about Prostate cancer is a malignant tumor of the • Antiemetics: prochlorperazine (Compa-
changes in sexual prostate gland, which can obstruct urine flow zine), ondansetron (Zofran)
activity. when encroaching on the bladder neck. It • Antineoplastics: doxorubicin (Adriamycin),
commonly metastasizes to bone, lymph cisplatin (Platinol)
nodes, the brain, and the lungs. • Corticosteroid: prednisone (Deltasone)
• Estrogen therapy: diethylstilbestrol
CAUSES • Immunosuppressant: cyclophosphamide
• Associated risk factors include family histo- (Cytoxan)
ry, age, race, vasectomy, increased dietary fat • Luteinizing hormone-releasing hormone ag-
• No known etiology onists: goserelin acetate (Zoladex), leuprolide
acetate (Lupron)
DATA COLLECTION FINDINGS • Nonsteroidal anti-inflammatory drugs: in-
• Decreased size and force of urine stream domethacin (Indocin), ibuprofen (Motrin)
• Difficulty and frequency of urination
920110.qxd 8/7/08 3:02 PM Page 331
• Oral flutamide (Eulexin) to block circulat- Renal calculi Just reading

ing testosterone about kidney stones
• Stool softener: docusate (Colace) Renal calculi, also known as kidney stones, hurts. But you
are crystalline substances that lodge in the shouldn’t skip this
INTERVENTIONS AND RATIONALES ureter. Under normal circumstances, calculi section.
• Monitor and record vital signs and fluid in- are dissolved and excreted in the urine. How-
take and output. Accurate intake and output ever, larger calculi can cause great pain and
are essential for correct fluid replacement ther- may cause urinary obstruction.
apy.
• Maintain adequate hydration to promote uri- CAUSES
nation. • Chemotherapy
• Check for signs of infection to detect compli- • Dehydration
cations. • Diet high in calcium, vita-
• Monitor the patient’s pain and note the ef- min D, milk, protein,
fectiveness of analgesia to promote comfort. oxalate, alkali
• Administer medications, as prescribed, to • Excessive vitamin C
maintain or improve the patient’s condition. intake
• Maintain the patient’s diet to maintain nu- • Genetics
tritional level and meet increased metabolic de- • Gout
mands. • Hypercalcemia
• Maintain the patency of the urinary catheter • Hyperparathyroidism
and note drainage to ensure urine drainage. • Idiopathic origin
• Encourage the patient to express feelings • Immobility
about the changes in body image and fear of • Leukemia
sexual dysfunction to encourage coping and • Polycythemia vera
adaptation. • Urinary stasis
• Encourage ambulation to prevent complica- • UTI
tions of immobility. • Urinary tract obstruction
• Provide postoperative, postchemotherapeu-
tic, and postradiation nursing care to prevent DATA COLLECTION FINDINGS
complications. • Chills and fever
• Cool, moist skin
Teaching topics • Costovertebral tenderness
• Managing changes in sexual activity • Diaphoresis
• Avoiding prolonged sitting, standing, and • Dysuria
walking • Flank pain
• Avoiding the strain of exercise and lifting • Frequency of urination
• Urinating frequently • Nausea and vomiting
• Avoiding coffee and cola beverages • Pallor
• Decreasing fluid intake during evening • Renal colic
hours • Syncope
• Performing perineal exercises • Urgency of urination
• Performing catheter care, as directed
• Self-monitoring for bloody urine, pain, burn- DIAGNOSTIC FINDINGS
ing, frequency, decreased urine output, and • 24-hour urine collection shows increased
loss of bladder control uric acid, oxalate, calcium, phosphorus, and
• Contacting the American Cancer Society creatinine levels.
• Contacting community agencies and re- • Blood chemistry shows increased calcium,
sources for supportive services phosphorus, creatinine, BUN, uric acid, pro-
tein, and alkaline phosphatase levels.
• Cystoscopy is used to visualize stones.
920110.qxd 8/7/08 3:02 PM Page 332
• Excretory urography reveals stones. • Force fluids to 3 qt (3 L)/day to moisten mu-

I don’t think I want
to supersize it. • KUB X-ray reveals stones. cous membranes and dilute chemicals within
Although smaller • Urinalysis shows pyuria, proteinuria, hema- the body.
calculi may pass turia, presence of WBCs, and increased urine • Maintain the patient’s diet to promote ade-
naturally with vigorous specific gravity. quate nutrition.
hydration, larger ones • Administer medications, as prescribed, to
may need to be NURSING DIAGNOSES maintain and improve the patient’s condition.
removed by surgery or • Acute pain • Apply warm soaks to flank to promote com-
other means. • Risk for infection fort.
• Impaired urinary elimination • If surgery was performed, check dressings
regularly for bloody drainage and report ex-
TREATMENT cessive amounts of bloody drainage to the
• Diet: for calcium stones, acid-ash with limit- doctor; use sterile technique to change the
ed intake of calcium and milk products; for dressing; maintain nephrostomy tube or in-
oxalate stones, alkaline-ash with limited indwelling urinary catheter if indicated; monitor
take of foods high in oxalate (cola, tea); for incision for signs of infection to promote heal-
uric acid stones, alkaline-ash with limited in- ing and detect complications.
take of foods high in purine
• Extracorporeal shock wave lithotripsy Teaching topics
(ESWL) to shatter calculi • Increasing fluid intake, especially during
• Increased fluid intake to 3 qt (3 L)/day hot weather, illness, and exercise
• Moist heat to flank; hot baths • Voiding whenever urge is felt
• Percutaneous nephrostolithotomy • Testing urine pH
• Surgery if other measures to remove the • Increasing fluids at night and voiding fre-
stone aren’t effective (type of surgery depen- quently
dent on the location of the stone)
Drug therapy Syphilis

• Acidifiers: ammonium chloride, methena-
mine mandelate (Mandelamine) Syphilis is a chronic, infectious STD that be-
• Alkalinizing agents: potassium acetate, sodi- gins in the mucous membranes and quickly
um bicarbonate becomes systemic, spreading to nearby
• Analgesics: morphine, hydromorphone (Di- lymph nodes and the bloodstream. This dis-
laudid) ease, when untreated, is characterized by pro-
• Antibiotics: cefazolin (Ancef), cefoxitin gressive stages: primary, secondary, latent,
(Mefoxin) and late (formerly called tertiary). In women,
• Antiemetic: prochlorperazine (Compazine) chancres can be overlooked because they of-
• Antigout agent: sulfinpyrazone (Anturane) ten develop internally.

• Monitor the patient’s pain and effectiveness • Exposure to the spirochete (spiral bacteri-
of analgesia, which allows for care plan modifi- um) Treponema pallidum through sexual con-
cation as needed. tact
• Monitor and record vital signs, intake and • Transmission from an infected mother to
output, and daily weight to evaluate renal sta- her fetus
tus.
• Monitor the patient’s urine for evidence of DATA COLLECTION FINDINGS
renal calculi. Strain all urine and save all solid Primary syphilis
material for analysis to determine spontaneous • Chancres on the genitalia, anus, fingers,
passage of calculi. lips, tongue, nipples, tonsils, or eyelids
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Secondary syphilis INTERVENTIONS AND RATIONALES In women,

• Symmetrical mucocutaneous lesions • Follow standard and contact precautions syphilitic chancres
• General lymphadenopathy when in direct contact with the patient, col- may be overlooked
• Headache lecting specimens, and treating lesions to pre- because they often
• Malaise vent the spread of infection. develop internally, on
• Anorexia • Check for a history of drug sensitivity be- the cervix or vaginal
• Weight loss fore administering the first dose of penicillin wall.
• Nausea to prevent anaphylaxis.
• Vomiting • With secondary syphilis, keep lesions clean
• Sore throat and dry. If they’re draining, dispose of conta-
• Slight fever minated materials properly to prevent the
DIAGNOSTIC FINDINGS • With late syphilis, provide supportive care
• Dark-field examination is used to identify T. to relieve the patient’s symptoms during pro-
pallidum from a lesion. This method is most longed treatment.
effective when moist lesions are present, as in • Urge patients to seek VDRL testing after 3,
primary, secondary, and prenatal syphilis. 6, 12, and 24 months to detect possible relapse.
• Fluorescent treponemal antibody-absorp- Patients treated for latent or late syphilis
tion test is used to identify antigens of T. pal- should receive blood tests at 6-month inter-
lidum in tissue, ocular fluid, cerebrospinal vals for 2 years to detect possible relapse.
fluid (CSF), tracheobronchial secretions, and • Refer the patient and his sexual partners for
exudates from lesions. This is the most sensi- HIV testing. High risk behaviors that caused
tive test available for detecting syphilis in all the patient to contract syphilis also place the pa-
stages. When reactive, it remains so perma- tient at risk for HIV.
nently.
• Venereal Disease Research Laboratory Teaching topics
(VDRL) slide test and rapid plasma reagin • Safer sex practices
test are used to detect nonspecific antibodies. • Importance of completing the course of
Both tests, if positive, become reactive 1 to 2 therapy even after symptoms subside
weeks after the primary lesion appears or 4 to • Follow-up VDRL testing
5 weeks after the infection begins.
• CSF examination is used to identify neuro-
syphilis when the total protein level is greater Testicular cancer Cancer of the
than 40 mg/100 ml, VDRL slide test is reac- testicle can usually be
tive, and CSF cell count exceeds five mononu- Testicular cancer affects the testes or testi- cured easily; however,
clear cells per microliter. cles, the two oval-shaped glandular organs in- if not treated early, it
can metastasize
side the scrotum that produce spermatozoa
through the lymph
NURSING DIAGNOSES and testosterone. Malignant testicular tumors nodes.
• Ineffective sexuality patterns primarily affect young to middle-aged men.
• Impaired skin integrity Testicular tumors in children are rare.
• Deficient knowledge (disease process and Most testicular tumors originate in gonadal
treatment plan) cells. About 40% are seminomas (uniform, un-
differentiated cells resembling primitive go-
TREATMENT nadal cells). The remainder are nonsemino-
Drug therapy mas (tumor cells showing various degrees of
• Antibiotics (the only treatment): penicillin G differentiation).
benzathine (Permapen); if allergic to peni- The prognosis varies with the cell type and
cillin, then erythromycin (Erythrocin) or disease stage. When treated with surgery and
tetracycline (Panmycin) radiation, almost all patients with localized
disease survive beyond 5 years.
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CONTRIBUTING FACTORS • Scrotal ultrasonography can be used to dif-

• Age (incidence peaks between ages 20 and ferentiate between a cyst and solid mass.
40) • Chest X-ray may show pulmonary metasta-
• Higher incidence in men with cryptorchi- sis.
dism and in men whose mothers used diethyl- • Excretory urography may reveal ureteral
stilbestrol during pregnancy deviation resulting from para-aortic node in-
volvement.
DATA COLLECTION FINDINGS • Serum alpha-fetoprotein and beta-human
• Firm, painless, smooth testicular mass, chorionic gonadotropin levels—indicators of
varying in size and sometimes producing a testicular tumor activity—provide a baseline
sense of testicular heaviness for measuring response to therapy and deter-
mining the prognosis.
In advanced stages • Surgical excision and biopsy of the tumor
• Ureteral obstruction and testis permits histologic verification of the
• Abdominal mass tumor cell type.
• Back pain • Inguinal exploration (examination of the
• Cough groin) is used to determine the extent of
• Hemoptysis nodal involvement.
• Shortness of breath
• Weight loss NURSING DIAGNOSES
• Fatigue • Disturbed body image
• Pallor • Fear
• Lethargy • Sexual dysfunction
DIAGNOSTIC FINDINGS TREATMENT

• Regular self-examinations and testicular pal- • Radiation therapy
pation during a routine physical examination • Surgery: orchiectomy (testicle removal;
may detect testicular tumors. most surgeons remove the testicle but not the
• Transillumination can distinguish between scrotum to allow for a prosthetic implant)
a tumor (which doesn’t transilluminate) and a • Retroperitoneal lymph node dissection (dis-
hydrocele or spermatocele (which does). section of lymph nodes posterior to the peri-
• CT scan can show metastasis. toneum)
• Bone marrow transplantation (follows
chemotherapy and radiation therapy in pa-
If the patient If he receives tients with unresponsive tumors)
receives vinblastine, cisplatin, check for • High-calorie diet provided in small frequent
watch for ototoxicity. feedings
neurotoxicity. • I.V. fluid therapy
Drug therapy
• Diuretics: furosemide (Lasix), mannitol
(Osmitrol)
• Antineoplastics: bleomycin (Blenoxane),
carboplatin (Paraplatin), cisplatin (Platinol),
dactinomycin (Cosmegen), etoposide
(VePesid), ifosfamide (Ifex), plicamycin
(Mithracin), vinblastine (Velban)
• Analgesics: morphine, fentanyl (Duragesic-
25)
920110.qxd 8/7/08 3:02 PM Page 335
• Antiemetics: trimethobenzamide (Tigan),

metoclopramide (Reglan), ondansetron
(Zofran)
• Hormone replacement therapy (after bilat-
eral orchiectomy)

• Develop a treatment plan that addresses the
patient’s psychological and physical needs to
enhance the patient’s well-being.
Before orchiectomy
• Reassure the patient that sterility and impo-
tence need not follow unilateral orchiectomy,
that synthetic hormones can restore hormon-
Pump up on practice
al balance, and that most surgeons don’t re-
move the scrotum. In many cases, a testicular
questions
prosthesis can correct anatomic disfigure- 1. The nurse has taught a client with genital
ment. These interventions can help allay the herpes how to prevent the spread of the her-
patient’s anxiety. pes simplex virus. Which client behavior
demonstrates an accurate understanding of
After orchiectomy transmission prevention techniques?
• For the first day after surgery, apply an ice 1. The client keeps the area moist.
pack to the scrotum to reduce swelling and 2. The client keeps his fingernails long.
provide analgesics to promote comfort. 3. The client wears tight-fitting blue jeans.
• Check for excessive bleeding, swelling, and 4. The client washes his hands before and
signs of infection to detect early signs of com- after touching the lesions.
plications and prevent treatment delay. Answer: 4. Because hand-to-body contact is a
• Provide an athletic supporter to minimize common method of transmitting the herpes
pain during ambulation. simplex virus, the client should wash his
hands before and after touching lesions to
During chemotherapy prevent the spread of the disease. To promote
• Give an antiemetic, as needed, to treat or lesion drying and client comfort, the client
prevent nausea and vomiting. should keep the affected area dry. To prevent
• Encourage small, frequent meals to main- scratching the lesions, the client should keep
tain oral intake despite anorexia. the fingernails short, instead of long. The
• Establish a mouth care regimen to prevent client should wear loose-fitting garments be-
breakdown of the oral mucosa. cause tight-fitting clothes help retain heat and
• Check for stomatitis to detect early signs and moisture, which can delay healing and cause
avoid treatment delay. discomfort.
• Encourage increased fluid intake and main- Client needs category: Safe, effective
tain I.V. fluids, a potassium supplement, and care environment
diuretics to prevent renal damage. Client needs subcategory: Safety and
infection control
Teaching topics Cognitive level: Comprehension
• Knowing disease process and treatment op-
tions
• Preventing and reporting infection
• Managing adverse reactions to chemothera-
py and radiation
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2. A client with fever and urinary urgency is Answer: 3. The nurse must prepare the client
asked to provide a urine specimen for culture and equipment before creating a sterile field,
and sensitivity. The nurse should instruct the putting on gloves, and performing other
client to collect the specimen from the: tasks. A straight urinary catheter, which
1. first stream of urine from the bladder. doesn’t have a balloon attached is inserted
2. middle stream of urine from the blad- until urine flows.
der. Client needs category: Safe, effective
3. final stream of urine from the bladder. care environment
4. full volume of urine from the bladder. Client needs subcategory: Safety and
Answer: 2. The midstream specimen is recom- infection control
mended because it’s less likely to be contami- Cognitive level: Knowledge
nated with microorganisms from the external
genitalia than other specimens. It isn’t neces-
sary to collect a full volume of urine for a
urine culture and sensitivity.
integrity
risk potential
4. A client with dysuria is prescribed

phenazopyridine (Pyridium). The nurse
should teach the client to expect urine to be:
1. greater in volume.
2. orange in color.
3. pungent in odor.
4. concentrated in consistency.
Answer: 2. Phenazopyridine causes the urine
to have an orange color. The other urine char-
3. Which steps should the nurse follow to in- acteristics aren’t caused by phenazopyridine.
sert a straight urinary catheter? Client needs category: Physiological
1. Create a sterile field, drape the client, integrity
clean the meatus, and insert the catheter Client needs subcategory: Pharmaco-
only 6 inches. logical therapies
2. Put on gloves, prepare the equipment, Cognitive level: Application
create a sterile field, expose the urinary
meatus, and insert the catheter 6⬙ 5. A client is scheduled for ESWL. When
(15.2 cm). teaching the client about ESWL, the nurse
3. Prepare the client and equipment, cre- should inform the client that the kidney
ate a sterile field, put on gloves, clean the stones will be:
urinary meatus, and insert the catheter un- 1. dissolved.
til urine flows. 2. shattered.
4. Prepare the client, prepare the equip- 3. radiated.
ment, create a sterile field, test the 4. suctioned.
catheter balloon, clean the meatus, and in-
sert the catheter until urine flows.
920110.qxd 8/7/08 3:02 PM Page 337
Answer: 2. ESWL is a procedure in which the nal causes and ureterolithiasis is a postrenal
client’s kidney stones are shattered or pulver- cause.
ized, not dissolved, radiated, or suctioned. Client needs category: Physiological
integrity Client needs subcategory: Physio-
Client needs subcategory: Physio- logical adaptation
logical adaptation Cognitive level: Comprehension
Cognitive level: Knowledge
8. A client reports finding a small lump in the
left breast near the nipple. What should the
nurse tell the client to do?
1. Inform the physician immediately.
2. Squeeze the nipple to check for
drainage.
3. Check the area after the next menstrual
period.
4. Put a heating pad on the area to reduce
inflammation.
Answer: 1. The client should notify the physi-
cian immediately because a breast lump may
6. The nurse is instructing the client with re- be a sign of breast cancer. The client should-
nal calculi about recommended daily fluid n’t squeeze the nipple to check for drainage
consumption. The nurse would be most until the physician examines the area. The
helpful by telling the client to drink approxi- client shouldn’t wait until after the next men-
mately: strual period to inform the physician of the
1. 4 cups per day. breast lump because prompt treatment may
2. 8 cups per day. be necessary. The client doesn’t need to place
3. 12 cups per day. a heating pad on the area because it would
4. 16 cups per day. have no effect on a breast lump.
Answer: 3. A client with renal calculi should Client needs category: Physiological
drink 3 L of fluid per day. This is equivalent to integrity
12 cups. Client needs subcategory: Physio-
Client needs category: Physiological logical adaptation
risk potential
7. A client with acute renal failure is being

checked to determine if the cause is prerenal,
renal, or postrenal. If the cause if prerenal,
which condition most likely caused it?
1. Heart failure
2. Glomerular nephritis
3. Ureterolithiasis
4. Aminoglycoside toxicity
Answer: 1. By causing inadequate renal perfu-
sion, heart failure can lead to prerenal failure.
Nephritis and aminoglycoside toxicity are re-
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9. The nurse is teaching a client with chronic 10. Following a diagnosis of bladder cancer,
renal failure about foods to avoid. It would be a client receives local radiation therapy and
most accurate for the nurse to teach the client experiences a dry skin reaction. In recom-
to avoid foods high in: mending care of the skin, the nurse should in-
1. monosaccharides. struct the client to avoid:
2. disaccharides. 1. lubrication.
3. iron. 2. cleansers.
4. protein. 3. cold packs.
Answer: 4. Proteins are typically restricted in 4. cotton garments.
clients with chronic renal failure because of Answer: 3. Cold packs over the area of a dry
their metabolites. Iron and carbohydrates reaction to radiation therapy are contraindi-
aren’t restricted. cated because they reduce capillary circula-
Client needs category: Physiological tion to the site and hamper healing. Lubrica-
integrity tion, cleansers and cotton garments aren’t un-
Client needs subcategory: Physio- conditionally contraindicated.
logical adaptation Client needs category: Physiological
Cognitive level: Comprehension integrity
risk potential
920111.qxd 8/7/08 3:54 PM Page 339
11 Integumentary
system
Taking care of the tips
In this chapter,
you’ll review:
Brush up on key The nails, which protect the tips of the fin-
gers and toes, are composed of dead cells
✐ components of the in-
tegumentary system
concepts filled with keratin.
and their functions The skin, hair, and nails make up the integu- Oil and sweat
✐ tests used to diag- mentary system, which serves as protection The integumentary system also contains
nose integumentary for the body’s inner organs. It also helps regu- three types of glands:
disorders late body temperature through the sweat • sebaceous (oil) glands, which lubricate
✐ common integumen- glands. the hair and the epidermis and are stimulated
tary disorders. At any time, you can review the major points by sex hormones
of this chapter by consulting the Cheat sheet • eccrine sweat glands, which regulate
on pages 340 and 341. body temperature through water secretion
• apocrine sweat glands, which are located
Outer defense layer in the axilla, nipple, anal, and pubic areas and
The skin provides the first line of defense secrete odorless fluid. (Decomposition of this
against microorganisms. It’s composed of fluid by bacteria causes odor.)
three layers:
the epidermis (outer layer), which con-

tains keratinocytes and melanocytes and acts
as a protective barrier against the environ-
Keep abreast of
ment diagnostic tests
the dermis (middle layer), a collagen lay-
Here are some diagnostic tests for assessing
er that supports the epidermis, contains
integumentary disorders as well as common
nerves and blood vessels, and is the origin of
nursing actions associated with each test.
hair, nails, sebaceous glands, eccrine sweat
glands, and apocrine sweat glands
Testing blood for this…
the hypodermis (third layer), which is A blood chemistr y test analyzes a blood
composed of loose connective tissue filled sample for potassium, sodium, calcium, phos-
with fatty cells and provides heat, insulation, phorus, ketones, glucose, osmolality, chlo-
shock absorption, and a nutritional reservoir ride, blood urea nitrogen, and creatinine.
(also known as subcutaneous tissue).
Nursing actions
Additional protection • Withhold food and fluids before the proce-
Hair provides protection and coverage for dure as directed.
most of the body, with the exception of the • Check the venipuncture site for bleeding
palms, lips, soles of the feet, nipples, penis, after the procedure.
and labia.
…And for that
Hematologic studies are used to analyze a
blood sample for red blood cells, white blood
920111.qxd 8/7/08 3:54 PM Page 340
340 Integumentary system
et
heat she
C
Integumentary refresher
ATOPIC DERMATITIS Key treatments
Key signs and symptoms • I.V. therapy: hydration and electrolyte replace-
• Erythematous lesions that eventually become ment using a fluid replacement formula such as
scaly and lichenified the Parkland formula.
• Excessively dry skin • Skin grafts
• Hyperpigmentation • Analgesic: morphine
• Skin eruptions • Antianxiety agent: lorazepam (Ativan)
Key test result • Antibiotic: gentamicin (Garamycin)
• Anti-infectives: mafenide (Sulfamylon), silver
• Serum immunoglobulin E levels are commonly
sulfadiazine (Silvadene), silver nitrate
elevated but this finding doesn’t confirm that the
• Antitetanus: tetanus toxoid
patient has atopic dermatitis.
• Colloid: albumin 5% (Albuminar-5)
Key treatments
Key interventions
• Antihistamines: diphenhydramine (Benadryl),
hydroxyzine (Atarax)
• Monitor fluid status.
• Corticosteroid: hydrocortisone (Dermacort)
• Maintain I.V. fluids.
Key interventions • Administer oxygen.
• Help the patient set up an individual schedule • Monitor total parenteral or enteral feedings.
and plan for daily skin care. • Maintain protective precautions.
• Instruct the patient to bathe in plain water. (He
Groovy. may have to limit bathing, according to the sever- HERPES ZOSTER
If I don’t have time ity of the lesions.) Tell him to bathe with a special Key signs and symptoms
to study the
nonfatty soap and tepid water (96° F [35.6° C]), to • Neuralgia
whole chapter, I
avoid using any soap when lesions are acutely • Severe, deep pain
can just review
the Cheat sheet. inflamed, and to limit baths and showers to 5 to 7 • Unilaterally clustered skin vesicles along pe-
minutes. ripheral sensory nerves on the trunk, thorax, or
• For scalp involvement, advise the patient to face
shampoo frequently and to apply corticosteroid Key test results
solution to the scalp afterward. • A skin study identifies the organism.
• Lubricate the skin after a shower or bath. • Visual inspection identifies vesicles along the
BURNS peripheral sensory nerves.
Key signs and symptoms Key treatments
• Superficial partial-thickness burn: erythema, • Analgesics: acetaminophen (Tylenol), codeine
edema, pain, blanching • Antianxiety agents: lorazepam (Ativan),
• Deep dermal partial-thickness burn: pain, ooz- hydroxyzine (Vistaril)
ing, fluid-filled vesicles; erythema; shiny and wet • Anti-inflammatory: triamcinolone (Aristocort)
subcutaneous layer after vesicles rupture • Antipruritic: diphenhydramine (Benadryl)
• Full-thickness burn: eschar, edema, little or no • Antiviral agents: acyclovir (Zovirax), valacy-
pain clovir (Valtrex), famciclovir (Famvir)
Key test result Key interventions
• Visual inspection allows the examiner to esti- • Monitor neurologic status.
mate the extent of the burn (determined by the • Monitor pain and note the effectiveness of
Rule of Nines and the Lund and Browder chart). analgesics.
• Prevent scratching and rubbing of affected ar-
eas.
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Integumentary refresher (continued)

PRESSURE ULCERS Key interventions
Key sign • Make sure the patient understands his prescribed therapy;
• Signs are determined by stage of ulceration. provide written instructions.
Key treatments • Watch for adverse reactions, especially allergic reactions to
anthralin; atrophy and acne from steroids; and burning, itching,
• High-protein, high-calorie diet in small, frequent feedings;
nausea, and squamous cell epitheliomas from PUVA therapy.
parenteral or enteral feedings if the patient is unable or unwilling
• Caution the patient receiving PUVA therapy to stay out of the
to take adequate nutrients orally
sun on the day of treatment and to protect his eyes with sun-
• Topical wound care according to facility protocol
glasses that screen UVA for 24 hours after treatment. Tell him to
• Wound debridement; tissue flap
wear goggles during any exposure to this light.
Key interventions
• Monitor skin integrity and watch for signs of infection. SKIN CANCER
• Monitor any bedridden patient for possible changes in skin col- Key signs and symptoms
or, turgor, temperature, and sensation. • Change in color, size, or shape of preexisting lesion
• Reposition the patient every 1 to 2 hours. • Irregular, circular bordered lesion with hues of tan, black, or
• Provide meticulous skin care and check bony prominences. blue (melanoma)
• Maintain the patient’s diet and encourage oral fluid intake. • Small, red, nodular lesion that begins as an erythematous mac-
ule or plaque with indistinct margins (squamous cell carcinoma)
PSORIASIS
• Waxy nodule with telangiectasis (basal cell epithelioma)
Key test result
• Itching
• A skin biopsy shows cytology positive for cancer cells.
• Lesions (red and usually well-defined patches)
• Pustules (with secondary infection) Key treatments
Key test result • Chemosurgery with zinc chloride
• Cryosurgery with liquid nitrogen
• A skin biopsy is positive for the disorder.
• Curettage and electrodesiccation
Key treatments • Antimetabolite: fluorouracil (Adrucil)
• Antipsoriatic agents: calcipotriene (Dovonex), anthralin (An-
Key interventions
thra-Derm)
• Monitor treated lesion sites.
• Corticosteroid ointments: hydrocortisone (Dermacort), clobeta-
• Administer medications as prescribed.
sol (Cormax)
• Provide postchemotherapy and postradiation nursing care.
• Ultraviolet light to retard cell production; may be used in con-
junction with psoralens (PUVA therapy)
cells (WBCs), erythrocyte sedimentation rate, Nursing actions

platelets, hemoglobin (Hb), and hematocrit • Check the patient’s medication list and note
(HCT). any that might interfere with the test results.
• Check the venipuncture site for bleeding af-
Nursing actions ter the procedure.
• Check the venipuncture site for bleeding af-
ter the procedure. Tissue punch test
A skin biopsy, also known as a punch biopsy,
…And also for this involves use of a circular punch instrument to
Coagulation studies analyze a blood sample remove a small amount of skin tissue for his-
for prothrombin time, international normal- tologic evaluation.
ized ratio, and partial thromboplastin time.
920111.qxd 8/7/08 3:54 PM Page 342
Nursing actions
Check it out.
Checking the test site • Make sure that written, informed consent
has been obtained.
for infection and
bleeding after the • After the procedure, check the site for
bleeding and infection.
care
procedure is a
common nursing Major integumentary disorders include atopic
responsibility Allergy exam dermatitis, burns, herpes zoster, pressure ul-
associated with skin Skin testing involves use of a patch, scratch, cers, psoriasis, and skin cancer.
tests. or intradermal injection to administer an aller-
gen to the skin’s surface or into the dermis.
The skin is then checked for reaction. Atopic dermatitis
Nursing actions Atopic dermatitis is a chronic skin disorder
• Keep the test area dry. characterized by superficial skin inflamma-
• Record the site, date, and time of test. tion and intense itching. It also may be called
• Inspect the test site for erythema, papules, atopic eczema or infantile eczema.
vesicles, edema, and induration. Atopic dermatitis may be associated with
• Record the date and time for the follow-up other atopic diseases, such as bronchial asth-
site reading. ma and allergic rhinitis. It usually develops in
infants and toddlers between ages 1 month
Scrape and study and 1 year, commonly in those with strong
A skin scraping involves scraping a small family histories of atopic disease. In many cas-
sample of skin, nail, or hair for evaluation un- es, these children acquire other atopic disor-
der a microscope. ders as they grow older.
Typically, this form of dermatitis flares and
Nursing actions subsides repeatedly before finally resolving
• After the procedure, check the scraping site during adolescence. However, it can persist
for bleeding and infection. into adulthood.
Under the microscope CONTRIBUTING FACTORS

A skin study is a microscopic examination of •Chemical irritants
Atopic dermatitis skin that includes a Gram stain, culture and •Food allergies
is characterized by sensitivity testing, cytology, and immunofluo- •Genetic predisposition
intense itching. rescence technique. •Immune dysfunction (possibly linked to ele-
Scratching the skin vated serum immunoglobulin E [IgE] levels
intensifies itching and Nursing actions or defective T-cell function)
creates red, weeping • Follow laboratory procedure guidelines. •Infections (with Staphylococcus aureus)
lesions.
• Note current antibiotic therapy.
UV inspection •Characteristic location of lesions: areas of
Wood’s light test involves use of ultraviolet flexion and extension, such as the neck, ante-
(UV) light to directly examine the skin. cubital fossa (inside the elbow), popliteal
folds (posterior surface of the knee), and be-
Nursing actions hind the ears
• Explain the procedure to the patient. • Erythematous lesions that eventually be-
come scaly and lichenified
• Excessively dry skin
• Hyperpigmentation
• Skin eruptions
920111.qxd 8/7/08 3:54 PM Page 343
DIAGNOSTIC FINDINGS • Instruct the patient to keep his fingernails

Preventing
• Serum IgE levels are commonly elevated, short to limit excoriation and secondary infec- excessive dryness of
but this finding doesn’t confirm atopic der- tions caused by scratching. the skin is critical in
matitis. • Lubricate the skin after a shower or bath to atopic dermatitis—
prevent excessive dryness. encourage the patient
NURSING DIAGNOSES • Apply occlusive dressings (such as a plastic to use moisturizers.
•Impaired skin integrity film) over a corticosteroid cream intermit-
•Disturbed body image tently, as necessary, to help clear lichenified
•Anxiety skin.
• Encourage the patient to verbalize his feel-
TREATMENT ings about his skin condition. Coping with dis-
•Washing of lesions with water and mild soap figurement is extremely difficult, especially for
•Environmental control of the offending aller- children and adolescents.
gens
Teaching topics
Drug therapy • Understanding factors that exacerbate the
• Antihistamines: diphenhydramine (Bena- condition (fabrics, detergents, stress)
dryl), hydroxyzine (Atarax) • Following appropriate skin care
• Corticosteroid: hydrocortisone (Derma- • Wearing clothing made of cotton
cort)
INTERVENTIONS AND RATIONALES Burns

•Warn that drowsiness is possible with the
use of an antihistamine to relieve daytime A burn destroys skin integrity and causes the
itching. Informing the patient about this poten- loss of intracellular fluid and electrolytes. A
tial adverse effect can help to prevent injury. burn is characterized by the extent (area) and
•If nocturnal itching interferes with sleep, depth of the burn. Most burns are a combina-
suggest methods for inducing natural sleep, tion of thicknesses:
such as drinking a glass of warm milk, to pre- • A superficial partial-thickness burn (previ-
vent overuse of sedatives. ously known as a first-degree burn) involves
•An antihistamine may also be useful at bed- only the epidermal layer.
Remember your
time because antihistamines relieve itching and • A deep dermal partial-thickness burn (pre- therapeutic role.
cause drowsiness. viously known as a second-degree burn) in- Encourage the patient
• Help the patient set up an individual sched- volves the epidermal and dermal layers. to express her feelings
ule and plan for daily skin care to help him • A full-thickness burn (previously known as about her skin
cope with the chronic condition and to promote third- and fourth-degree burns) involves epi- condition.
compliance. dermal, dermal, subcutaneous layers, and
• Instruct the patient to bathe in plain water. nerve endings, muscle, and bone.
(He may have to limit bathing, according to
the severity of the lesions.) Tell him to bathe Number 9…Number 9
with a special nonfatty soap and tepid water The Rule of Nines is a method used to esti-
(96° F [35.6° C]), to avoid using any soap mate the size of a burned area. With this
when lesions are acutely inflamed, and to lim- method, a person’s skin area is divided into
it baths or showers to 5 to 7 minutes. These several sections, each representing 9% (or
measures prevent worsening of the condition. multiples of 9%) of the total body area. By ob-
• For scalp involvement, advise the patient to serving the size and location of a burn and as-
shampoo frequently and to apply corticoste- signing the appropriate body percentage, the
roid solution to the scalp afterward to improve nurse can roughly determine what percent-
skin integrity. age of a patient’s body has been burned.
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Lund and Browder TREATMENT

The Lund and Browder chart is another • Biological dressings
method of estimating body surface area that’s • Diet high in protein, fat, calories, and carbo-
been burned. This method accounts for the hydrates with small, frequent feedings
changes in body proportion that occur with • Early excisional therapy
age. It helps determine a patient’s exact fluid • Escharotomy (surgical excision of burned
replacement requirements after a burn injury tissue)
because it’s more accurate. • I.V. therapy: hydration and electrolyte re-
placement, using a fluid replacement formula
CAUSES such as the Parkland formula
• Chemical: acids, alkalies, vesicants • Isolation to protect the patient from infec-
• Electrical: lightning, electrical wires tion
• Mechanical: friction • Skin grafts
• Radiation: X-ray, sun, nuclear • Splints to maintain proper joint position and
• Thermal: flame, frostbite, scald prevent contractures
• Transfusion therapy of fresh frozen plasma,
DATA COLLECTION FINDINGS platelets, packed RBCs, and albumin
• Superficial partial-thickness: erythema, • Withholding oral food and fluids until al-
edema, pain, blanching lowed
• Deep dermal partial-thickness: pain, oozing,
fluid-filled vesicles, erythema, shiny and wet Drug therapy
subcutaneous layer after vesicles rupture • Analgesic: morphine
• Full-thickness: eschar, edema, little or no • Antacids: magnesium and aluminum hy-
pain droxide (Maalox), aluminum hydroxide gel
(AlternaGEL)
DIAGNOSTIC FINDINGS • Antianxiety agent: lorazepam (Ativan)
• Visual inspection allows the examiner to es- • Antibiotic: gentamicin (Garamycin)
Don’t get timate the extent of the burn (determined by • Anti-infectives: mafenide (Sulfamylon), sil-
burned on the the Rule of Nines and the Lund and Browder ver sulfadiazine (Silvadene), silver nitrate
NCLEX! Make chart). • Antitetanus: tetanus toxoid
time to study a
• A 24-hour urine collection shows decreased • Colloid: albumin 5% (Albuminar-5)
little bit each
day. creatinine clearance and negative nitrogen • Diuretic: mannitol (Osmitrol)
balance. • Histamine antagonists: cimetidine (Taga-
• Arterial blood gas analysis shows metabolic met), ranitidine (Zantac), famotidine (Pepcid),
acidosis. nizatidine (Axid)
• As indicated, blood chemistry test shows in- • Mucosal barrier fortifier: sucralfate
creased potassium level and decreased sodi- (Carafate)
um, albumin, complement fixation, and im- • Vitamins: phytonadione (AquaMEPHY-
munoglobulin levels. TON), cyanocobalamin (vitamin B12)
• Hematology shows increased Hb and HCT
and decreased fibrinogen and platelets and INTERVENTIONS AND RATIONALES
WBC count. • Monitor respiratory status. Upper airway
• Urine chemistry shows hematuria and myo- injury is common with burns to the face, neck,
globinuria. and chest. Edema may narrow airways.
• Monitor fluid status to detect hypovolemia.
NURSING DIAGNOSES • If the patient has undergone skin grafting,
• Deficient fluid volume keep pressure off the donor site to maintain
• Acute pain blood flow to the site and promote wound heal-
• Risk for infection ing.
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• Monitor for signs of infection to determine Herpes zoster

whether the treatment plan must be altered.
• Check the effectiveness of pain medication Herpes zoster, also known as shingles, is an
to promote comfort. acute viral infection of nerve structures
• Monitor and record vital signs, fluid intake caused by varicella zoster; affected areas in-
and output, stool for occult blood, calorie clude the spinal and cranial sensory ganglia
count, daily weight, and neurovascular checks and posterior gray matter of the spinal cord.
to detect complications. Herpes zoster produces localized vesicular
• Monitor bowel sounds to determine motility skin lesions confined to a dermatome and se-
of the GI tract. vere neurologic pain in peripheral areas inner- Each nerve
• Maintain I.V. fluids to maintain hydration vated by the inflamed root ganglia. emanates from the
and replace fluid loss. spine and sends
signals to a skin area
• Administer oxygen to meet cellular de- CAUSES called a dermatome.
mands. • Cytotoxic drug-induced immunosuppres-
• Provide suctioning; assist with turning, sion
coughing, and deep breathing; and perform • Debilitating disease
chest physiotherapy and postural drainage to • Exposure to varicella zoster
maintain a patent airway. • Hodgkin’s disease
• Monitor total parenteral nutrition or admin-
ister enteral feedings to meet the patient’s in- DATA COLLECTION FINDINGS
creased metabolic demands. • Anorexia
• Administer medications, as prescribed, to • Edematous skin
maintain or improve the patient’s condition. • Erythema
• Encourage the patient to express feelings • Fever
about disfigurement, immobility from scar- • Headache
ring, and a fear of dying to encourage him to • Malaise
adopt coping mechanisms. • Neuralgia
• Provide treatments: range-of-motion (ROM) • Paresthesia
exercises, Hubbard tank (for immersing the • Pruritus
patient), bed cradle, splints, and Jobst cloth- • Severe, deep pain
ing to maintain ROM and prevent complica- • Unilaterally clustered skin vesicles along
tions. peripheral sensory nerves on the trunk, tho-
• Elevate the affected extremities to promote rax, or face
venous drainage and decrease edema. Chickenpox-like
• Maintain a warm environment during acute DIAGNOSTIC FINDINGS vesicles are the
period because the patient is unable to regulate • A skin study identifies the infecting organ- key sign of herpes
body temperature. ism. zoster.
• Maintain protective precautions to prevent • Visual inspection identifies vesicles along
transmission of infection to the patient. the peripheral sensory nerves.
• Provide skin and mouth care to promote
comfort. NURSING DIAGNOSES
• Acute pain
Teaching topics • Risk for infection
• Following dietary recommendations and re- • Impaired skin integrity
strictions
• Avoiding restrictive clothing TREATMENT
• Using splints and Jobst clothing • Comfort promotion
• Contacting community agencies and re-
sources
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Drug therapy CAUSES

• Analgesics: acetaminophen (Tylenol), • Pressure, particularly over bony promi-
codeine nences
• Anti-inflammatory: triamcinolone (Aristo- • Shearing, friction
cort)
• Antianxiety agents: lorazepam (Ativan), hy- Risk factors
droxyzine (Vistaril) • Diabetes
• Antipruritic: diphenhydramine (Benadryl) • Immobility
• Antiviral agents: acyclovir (Zovirax), famci- • Obesity or emaciation
clovir (Famvir), valacyclovir (Valtrex) • Poor hydration
• Nerve blocker: lidocaine (Xylocaine) • Poor nutrition

• Monitor the patient’s neurologic status to Signs and symptoms of pressure ulcers occur
determine a baseline and then detect changes. in various stages.
• Note the patient’s level of pain and the ef-
fectiveness of analgesics to promote comfort Deep-tissue injury
and evaluate the need for a change in the cur- • Skin discoloration: purple or maroon local-
rent treatment plan. ized area
• Monitor and record vital signs, laboratory • Intact skin or blood-filled blister
results, and cranial nerve function to deter-
mine a baseline and then detect changes. Stage 1
• Administer medications, as directed, to • Intact skin
maintain or improve the patient’s condition. • Nonblanchable erythema
about changes in his physical appearance and Stage 2
the recurrent nature of the illness to help him • Open or ruptured skin
adapt. • Partial-thickness skin loss involving the epi-
• Prevent scratching and rubbing of affected dermis and dermis
areas to prevent infection. • Shallow ulcer, without slough
Teaching topics Stage 3

• Avoiding wool and synthetic clothing • Deep crater with or without undermining of
• Wearing lightweight, loose cotton clothing adjacent tissue
• Keeping blisters intact • Full-thickness skin loss involving damage
• Promoting skin care or necrosis of subcutaneous tissue, which
may extend down to, but not through, under-
lying fasciae
Pressure ulcers • Slough (possible)
Pressure ulcers are localized areas of cellular Stage 4

necrosis that occur most commonly in skin • Damage to muscle, bone, tendon, or joint
and subcutaneous tissue over bony promi- • Full-thickness skin loss with extensive de-
nences. These ulcers may be superficial, struction
caused by local skin irritation with subse- • Tissue necrosis; slough or eschar (possi-
quent surface maceration, or deep, originat- ble)
ing in underlying tissue. Deep lesions may go • Tunneling or undermining (possible)
undetected until they penetrate the skin; by
then, they usually have caused subcutaneous
damage.
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Preventing pressure ulcers

As a health care provider, you play a key with less force over a long period of • Turn or reposition the patient every 1 to
role in maintaining the patient’s skin in- time—impairs circulation, depriving tis- 2 hours, unless contraindicated.
tegrity by promoting comfort through sues of oxygen and nutrients. If left un- • Lift the patient rather than sliding him
averting dryness and itching and pre- treated, ischemic areas can progress to because sliding causes friction.
venting pressure ulcers, a major compli- tissue breakdown and infection. • Use pillows to position the patient.
cation. Because your patient’s skin con- Most pressure ulcers develop over bony • Avoid placing your patient directly on
dition largely depends on his overall prominences, where friction and shear- his trochanter.
health, you’ll need to help him maintain ing combine with pressure to break down • Except for brief periods, avoid raising
optimal nutrition and hydration. You may skin and underlying tissues. the head of the bed more than 30 de-
also need to provide additional guidance grees to prevent shearing.
MAKING THE DIFFERENCE
in personal hygiene and how to protect • As appropriate, perform active and
Preventing pressure ulcers is crucial, es-
the skin from harsh environmental condi- passive range-of-motion exercises to re-
pecially in older adults, because ulcers
tions. lieve pressure and promote circulation.
take a long time to heal, increasing the
• Keep the patient’s skin surfaces clean,
PUTTING ON THE PRESSURE patient’s risk of infection and other com-
and use moisturizers and moisture barri-
As their name implies, pressure ulcers plications.
ers.
develop when pressure—applied with To help prevent pressure ulcers, follow
• Take steps to improve the patient’s nu-
great force for a short period of time or these steps:
tritional and hydration status.
Unstageable INTERVENTIONS AND RATIONALES

• Full-thickness wound covered with eschar • Monitor the patient’s skin integrity and
or slough that prevents full assessment of ul- watch for signs of infection to detect complica-
cer tions. Every 1 to 2 hours:
That’s how often you
• Monitor a bedridden patient for possible
need to reposition a
DIAGNOSTIC FINDINGS changes in skin color, turgor, temperature, patient to avoid
• Visual inspection identifies a pressure ulcer. and sensation to prevent further skin break- pressure ulcers.
• A wound culture and sensitivity identifies down.
the infecting organism. • Reposition the patient every 1 to 2 hours to
prevent pressure ulcers. (See Preventing pres-
NURSING DIAGNOSES sure ulcers.)
• Impaired physical mobility • Provide meticulous skin care and check
• Imbalanced nutrition: Less than body re- bony prominences to help prevent development
quirements of pressure ulcers.
• Impaired skin integrity • Maintain the patient’s diet and encourage
oral fluid intake to promote wound healing.
TREATMENT • Provide wound care to promote healing.
• High-protein, high-calorie diet in small, fre- • Provide ROM exercises to promote circula-
quent feedings; parenteral or enteral feedings tion.
if the patient is unable or unwilling to take ad-
equate nutrients orally Teaching topics
• Topical wound care according to the facili- • Avoiding prolonged periods of immobility
ty’s protocol • Performing meticulous skin care
• Wound debridement; tissue flap • Changing positions frequently when bed-
ridden
• Recognizing the signs of skin breakdown
• Recognizing the signs and symptoms of
infection
920111.qxd 8/7/08 3:54 PM Page 348
Flare-ups of Psoriasis • Antipsoriatic agents: calcipotriene

psoriasis are (Dovonex), anthralin (Anthra-Derm)
commonly related to Psoriasis, a chronic, recurrent disease, is • Antihypocalcemic agent: calcitriol (Rocal-
specific factors such marked by epidermal proliferation. Lesions trol)
as stress. appear as erythematous papules and plaques • Antineoplastic agent: methotrexate (Trex-
covered with silver scales and vary widely in all)
severity and distribution. • Immunosuppressants: alefacept (Amevive),
Although this disorder commonly affects cyclosporine (Gengraf)
young adults, it may strike at any age, includ-
ing infancy. Psoriasis is characterized by re- INTERVENTIONS AND RATIONALES
curring partial remissions and exacerbations. • Make sure the patient understands his pre-
scribed therapy; provide written instructions
CAUSES to avoid confusion and promote compliance.
•Genetic predisposition • Watch for adverse reactions, especially al-
lergic reactions to anthralin, atrophy and acne
DATA COLLECTION FINDINGS from steroids, and burning, itching, nausea,
•Arthritic symptoms and squamous cell epitheliomas from PUVA
•Characteristic locations of lesions: scalp, therapy to prevent complications.
chest, elbows, knees, back, buttocks • Caution the patient receiving PUVA therapy
• Itching to stay out of the sun on the day of treatment
• Lesions (red and usually forming well- and to protect his eyes with sunglasses that
defined patches) screen UVA for 24 hours after treatment. Tell
• Pain him to wear goggles during any exposure to
• Patches consisting of silver scales that flake this light. These measures protect the patient
off or thicken and cover the lesions from injury caused by excessive ultraviolet A
• Pustules (if secondary infection is present) exposure.
• Be aware that psoriasis can cause stress
DIAGNOSTIC FINDINGS and emotional upset. Assure the patient that
• A skin biopsy is positive for the disorder. psoriasis isn’t contagious and that although
• Blood studies reveal elevated serum uric exacerbations and remissions occur, they’re
acid level in severe cases, due to accelerated controllable with treatment. Appropriate
nucleic acid degradation; indications of gout teaching helps the patient develop healthy cop-
are absent. ing strategies
• Help the patient learn to cope with stressful
NURSING DIAGNOSES situations because they tend to exacerbate psori-
• Impaired skin integrity asis.
• Disturbed body image Teaching topics
• Correctly applying prescribed ointments,
TREATMENT creams, and lotions (a steroid cream, for ex-
• Tar, wet dressings, or oatmeal baths ample, should be applied in a thin film and
• UV light to retard cell production; may be rubbed gently into the skin until the cream
used in conjunction with psoralens (PUVA disappears)
therapy) • Avoiding occlusive dressings over anthralin
• Using mineral oil, then soap and water, to
Drug therapy remove anthralin
• Corticosteroid ointments: hydrocortisone • Washing the skin gently, not vigorously
(Dermacort), clobetasol (Cormax) • Using a soft brush to remove scales
• Corticosteroid: intralesional steroid injec- • Contacting the National Psoriasis Foun-
tions dation
920111.qxd 8/7/08 3:54 PM Page 349
Skin cancer NURSING DIAGNOSES

• Anxiety
Skin cancer is a malignant primary tumor of • Disturbed body image
the skin. There are three types: • Impaired skin integrity
• Basal cell carcinoma is the most common
form of skin cancer and is usually caused by TREATMENT
prolonged exposure to the sun. It tends to • Chemosurgery with zinc chloride
grow slowly and rarely metastasizes. • Cryosurgery with liquid nitrogen
• Melanoma is a neoplasm that arises from • Curettage and electrodesiccation
melanocytes. Melanoma spreads quickly • Radiation therapy
through the lymph and vascular systems and
metastasizes to the lymph nodes, skin, liver, Drug therapy
lungs, and central nervous system. It’s the • Alkylating agents: carmustine (BiCNU),
most lethal form of skin cancer. dacarbazine (DTIC-Dome)
• Squamous cell carcinoma grows more • Antiemetics: prochlorperazine (Com-
rapidly than basal cell carcinoma. It requires pazine), ondansetron (Zofran)
early treatment to prevent metastasis. • Antimetabolite: fluorouracil (Adrucil)
• Antineoplastics: hydroxyurea (Hydrea),
CAUSES vincristine (Oncovin)
• Chemical irritants • Immunotherapy for melanoma: bacille
• Friction or chronic irritation Calmette-Guérin vaccine
• Heredity • Unclassified drug: imiquimod (Aldara) for
• Immunosuppressive drugs superficial basal cell carcinoma
• Infrared heat or light
• Precancerous lesions: leukoplakia, nevi, INTERVENTIONS AND RATIONALES
senile keratoses • Monitor skin punch biopsy site for bleeding.
• Radiation • Monitor lesions. Regular observation allows
• UV rays early detection in case of recurrence.
• Monitor and record vital signs to determine
DATA COLLECTION FINDINGS baseline and detect changes.
• Change in color, size, or shape of an exist- • Administer medications as prescribed to
ing lesion maintain and improve the patient’s condition.
• Irregular, circular bordered lesion with • Encourage the patient to express feelings
hues of tan, black, or blue (in the case of about changes in body image and a fear of dy-
melanoma) ing to help him accept changes in body image.
• Local soreness • Provide postchemotherapy and postradia-
• Oozing, bleeding, crusting lesion tion nursing care to promote healing.
• Pruritus
• Small, red, nodular lesion that begins as an Teaching topics
erythematous macule or plaque with indis- • Avoiding contact with chemical irritants
tinct margins (in the case of squamous cell • Wearing sun block and layered clothing
carcinoma) when outdoors
• Waxy nodule with telangiectasis (in the case • Self-monitoring for lesions that don’t heal
of basal cell epithelioma) and moles that change characteristics
• Removing moles that are constantly irri-
DIAGNOSTIC FINDINGS tated
• A skin biopsy shows cytology positive for • Contacting the Skin Cancer Foundation
cancer cells. • Contacting community agencies and other
resources
920111.qxd 8/7/08 3:54 PM Page 350
2. A client undergoes a circular skin punch

biopsy to confirm a diagnosis of skin cancer.
Immediately following the procedure, the
nurse should observe the site for what reac-
tion?
1. Infection
2. Dehiscence
3. Hemorrhage
4. Swelling
Answer: 3. The nurse’s main concern follow-
ing a circular skin punch biopsy is to monitor
the site for bleeding. Dehiscence is more like-
ly in larger wounds such as surgical incisions
Pump up on practice of the abdomen or thorax. Later, infection is a
possible consequence of a skin punch. Swel-
questions ling is a normal reaction associated with any
event that traumatizes the skin.
1. A client experiences problems with body Client needs category: Physiological
temperature regulation associated with a skin integrity
impairment. Which gland is most likely in- Client needs subcategory: Reduction of
volved? risk potential
1. Eccrine Cognitive level: Application
2. Sebaceous
3. Apocrine
4. Endocrine
Answer: 1. Eccrine glands are associated with
body temperature regulation, sebaceous
glands lubricate the skin and hair, and apoc-
rine glands are involved in bacteria decompo-
sition. Endocrine glands are a group of glands
that secrete hormones that regulate body
processes, such as metabolism and glucose
balance. 3. A client undergoes hypersensitivity testing
Client needs category: Physiological with the intradermal technique. When the
integrity nurse administers the allergen, at what angle
Client needs subcategory: Physio- should the needle be inserted?
logical adaptation 1. 0 degrees
Cognitive level: Comprehension 2. 15 degrees
3. 45 degrees
4. 90 degrees
Answer: 2. The proper angle for intradermal
injections is 15 degrees. There are no injec-
tions requiring a 0-degree insertion. The sub-
cutaneous angle is 45 degrees, and the intra-
muscular angle is 90 degrees.
integrity
logical therapies
920111.qxd 8/7/08 3:54 PM Page 351
cause intact healthy skin is the body’s first

line of defense. To help a client maintain
healthy skin, the nurse should avoid strong or
harsh detergents and should use mild soap.
The nurse shouldn’t remove adhesive tape
too quickly because this action can strip or
scrape the skin. The nurse should recom-
4. What is the best method for preventing hy- mend wearing loose clothes in hot weather to
povolemic shock in a client admitted with se- promote heat loss by evaporation.
vere burns? Client needs category: Health promo-
1. Administering dopamine (Intropin) tion and maintenance
2. Applying medical antishock trousers Client needs subcategory: None
3. Infusing I.V. fluids Cognitive level: Comprehension
4. Infusing fresh frozen plasma
Answer: 3. During the early postburn period, 6. The skin lesions evident in herpes zoster
large amounts of plasma fluid extravasate into are similar to those seen in:
interstitial spaces. Replacing the lost fluid is 1. impetigo.
necessary to prevent hypovolemic shock; this 2. syphilis.
is best accomplished with crystalloid and col- 3. varicella.
loid solutions. Dopamine causes vasoconstric- 4. rubella.
tion and elevates blood pressure, but it does- Answer: 3. Varicella (chickenpox) characteris-
n’t prevent hypovolemia in burn clients. Med- tically has vesicles as the hallmark lesion
ical antishock trousers would be applied to much like herpes zoster. Impetigo has pus-
treat—not prevent—shock. Fresh frozen plas- tules. The primary lesion in syphylis is the
ma is expensive and introduces a slight risk of chancre; in rubella, the lesion is a macu-
disease transmission. lopapular rash.
integrity integrity
Client needs subcategory: Physio- Client needs subcategory: Physio-
logical adaptation logical adaptation
Cognitive level: Application Cognitive level: Comprehension
7. A client with widespread herpes zoster is

placed on I.V. hydrocortisone (Solu-Cortef).
The nurse should be aware that the drug can
cause an elevation of which serum chemistry
value?
1. Potassium
2. Calcium
3. Glucose
5. Which nursing intervention can help a 4. Magnesium
client maintain healthy skin? Answer: 3. Corticosteroids are known to ele-
1. Keep the client well hydrated. vate the blood glucose level and tend to lower
2. Bathe the client without soap. serum potassium and calcium levels. Their ef-
3. Remove adhesive tape quickly from the fect on magnesium isn’t substantial.
skin. Client needs category: Physiological
4. Recommend tight-fitting clothes for hot integrity
weather. Client needs subcategory: Pharmaco-
Answer: 1. Keeping the client well hydrated logical therapies
helps prevent skin cracking and infection be- Cognitive level: Comprehension
920111.qxd 8/7/08 3:54 PM Page 352
9. Deep partial-thickness burn wounds are

characterized by:
1. erythema.
2. blanching.
3. eschar.
4. fluid-filled vesicles.
Answer: 4. Deep partial-thickness skin de-
struction (also referred to as second-degree
burns) is characterized by fluid-filled vesicles.
Erythema and blanching on pressure are
8. A 19-year-old female client comes to a clin- characteristic of partial-thickness skin de-
ic with dark red lesions on her hands, wrists, struction. Eschar is a manifestation of full-
and waistline. She has scratched several of thickness skin destruction.
the lesions until they’re open and bleeding. Client needs category: Physiological
The nurse instructs the client to try pressing integrity
on the itchy lesions. What is the rationale for Client needs subcategory: Physio-
this intervention? logical adaptation
1. Pressing the skin promotes beneficial Cognitive level: Knowledge
microorganisms.
2. Pressing is suggested before scratch- 10. The nurse is caring for a client with a
ing. new donor site that was harvested to treat a
3. Pressing the skin promotes breaks in burn. The nurse should position the patient
the skin. to:
4. Pressing the skin stimulates nerve end- 1. allow ventilation of the site.
ings. 2. make the site dependent.
Answer: 4. Pressing the skin stimulates nerve 3. avoid pressure on the site.
endings, doesn’t promote breaks in the skin, 4. keep the site fully covered.
and can reduce the sensation of itching. Answer: 3. A universal concern in the care of
Scratching the skin spreads microorganisms donor sites for burn care is to keep the site
and opens a portal for the entry of bacteria. away from sources of pressure. Ventilation of
Client needs category: Physiological the site and keeping the site fully covered are
integrity practices in some institutions but aren’t hall-
Client needs subcategory: Physio- marks of donor site care. The donor site
logical adaptation shouldn’t be placed in a dependent position.
Cognitive level: Application Client needs category: Physiological
integrity
logical adaptation
920111.qxd 8/7/08 3:54 PM Page 353
Pump up on more practice questions

1. A client experiences abdominal pain and 3. The nursing staff has just been taught how
exhibits blood in his stools and emesis. He’s to use and care for a new blood glucose moni-
scheduled to undergo several diagnostic tests. tor. Which nursing intervention demonstrates
It isn’t necessary for the nurse to withhold all the proper use of a blood glucose monitor?
food from the client if he’s scheduled for: 1. Take off your gloves before removing
1. an endoscopy. the test strip.
2. a fecal occult blood test. 2. Smear the drop of blood onto the
3. an endoscopic retrograde cholangiopan- reagent pad.
creatography. 3. Calibrate the machine after installing a
4. a barium swallow. new battery.
Answer: 2. The client may eat normally when a 4. Start the timer on the machine while
fecal occult blood test is scheduled; however, gathering supplies.
for endoscopic tests, an upper GI series, or a Answer: 3. To obtain accurate readings, the
barium swallow, the client should have noth- nurse should calibrate the machine whenever
ing by mouth before the test. a new battery is installed. To adhere to stan-
Client needs category: Physiological dard precautions and prevent contact with
integrity blood, the nurse’s hands should remain
Client needs subcategory: Reduction of gloved throughout blood glucose testing. The
risk potential nurse should drop the blood—not smear it—
Cognitive level: Application on the reagent pad because smearing can
cause an inaccurate reading. To ensure accu-
2. The nurse is providing teaching for a client rate results, the nurse shouldn’t start the
with a hiatal hernia. The nurse asks the client timer before the sample is collected.
which foods he regularly consumes. What Client needs category: Safe, effective
answer would indicate the need for more care environment
teaching on this topic? Client needs subcategory: Safety and
1. Milk products infection control
2. Small meals Cognitive level: Knowledge
3. Fatty foods
4. Soft drinks 4. A client with Crohn’s disease asks the
Answer: 4. Carbonated beverages stimulate nurse which food she should eat. What should
belching and gastric reflux, causing lower the nurse recommend?
esophageal irritation and the associated pain 1. Celery
of hiatal hernia. Milk products, small meals, 2. Peanut butter
and fatty foods aren’t prohibited in the diet of 3. Honey
a patient with hiatal hernia. 4. Fudge
Client needs category: Physiological Answer: 3. The dietary recommendations for
integrity regional enteritis are foods high in protein,
Client needs subcategory: Reduction of carbohydrates, and calories and low in fat,
risk potential residue, and fiber. Honey is a high-calorie car-
Cognitive level: Analysis bohydrate. Celery isn’t recommended be-
cause it’s high in residue and fiber. Peanut
butter isn’t recommended because it’s high in
920111.qxd 8/7/08 3:54 PM Page 354
354 Care of the adult
fat. Fudge is typically high-fat and shouldn’t Client needs category: Physiological
be recommended. integrity
Client needs category: Physiological Client needs subcategory: Physio-
integrity logical adaptation
Client needs subcategory: Reduction of Cognitive level: Application
risk potential
5. A client is prescribed misoprostol (Cy-

totec) for treatment of a gastric ulcer. The
nurse should be alert for which common,
dose-related adverse reaction?
1. Diarrhea
2. Nausea
3. Vomiting
4. Bloating
Answer: 1. Misoprostol commonly causes di- 7. The nurse is seeking to meet the nutrition-
arrhea. This reaction is usually dose-related. al needs of a client with acute peritonitis. The
Nausea and vomiting are adverse reactions nurse should monitor:
that might be associated with misoprostol ad- 1. nasal enteral feedings.
ministration, but they’re uncommon. Bloating 2. gastric enteral feedings.
isn’t an adverse reaction to misoprostol. 3. oral feedings.
Client needs category: Physiological 4. parenteral feedings.
integrity Answer: 4. To avoid the introduction of nutri-
Client needs subcategory: Pharmaco- tional products into the abdominal cavity
logical therapies through a perforation of the GI tract, the
Cognitive level: Knowledge client with peritonitis is typically fed using the
parenteral route either with total parenteral
6. A diabetic client suddenly develops hypo- nutrition or peripheral parenteral nutrition.
glycemia. What should the nurse do first? Feedings through an enteral tube or the oral
1. Give the client a glass of orange juice to route are avoided.
drink. Client needs category: Physiological
2. Administer 5 more units of regular integrity
insulin. Client needs subcategory: Physio-
3. Check the client’s blood glucose level. logical adaptation
4. Call the client’s physician. Cognitive level: Application
Answer: 1. Drinking a glass of orange juice
should raise the client’s blood glucose level, 8. The nurse is providing discharge teaching
thus correcting hypoglycemia. Receiving ad- to a client with pancreatitis. The nurse and
ditional insulin lowers the client’s blood glu- client are discussing hyperglycemia. Which of
cose level even further, causing hypoglycemia the following symptoms is the nurse most
to worsen. The nurse shouldn’t take the time likely to bring up in her discussion?
to check the client’s blood glucose level or 1. Thirst
call the physician first because the client 2. Oliguria
needs immediate attention to prevent uncon- 3. Weight gain
sciousness. Blood glucose level should be 4. Loss of appetite
checked after the client consumes the orange Answer: 1. One of the classic manifestations of
juice. hyperglycemia is polydipsia (extreme thirst).
With hyperglycemia, the expectation is
polyuria rather than oliguria. Typically,
weight loss is a manifestation of hypergly-
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Pump up on more practice questions 355
cemia because the cells aren’t being nour- 11. A client with Cushing’s syndrome is ad-
ished because of a lack of insulin. With mitted to the medical-surgical unit. During
hyperglycemia, the client typically experi- the admission process, the nurse notes that
ences hunger rather than a loss of appetite. the client is agitated and irritable, has poor
Client needs category: Physiological memory, reports loss of appetite, and appears
integrity disheveled. These findings are consistent
Client needs subcategory: Reduction of with which problem?
risk potential 1. Depression
Cognitive level: Knowledge 2. Neuropathy
3. Hypoglycemia
9. After an arteriogram procedure, a client 4. Hyperthyroidism
reports itching skin. The nurse notes red Answer: 1. Agitation, irritability, poor memory,
blotches on the client’s trunk. How should loss of appetite, and neglect of the client’s ap-
the nurse respond initially? pearance may signal depression, which is
1. Notify the physician. common in clients with Cushing’s syndrome.
2. Administer an antihistamine. Neuropathy affects clients with diabetes mel-
3. Check vital signs. litus, not Cushing’s syndrome. Although hy-
4. Plan to monitor findings closely. poglycemia can cause irritability, it also pro-
Answer: 3. An arteriogram involves adminis- duces increased appetite, rather than loss of
tration of a radiopaque dye. Some clients are appetite. Hyperthyroidism typically causes
hypersensitive to the dye and exhibit related such signs as goiter, nervousness, heat intol-
manifestations or pruritus and urticaria. More erance, and weight loss despite increased ap-
severe manifestations can also occur, includ- petite.
ing hypotension and dyspnea. Therefore, it’s Client needs category: Psychosocial
important to monitor vital signs initially. The integrity
other responses have lesser priority. Client needs subcategory: None
Client needs category: Physiological Cognitive level: Comprehension
integrity
Client needs subcategory: Physio- 12. A 26-year-old client with chronic renal
logical adaptation failure expects to receive a kidney transplant.
Cognitive level: Application Recently, the physician told the client that
he’s a poor candidate for a transplant because
10. A client develops recurrent urolithiasis. of chronic uncontrolled hypertension and dia-
What mineral will most likely be restricted in betes mellitus. Now, the client tells the nurse,
the client’s diet? “I want to go off dialysis. I’d rather not live
1. Phosphorus than be on this treatment for the rest of my
2. Calcium life.” How should the nurse respond?
3. Magnesium 1. “We all have days when we don’t feel
4. Sodium like going on.”
Answer: 2. In most cases, renal stones are 2. “You’re feeling upset about the news
heavily composed of calcium; therefore, you got about the transplant.”
calcium-restricted diets will be prescribed in 3. “The treatments are only three times a
recurrent urolithiasis. The other minerals list- week. You can live with that.”
ed aren’t typically restricted in the diet of the 4. “Whatever decision you make, we will
client with urolithiasis. support you.”
Client needs category: Physiological Answer: 2. In reflecting the client’s implied
integrity feelings, the nurse is promoting communica-
Client needs subcategory: Reduction of tion. Using responses such as “We all have
risk potential days when we don’t feel like going on” fails to
Cognitive level: Application address the individual client’s needs. Remind-
ing the client of the treatment frequency isn’t
920111.qxd 8/7/08 3:54 PM Page 356
addressing the client’s needs. Offering sup- provides information about liver damage, and
port is therapeutic but doesn’t address the BUN measurement provides information
client’s expressed need to discuss the deci- about kidney function.
sion to go off dialysis. Client needs category: Health promo-
Client needs category: Psychosocial tion and maintenance
integrity Client needs subcategory: None
Client needs subcategory: None Cognitive level: Knowledge
15. The nurse is instructing a client regard-
13. A client experiences urinary retention ing skin tests for hypersensitivity reactions.
from benign prostatic hyperplasia and under- The nurse should teach the client to:
goes a transurethral resection of the prostate. 1. keep skin test areas moist with a mild
Following the procedure, the client receives lotion.
continuous bladder irrigation. The nurse no- 2. stay out of direct sunlight until tests are
tices that the drainage from the catheter has read.
stopped. How should the nurse respond? 3. wash the sites daily with a mild soap.
1. Replace the existing catheter. 4. have the sites read on the scheduled
2. Increase the infusion rate. date.
3. Irrigate the catheter. Answer: 4. An important facet of evaluating
4. Notify the urologist. skin tests is to read the skin test results at the
Answer: 3. Most likely, the apparatus is proper time. Evaluating the skin test too late
blocked by a blood clot, which the nurse may or too early will give inaccurate and unreliable
remove by either gentle aspiration of the clot results. The sites should be kept dry. There’s
from the catheter or irrigation through the no requirement to wash the sites with soap,
out-port. It’s probably unnecessary to replace and direct sunlight isn’t prohibited.
the apparatus. Increasing the flow may cause Client needs category: Health promo-
bladder distention and pain. Calling the physi- tion and maintenance
cian isn’t an appropriate initial nursing re- Client needs subcategory: None
sponse because the nurse has the autonomy Cognitive level: Application
to solve this problem without calling the
physician first. 16. A client is admitted to the hospital with
Client needs category: Physiological an acute exacerbation of asthma. Auscultation
integrity of the lungs reveals almost absent breath
Client needs subcategory: Physio- sounds. Thirty minutes after administering al-
logical adaptation buterol by nebulizer, the nurse auscultates dif-
Cognitive level: Application fuse inspiratory and expiratory wheezes
throughout all lung fields. This finding most
14. A nurse is assisting with a screening clin- likely represents:
ic. A client visits the clinic to be screened for 1. increased airflow.
prostate cancer. Which laboratory measure is 2. no change in airflow
used to screen for prostate cancer? 3. decreased airflow.
1. Creatinine kinase (CK) 4. no correlation with airflow.
2. Aspartate aminotransferase (AST) Answer: 1. Changes in breath sounds provide
3. Blood urea nitrogen (BUN) a general indication of response to treatment.
4. Prostate-specific antigen (PSA) Nearly absent breath sounds or no breath
Answer: 4. PSA measurement is widely used sounds indicate severe airflow obstruction. A
as a screening test for prostate cancer. CK noisy chest is a sign that air is flowing
measurement is most commonly associated through the air passages even though they’re
with myocardial damage, AST measurement partially obstructed.
920111.qxd 8/7/08 3:54 PM Page 357
Client needs category: Physiological 3. Temperature 99.0° F (37.2° C),

integrity pulse 110 beats/minute, respirations
Client needs subcategory: Physio- 20 breaths/minute, blood pressure
logical adaptation 136/88 mm Hg
Cognitive level: Application 4. Temperature 98.8° F (37.1°C), pulse
72 beats/minute, respirations 12 breaths/
minute, blood pressure 118/72 mm Hg
Answer: 3. Levothyroxine can cause tachycar-
dia, indicated here by a pulse rate of 110
beats/minute. Tachycardia is an indication of
thyroid toxicity. None of the other choices in-
dicate that the nurse should withhold the
dose and consult the physician.
integrity
17. A client is scheduled to undergo a 24- logical therapies
hour urine test beginning at 8 a.m. on the first Cognitive level: Application
day and ending at the same time on the sec-
ond day. The nurse should instruct the client 19. A client with diabetes mellitus and a
to: hearing impairment is admitted to the med-
1. discard the second-day 8 a.m. sample. ical-surgical unit. For this client, the nursing
2. discard the first and last samples. team is developing a care plan that includes
3. discard the first-day 8 a.m. sample. daily self-administration of insulin. Which in-
4. retain all samples collected. tervention should the team include in the
Answer: 3. In a 24-hour urine test, the first plan?
sample is discarded and the last sample is 1. Use facial expressions as needed.
retained. 2. Chew gum while giving instructions.
Client needs category: Health promo- 3. Shine a light on the client’s face.
tion and maintenance 4. Raise an arm or hand to get the client’s
Client needs subcategory: None attention.
Cognitive level: Application Answer: 4. The nurse should avoid relying on
facial expressions to get the client’s attention
18. The nurse is planning to administer because these expressions may be misinter-
levothyroxine (Synthroid) to an adult client. preted. A client who depends on visual cues
Which vital sign measurements indicate that might think they’re signs of annoyance or oth-
the nurse should consider withholding the er feelings. The nurse shouldn’t chew gum
dose and consulting the physician? when teaching a client with limited hearing
1. Temperature 97.8° F (36.6° C), pulse because chewing can distort the sounds that
88 beats/minute, respirations 22 breaths/ the client can hear. If needed, a light may be
minute, blood pressure 110/70 mm Hg shone on the nurse’s face—not the client’s
2. Temperature 98.4° F (36.9° C), face—to help the client lip-read.
pulse 54 beats/minute, respirations Client needs category: Safe, effective
16 breaths/minute, blood pressure care environment
100/56 mm Hg Client needs subcategory: Safety and
infection control
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of infection; therefore, it’s most important to

discover the cause of the fever as soon as pos-
sible. Antipyretics should be withheld until
cultures have been obtained. Isolation isn’t in-
dicated unless the absolute neutrophil count
is less than 1,000. Cooling measures may be
indicated after cultures have been obtained.
20. A client scheduled for a gastroscopy has integrity
had nothing by mouth since midnight. The Client needs subcategory: Reduction of
procedure is scheduled for 8 a.m. At 6:30 risk potential
a.m., the nurse collects a capillary blood glu- Cognitive level: Application
cose sample that registers 40 mg/dl on the
glucose monitor. The client is alert, has clear 22. Which clinical finding distinguishes
speech, and states, “I don’t feel like my sugar rheumatoid arthritis from osteoarthritis and
is too low.” Initially, the nurse should: gouty arthritis?
1. document the finding and withhold the 1. Crepitus with range of motion
client’s morning insulin. 2. Symmetry of joint involvement
2. repeat the capillary blood glucose test. 3. Elevated serum uric acid levels
3. give the client an oral simple sugar. 4. Dominance in weight-bearing joints
4. immediately inform a registered nurse Answer: 2. Rheumatoid arthritis is bilateral
(RN) so she can administer dextrose 50 g and symmetrical; in contrast, osteoarthritis
I.V. and gouty arthritis are unilateral. Crepitus is
Answer: 2. An error may have occurred in ob- most associated with osteoarthritis. Elevated
taining the result because the client is asymp- serum uric acid levels are seen in gouty
tomatic for hypoglycemia but the capillary arthritis; weight-bearing joint dominance oc-
blood glucose reading is significantly subnor- curs in osteoarthritis.
mal. The nurse should repeat the test to de- Client needs category: Physiological
termine whether she should notify the RN to integrity
administer I.V. glucose because the client Client needs subcategory: Physio-
should not receive anything by mouth. Re- logical adaptation
sponding to the reading has precedence over Cognitive level: Comprehension
documenting findings because the blood glu-
cose reading is so low. 23. A client has a newly created colostomy.
Client needs category: Physiological After participating in counseling with the
integrity nurse and receiving support from his spouse,
Client needs subcategory: Physio- the client decides to change the colostomy
logical adaptation pouch unaided. Which behavior suggests that
Cognitive level: Application the client is beginning to accept the change in
body image?
21. A client who receives immunosuppres- 1. The client closes his eyes when the ab-
sive drugs for systemic lupus erythematosus domen is exposed.
develops a fever. The nurse should: 2. The client avoids talking about his re-
1. administer an antipyretic. cent surgery.
2. place the client in isolation. 3. The client asks his spouse to leave the
3. apply cooling measures immediately. room.
4. obtain cultures to try to identify the 4. The client touches his altered body
cause. part.
Answer: 4. Immunosuppressive drugs impair Answer: 4. By touching his body, the client
the client’s immunocompetence and predis- recognizes the bodily change and establishes
pose him to infection. Fever is a manifestation that the change is real. Closing his eyes, not
920111.qxd 8/7/08 3:54 PM Page 359
looking at his abdomen when the colostomy that isn’t Rh-compatible is less severe and oc-
is exposed, or avoiding any discussion of his curs several days to 2 weeks after a transfu-
surgery reflects denial, instead of acceptance sion. Bacterial contamination of donor blood
of the change. Asking his spouse to leave the causes a high fever, nausea, vomiting, diar-
room signifies that the client is ashamed of rhea, abdominal cramps and, possibly, shock.
the change and isn’t coping with it. Client needs category: Physiological
Client needs category: Psychosocial integrity
integrity Client needs subcategory: Pharmaco-
Client needs subcategory: None logical therapies
24. Which of the following is a warning sign 26. Which of the following is a characteristic
of colon cancer? sign of systemic lupus erythematosus (SLE)?
1. Hoarseness 1. A butterfly rash
2. Indigestion 2. Watery eyes
3. Rectal bleeding 3. Diplopia
4. A sore that doesn’t heal 4. Ptosis
Answer: 3. Rectal bleeding of dark to bright Answer: 1. A butterfly rash (lesions over the
red blood is a warning sign of colon cancer. cheeks and bridge of the nose in a butterfly
Hoarseness, indigestion, and a sore that does- pattern) is a characteristic sign of SLE. It may
n’t heal are potential warning signs of other be accompanied by photosensitivity, oral or
disorders. nasopharyngeal ulcerations, arthritis, and
Client needs category: Health promo- proteinuria. Watery eyes are associated with
tion and maintenance hay fever and diplopia, and ptosis may signal
Client needs subcategory: None myasthenia gravis.
Cognitive level: Knowledge Client needs category: Physiological
integrity
25. A few minutes after a blood transfusion Client needs subcategory: Physio-
was started, the nurse notes that the client logical adaptation
has chills, dyspnea, and urticaria. The nurse Cognitive level: Knowledge
stops the transfusion and reports this to the
physician because the client is probably expe- 27. A client with a herniated nucleus pulpo-
riencing which problem? sus of the lumbar spine is scheduled for a
1. A hemolytic reaction to mismatched laminotomy. The nurse is providing preopera-
blood tive teaching. How should the nurse instruct
2. A hemolytic reaction to blood that isn’t the client to get out of bed after the proce-
Rh-compatible dure?
3. A hemolytic reaction caused by expo- 1. Pulling himself up using an over-the-
sure to an antigen bed trapeze
4. A hemolytic reaction caused by bacteri- 2. Logrolling to a side-lying position
al contamination of donor blood 3. Twisting to a sitting position
Answer: 3. Hemolytic allergic reactions are 4. Avoiding use of the abdominal muscles
fairly common and may cause chills, fever, Answer: 2. Following back surgery such as a
urticaria, tachycardia, dyspnea, chest pain, laminotomy, it’s best for the client to initially
hypotension, and other signs of anaphylaxis get out of bed by logrolling to his side. Using
after blood transfusion begins. Although rare, an over-the-bed trapeze or twisting may put
a hemolytic reaction to mismatched blood can strain on the surgical site. When reposition-
occur, triggering a more severe reaction and ing, the client should actually tighten his ab-
possibly leading to disseminated intravascular dominal muscles.
coagulation. A hemolytic reaction to blood
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Client needs category: Physiological Answer: 1. A common sign of Parkinson’s dis-

integrity ease is tremors. Successful therapy with
Client needs subcategory: Reduction of carbidopa-levodopa should result in diminu-
risk potential tion of tremors. More frequent swallowing
Cognitive level: Application and lacrimation aren’t manifestations of
Parkinson’s disease. Seizures aren’t associat-
28. To prevent dislocation in a client on the ed with Parkinson’s disease.
first postoperative day after a right total hip Client needs category: Physiological
replacement, the nurse should avoid position- integrity
ing him: Client needs subcategory: Pharmaco-
1. with the right leg externally rotated. logical therapies
2. in the left lateral decubitus position. Cognitive level: Application
3. with the legs adducted.
4. in semi-Fowler’s position. 30. The nurse is providing care for a client
Answer: 3. To prevent dislocation following a experiencing a myasthenic crisis. Which body
total hip replacement, leg adduction should system should the nurse monitor most care-
be avoided. Instead, the legs should be ab- fully?
ducted. External rotation of the affected leg is 1. Respiratory
appropriate as well as sitting at a 45-degree 2. Immune
angle. 3. Cardiovascular
Client needs category: Physiological 4. Hepatic and renal
integrity Answer: 1. The client’s ability to ventilate and
Client needs subcategory: Reduction of oxygenate are at great risk during a myas-
risk potential thenic crisis. Mechanical ventilation is often
Cognitive level: Application required. The immune, cardiovascular, hepat-
ic, and renal systems may be involved, but
29. A client with Parkinson’s disease is re- they aren’t the primary body systems in
ceiving carbidopa-levodopa (Sinemet). The jeopardy.
best indication of the effectiveness of the Client needs category: Physiological
drug is a decrease in the frequency of the integrity
client’s: Client needs subcategory: Physio-
1. tremors. logical adaptation
2. swallowing. Cognitive level: Comprehension
3. seizures.
4. lacrimation.
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Part III Psychiatric care

12 Essentials of psychiatric nursing 363
13 Somatoform & sleep disorders 373
14 Anxiety & mood disorders 387
15 Cognitive disorders 399
16 Personality disorders 409
17 Schizophrenic & delusional disorders 417
18 Substance-related disorders 429
19 Dissociative disorders 437
20 Sexual disorders 445
21 Eating disorders 453

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12 Essentials of
psychiatric nursing
Connect the dots
In this chapter,
you’ll review:
Brush up on key Succinct rephrasing of key patient state-
ments helps ensure understanding and em-
✐ the nurse’s role in
psychiatric care
concepts phasizes important points in the patient’s
message. For example, say, “You’re feeling
✐ psychiatric assess- Effective patient care requires consideration angry, and you say it’s because of the way
ment of the psychological and physiologic aspects your friend treated you yesterday.”
✐ tests commonly used of health. A patient who seeks medical help
to diagnose psychi- for chest pain, for example should also be as- Keep the door open
atric disorders. sessed for anxiety or depression. As a nurse, Using broad openings and general state-
you’ll need a fundamental understanding of ments to initiate conversation encourages the
communication techniques as well as an un- patient to talk about any subject that comes to
derstanding of psychiatric disorders. mind. These openings allow the patient to fo-
cus the conversation and demonstrate a will-
The key to any relationship ingness to interact. An example of this tech-
Therapeutic communication is the founda- nique is: “Is there something you would like
tion for developing a nurse-patient relation- to talk about?”
ship, which makes it a vital topic for the
NCLEX. It’s the primary intervention in psy- Polish the rough edges
chiatric nursing. Therapeutic communication Asking the patient to clarify a confusing or
requires awareness of the patient’s verbal and vague message demonstrates the nurse’s de-
nonverbal messages. sire to understand what the patient is saying.
To uncover and investigate the patient’s in- It can also elicit precise information crucial to
ner thoughts, personal problems, and emo- the patient’s recovery. An example of clarify-
tions, establish trust and help the patient feel ing is: “I’m not sure I understood what you
safe and respected. A therapeutic relationship said.”
helps the patient feel understood as well as
Are you comfortable about discussing his problems. It A sharper focus
listening? can help him develop better ways to meet his Using the technique called focusing assists
emotional needs and develop satisfying rela- the patient in redirecting attention toward
tionships. something specific. This fosters the patient’s
self-control and helps avoid vague generaliza-
Tuned in? tions, which enables the patient to accept re-
Listening intently to the patient enables you sponsibility for facing problems. “Let’s go
to hear and analyze what the patient is saying back to what we were just talking about,” is
and to learn about the patient’s communica- one example of this technique.
tion patterns.
It’s golden
Refraining from comment can have several
benefits: Silence gives the patient time to
talk, think, and gain insight into problems. It
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364 Essentials of psychiatric nursing
also gives you the opportunity to gather more • medication history

It’s a lot to
juggle, but consider information. Use this technique judiciously, to • past psychiatric and physical illness
all aspects of avoid giving the impression of disinterest or • personal or developmental history
patient functioning: judgment. • family history
biological, • social history, including whether the client
psychological, Valuable assistance has a viable support system or whether the
and social. When used correctly, the technique of sug- client is homeless
gesting collaboration gives the patient the • cultural considerations that may affect the
opportunity to explore the pros and cons of a patient’s outcome—for example, some cul-
suggested approach. Take care to avoid di- tures feel seeking mental health care is a sign
recting the patient. An example of this tech- of weakness, and others prefer natural reme-
nique is: “Perhaps we can meet with your par- dies instead of prescription medications.
ents to discuss the matter.”
Gathering data #2: Getting physical
A two-way street The physical examination is used to gather
Using the technique called sharing impres- objective data that will help confirm or rule
sions, describe the patient’s feelings and out observations made during the health his-
then seek corrective feedback from the pa- tory interview.
tient. This allows the patient to clarify any In addition to the information collected dur-
misperceptions and gives a better understanding the routine physical examination, collect
ing of the patient’s true feelings. For example, data about the psychological aspects of the pa-
say, “Tell me whether my perception of what tient’s condition. Be sure to note these as-
you’re telling me agrees with yours.” pects of the patient:
• General appearance—The patient’s appear-
ance indicates his general emotional and men-
tal status. Note specifically his dress and
Brush up on data grooming.
• Behavior—Note the patient’s demeanor and
collection overall attitude as well as any extraordinary
behavior.
As a nurse, you’re likely to be the health care • Mood—Ask the patient to describe his cur-
provider who develops a long-term relation- rent feelings in concrete terms and to suggest
ship with the patient. Therefore, you’re likely possible reasons for these feelings. Be sure to
most capable of determining the emotional note inconsistencies between body language
and mental health care needs of a patient and and mood.
identifying the appropriate interventions. • Thought processes and cognitive fun-
During the data collection stage, determine ction—The patient’s orientation to time, place,
a patient’s psychological and physiologic sta- or person can indicate confusion or
tus by assessing: disorientation. The presence of delusions,
• the patient’s history hallucinations, obsessions, compulsions,
• the patient’s physical status fantasies, and daydreams should be noted.
• laboratory and diagnostic tests. • Coping mechanisms—A patient faced with a
stressful situation may adopt excessive coping
Gathering data #1: Getting or defense mechanisms, which operate on an
history unconscious level to protect the ego. Exam-
A complete patient histor y provides infor- ples include denial, regression, displacement,
mation about: projection, reaction formation, and fantasy.
• the patient’s chief complaint or concern Some patients may turn to drugs and alcohol.
• the history of the current illness
920112.qxd 8/7/08 3:03 PM Page 365
• Potential for self-destructive behavior—A Nursing actions

patient who has lost touch with reality may • Withhold food and fluids before the proce-
cut or mutilate his body to focus on physical dure as directed.
pain, which may be less overwhelming than • Check the site for bleeding after the pro-
his emotional distress. cedure.
Blood study #2
A hematologic study analyzes a blood sam-
Keep abreast of ple for red blood cells, white blood cells, ery-
throcyte sedimentation rate, platelets, hemo-
diagnostic tests globin, and hematocrit.
Diagnosing psychiatric disorders differs from Nursing actions

diagnosing other medical disorders. (See The • Note the patient’s current drug therapy be-
authority.) Many medical tests involve instru- fore the procedure.
mentation and physical analyses, but psycho- • Check the venipuncture site for bleeding
logical testing focuses on questioning and ob- after the hematologic study.
serving the patient.
Performing diagnostic tests on a patient Blood study #3
with a suspected psychiatric disorder may A coagulation study analyzes a blood sample
help diagnose it accurately, can reveal under- for prothrombin time, international normal-
lying physiologic disorders, helps establish ized ratio, and partial thromboplastin time.
the patient’s normal renal and hepatic func-
tion, and monitors for therapeutic medication Nursing actions
levels. • Note the patient’s current drug therapy be-
fore taking the blood sample.
Blood study #1 • Check the venipuncture site for bleeding
A blood chemistr y test assesses a blood after the procedure.
sample for potassium, sodium, calcium, phos-
phorus, glucose, bicarbonate, blood urea AIDS-related blood study #1
nitrogen, creatinine, protein, albumin, osmo- An enzyme-linked immunosorbent assay
lality, amylase, lipase, alkaline phosphatase, involves analyzing a blood sample to detect The DSM is
ammonia, bilirubin, lactate dehydrogenase, the human immunodeficiency virus (HIV)-1 updated regularly.
Make sure your
aspartate aminotransferase, and alanine antibody. Patients with acquired immunodefi-
information is
aminotransferase. ciency syndrome may experience psychiatric up-to-date!
complications.
The authority
Published by the American Psychiatric Associa- ditions and describes diagnostic criteria that
tion, the Diagnostic and Statistical Manual of must be met to support each diagnosis.
Mental Disorders (DSM) is a standard interdisci- The current manual is a text revision of the
plinary psychiatric diagnostic system designed fourth edition, commonly known as DSM-IV-TR.
to be used by all members of the mental health The DSM is updated regularly to include new
care team. The manual includes a complete de- concepts and revised information about psycho-
scription of psychiatric disorders and other con- logical disorders.
920112.qxd 8/7/08 3:03 PM Page 366

• Verify that informed consent has been ob- • Determine whether the patient can lie still
tained and documented. long enough for the test.
• Provide the patient with appropriate pretest • Reassure the patient that electrical shock
counseling. won’t occur.
• After the procedure, check the venipunc- • Explain that the patient will be subjected to
ture site for bleeding. stimuli, such as lights and sounds.
• Withhold food for 8 hours before the pro-
AIDS-related blood study #2 cedure.
A Western blot test analyzes a blood sample • Withhold medications and caffeine for 24 to
to detect the presence of specific viral pro- 48 hours before the procedure as ordered.
teins, which confirm the presence of an HIV
infection. Dye job
A computed tomography scan, used to
Nursing actions identify brain abnormalities, produces a finely
• Verify that informed consent has been ob- detailed image of the brain and its structures.
tained and documented. It may be performed with or without the injec-
• After the procedure, check the venipunc- tion of a contrast dye.
ture site for bleeding.
Nursing actions
Drug detection • Note any patient allergies to iodine, sea-
Toxicology screening analyzes a urine speci- food, and radiopaque dyes.
men to detect the presence of drugs. • Allay the patient’s anxiety.
• Inform the patient about possible throat irri-
Nursing actions tation and flushing of the face, if a contrast
• Make sure that written, informed consent dye is injected.
has been obtained.
• Watch the patient urinate to make sure that Mental picture
the specimen hasn’t been tampered with, and Magnetic resonance imaging involves the
process the specimen according to facility use of electromagnetic energy to create a de-
protocol. tailed visualization of the brain and its struc-
tures.
Brain meter-reading
An electroencephalogram records the elec- Nursing actions
Don’t trical activity of the brain. Using electrodes, • Obtain a written informed consent accord-
worry. It’s this noninvasive test creates a graphic repre- ing to facility policy.
not that sentation of brain activity. • Be aware that patients with pacemakers,
kind of test. surgical and orthopedic clips, or shrapnel
can’t be scanned.
• Remove jewelry and metal objects from the
patient before testing.
• Determine whether the patient can lie still
long enough for the test.
• Administer sedation as prescribed.
Brain metabolism test

Positron emission tomography involves in-
jection of a radioisotope, which allows visual-
ization of the brain’s oxygen uptake, blood
flow, and glucose metabolism.
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Nursing actions Measuring depression

• Determine whether the patient can lie still The Beck Depression Inventor y helps to
during the test. diagnose depression, determine its severity,
• Withhold alcohol, tobacco, and caffeine for and monitor the patient’s response to treat-
24 hours before the procedure. ment.
• Withhold medications, as directed, before
the procedure. What’s on the menu?
• Check the injection site for bleeding after The Eating Attitudes Test is used to detect
the procedure. patterns that suggest an eating disorder.
Who are you?

The Minnesota Multiphasic Personality
Keep abreast of Inventor y helps to identify personality traits
and ego function in adolescents and adults.
psychological tests Test results include information on coping
strategies, defenses, strengths, gender identi-
Psychological tests are used to evaluate the fication, and self-esteem. The pattern of the
patient’s mood, personality, and mental status. tests results may strongly suggest a diagnos-
Those for alcoholism and cocaine addiction tic category, point to a suicide risk, or indicate
are typically performed by an addiction spe- the patient’s potential for violence.
cialist. Here’s a review of the most common
psychological tests. Alcoholism test #1
The Michigan Alcoholism Screening Test
Pop quiz is a 24-item timed test. A score of 5 or higher
The Mini–Mental Status Examination mea- classifies the patient as an alcoholic.
sures the patient’s orientation, registration,
recall, calculation, language, and motor skills. Alcoholism test #2
The CAGE Questionnaire is a four-question
Cognitive capacity tool in which two or three positive responses
The Cognitive Capacity Screening Exami- indicate alcoholism.
nation measures the patient’s orientation,
memory, calculation, and language. Cocaine addiction tests
The Cocaine Addiction Severity Test and
General knowledge the Cocaine Assessment Profile are used
The Cognitive Assessment Scale measures when cocaine use is suspected.
the patient’s orientation, general knowledge,
mental ability, and psychomotor function.
Measuring what’s lost

The Global Deterioration Scale is used to
assess and determine the stage of the pa-
tient’s primary degenerative dementia, based
care
on orientation, memory, and neurologic A variety of treatment options coexist in psy-
function. chiatric and mental health care. Use one spe-
cific treatment approach or a combination of
Getting by approaches to guide patient care.
The Functional Dementia Scale measures
the patient’s orientation, affect, and ability to
perform activities of daily living.
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One on one Changing ideas

Individual therapy is the establishment of a Cognitive therapy employs strategies to
structured relationship with a patient in an at- modify the beliefs and attitudes that influence
tempt to achieve change in the patient. Work a patient’s feelings and behaviors.
with the patient to develop an approach to re- Some basic cognitive interventions include:
solve conflict, decrease emotional pain, and • teaching thought substitution
develop appropriate ways of meeting the pa- • identifying problem-solving strategies
tient’s needs. This relationship with the pa- • finding ways to modify negative self-talk
tient consists of three overlapping phases: • role playing
• In the orientation phase, build a connection • modeling strategies for coping.
with the patient by establishing rapport and a
sense of trust (formulate goals during this The real world
phase). Reality therapy involves focusing on helping
• In the working phase, the patient becomes the patient meet two basic emotional needs:
increasingly involved in self-exploration • loving and being loved
(assist the patient as he tries to develop self- • feeling worthwhile and feeling that others
understanding, and encourage him to take are worthwhile.
risks in terms of changing dysfunctional be- Emphasize the patient’s personal responsi-
havior). bility for his behavior, controlling his own life,
• In the termination phase, work with the pa- and fulfilling his own basic needs.
tient to determine that closure of the relation-
ship is appropriate (you and the patient agree All in the family
that the problem that initiated the relationship During family therapy, the entire family is
has been alleviated or has become manage- considered the treatment unit. The primary
able). goal of therapy is to improve the functioning
of the family. The types of patients that can
Milling around benefit most from family therapy are those in-
During milieu therapy, use all aspects of the volved in marital issues, intergenerational
hospital environment in a therapeutic manner. conflicts, sibling concerns, and family crises,
Patients are exposed to rules, expectations, such as death and divorce.
peer pressure, and social interactions. En-
courage the patient to communicate, and pro- The gang’s all here
vide opportunities for enhancing self-esteem Group therapy includes an advanced prac-
and learning new skills and behaviors. The tice nurse–therapist and six to eight people
goal of therapy is to enable the patient to live who meet regularly for the purpose of in-
outside the institutional setting. creasing self-awareness, improving interper-
sonal relationships, and changing maladaptive
Treating disease and imbalance behavioral problems. Like individual therapy,
Biological therapies are called for when group therapy goes through the orientation
emotional and behavioral disturbances are phase, working phase, and termination phase.
thought to be caused by chemical imbalances
or by disease-causing organisms. Urgent care
Some examples of biological therapies are: Crisis inter vention is a systemic type of
• psychoactive drugs short-term therapy for a patient, family, or
• electroconvulsive therapy. group that’s experiencing a stressful situation.
Initiate actions to decrease the patient’s sense
of personal danger and facilitate the patient’s
ability to control the situation.
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Answer: 4. Inquiring about the client’s way of

life allows the nurse to further explore the
message he’s trying to convey. Option 1 has
too narrow a focus and doesn’t permit a full
exploration of the client’s experience. Option
2 is incorrect because the client could misin-
terpret it as a challenge and become even
more defensive. Option 3 is incorrect because
the nurse shouldn’t identify the client’s feel-
ings for him.
Trance time Client needs category: Psychosocial
Hypnosis is a method of inducing deep relax- integrity
ation by altering the patient’s state of con- Client needs subcategory: None
sciousness. The result of hypnotic induction Cognitive level: Application
is a trancelike state during which patients use
memories, mental associations, and concen- 2. The nurse is working with a client who has
tration to discover experiences that are con- just stimulated her anger by using a conde-
nected to their current distress. Hypnosis is scending tone of voice. Which of the following
effective for dealing with anxiety disorders, responses by the nurse would be the most
some types of pain, repressed traumatic therapeutic?
events, and addictive disorders. 1. “I feel angry when I hear that tone of
voice.”
2. “You make me so angry when you talk
to me that way.”
3. “Are you trying to make me angry?”
4. “Why do you use that condescending
tone of voice with me?”
Answer: 1. This response allows the nurse to
provide feedback without making the client
responsible for the nurse’s reaction. Option 2
is accusatory and blocks communication. Op-
tion 3 is a challenging remark that can lead
to power struggles, lowers the client’s self-
esteem, and blocks opportunities for open
communication. Avoid “why” questions such
Pump up on practice as the one in option 4 because these ques-
tions put the client on the defensive.
questions Client needs category: Psychosocial
integrity
1. A 35-year-old client tells the nurse that he Client needs subcategory: None
never disagrees with anyone and that he has Cognitive level: Application
loved everyone he has ever known. What
would be the nurse’s best response to this 3. A client on the unit tells the nurse that his
client? wife’s nagging really gets on his nerves. He
1. “How do you manage to do that?” asks the nurse whether she’ll talk with his
2. “That’s hard to believe. Most people wife about her nagging during their family
couldn’t do that.” session tomorrow afternoon. Which of the
3. “What do you do with your feelings of following responses would be the most thera-
dissatisfaction or anger?” peutic?
4. “How did you come to adopt such a way
of life?”
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Answer: 4. This response answers the ques-

tion honestly and nonjudgmentally and helps
to preserve the client’s self-esteem. Option 1
is an open and candid response but diminish-
es the client’s self-esteem. Option 2 doesn’t
answer the client’s question and isn’t helpful.
1. “Tell me more specifically about her Option 3 would increase the client’s anxiety
complaints.” because her inability to walk is directly relat-
2. “Can you think why she might nag you ed to an unconscious psychological conflict
so much?” that hasn’t yet been resolved.
3. “I’ll help you think about how to bring Client needs category: Psychosocial
this up yourself tomorrow.” integrity
4. “Why do you want me to initiate this Client needs subcategory: None
discussion in tomorrow’s session rather Cognitive level: Application
than you?”
Answer: 3. The client needs to learn how to
communicate directly with his wife about her
behavior. The nurse’s assistance will enable
him to practice a new skill and will communi-
cate the nurse’s confidence in his ability to
confront this situation directly. Options 1 and
2 inappropriately direct attention away from
the client and toward his wife, who isn’t pres-
ent. Option 4 implies that there might be a le-
gitimate reason for the nurse to assume re-
sponsibility for something that rightfully be-
longs to the client. Instead of focusing on his
problems, he’ll waste time convincing the 5. A 42-year-old client arrives in the emer-
nurse why she should do his work. gency department with uncontrollable crying
Client needs category: Psychosocial and anxiety. Her husband of 17 years has re-
integrity cently asked her for a divorce. The client is
Client needs subcategory: None sitting in a chair, rocking back and forth.
Cognitive level: Application Which is the best response for the nurse to
make?
4. The nurse is caring for a client diagnosed 1. “You must stop crying so that we can
with conversion disorder who has developed discuss your feelings about the divorce.”
paralysis of her legs. Diagnostic tests fail to 2. “Once you find a job, you’ll feel much
uncover a physiologic cause. During the better and more secure.”
working phase of the nurse-client relation- 3. “I can see how upset you are. Let’s sit in
ship, the client says to her nurse, “You think I the office so that we can talk about how
could walk if I wanted to, don’t you?” What you’re feeling.”
would be the nurse’s best response? 4. “Once you have a lawyer looking out
1. “Yes, if you really wanted to, you for your interests, you’ll feel better.”
could.” Answer: 3. This response validates the client’s
2. “Tell me why you’re concerned about distress and provides an opportunity for her
what I think.” to talk about her feelings. Because clients in
3. “Do you think you could walk if you crises have difficulty making decisions, the
wanted to?” nurse must be directive as well as supportive.
4. “I think you are unable to walk now, Option 1 doesn’t provide the client with ade-
whatever the cause.” quate support. Options 2 and 4 don’t acknowl-
edge the client’s distress. Moreover, clients in
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crises can’t think beyond the immediate mo- disoriented. Which of the following actions
ment, so discussing long-range plans isn’t should take priority?
helpful. 1. Stabilize the client’s medical needs.
Client needs category: Psychosocial 2. Stabilize the client’s psychological
integrity needs.
Client needs subcategory: None 3. Attempt to locate the nearest family
Cognitive level: Application members to get an accurate history.
4. Arrange a transfer to the nearest med-
ical facility.
Answer: 1. The possibility of frostbite and the
cause of confusion must be evaluated before
the other interventions. The other choices
don’t address the client’s immediate medical
needs.
integrity
risk potential
6. A 60-year-old client is hospitalized after

complaining of difficulty sleeping, extreme ap-
prehension, shortness of breath, and a sense
of impending doom. Which response by the
nurse would be best?
1. “You have nothing to worry about.
You’re in a safe place. Try to relax.”
2. “Has anything happened recently that
may have triggered these feelings?”
3. “We’ve given you a medication that will
help to decrease these feelings of anxiety.”
4. “Take some deep breaths and try to
calm down.”
Answer: 2. This provides support, reassur- 8. What occurs during the work phase of the
ance, and an opportunity to gain insight into nurse-client relationship?
the cause of the client’s anxiety. Option 1 dis- 1. The nurse identifies the client’s needs
misses the client’s feelings and offers false re- and develops a care plan.
assurance. Options 3 and 4 don’t allow the 2. The nurse and client together evaluate
client to discuss his feelings, which he must and modify the goals of the relationship.
do to understand and resolve the cause of his 3. The nurse and client discuss their feel-
anxiety. ings about terminating the relationship.
Client needs category: Psychosocial 4. The nurse and client explore each oth-
integrity er’s expectations of the relationship.
Client needs subcategory: None Answer: 2. The therapeutic nurse-client rela-
Cognitive level: Application tionship consists of three overlapping phases:
the orientation, the work, and the termina-
7. A 26-year-old male client is admitted to an tion. During the work phase, the nurse and
inpatient psychiatric hospital after having the client together evaluate and refine goals
been picked up by the local police while walk- established during the orientation phase. In
ing around the neighborhood at night without addition, major therapeutic work takes place,
shoes in the snow. He appears confused and and insight is integrated into a plan of action.
920112.qxd 8/7/08 3:03 PM Page 372
The orientation phase involves assessing the 10. A therapeutic nurse-client relationship
client, formulating a contract, exploring feel- begins with the nurse’s:
ings, and establishing expectations about the 1. sincere desire to help others.
relationship. During the termination phase, 2. acceptance of others.
the nurse prepares the client for separation 3. self-awareness and understanding.
and explore his feelings about the end of the 4. sound knowledge of psychiatric nurs-
relationship. ing.
Client needs category: Psychosocial Answer: 3. Although all of the options are de-
integrity sirable, the nurse’s knowledge of self is the
Client needs subcategory: None basis for building a strong, therapeutic nurse-
Cognitive level: Knowledge client relationship. Being aware of and under-
standing her personal feelings and behavior is
9. The optimal number of clients in a group a prerequisite for understanding and helping
for group therapy would be: clients.
1. 6 to 8. Client needs category: Safe, effective
2. 10 to 12. care environment
3. 3 to 5. Client needs subcategory: Coordinated
4. unlimited. care
Answer: 1. Clinicians generally consider 6 to Cognitive level: Knowledge
8 people to be the ideal number of clients for
a therapeutic group. The size allows oppor-
tunities for maximum therapeutic exchange
and participation. In groups of 5 or fewer,
participation commonly is inhibited by self-
consciousness and insecurity. In groups larg-
er than 8, participation and exchange among
certain members may be lost.
Client needs category: Psychosocial
Okay. Now
integrity
let’s get into
Client needs subcategory: None the nitty-gritty
Cognitive level: Application of psych
disorders.
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13 Somatoform & sleep

disorders
tress. Anyone who feels the pain of a sore
In this chapter,
you’ll review:
Brush up on key throat or the ache of flu has a somatic symp-
tom, but it isn’t considered somatization un-
✐ stages of sleep
✐ key concepts related
concepts less the physical symptoms are an expression
of emotional stress.
to sleep and somato- The patient with a sleep disorder commonly
form disorders suffers from excessive daytime sleepiness All bottled up
✐ common sleep and and impaired ability to perform daily tasks Internalization refers to the condition in
somatoform disor- safely or properly. The patient with a somato- which a patient’s anxiety, stress, and frustra-
ders. form disorder commonly suffers physical tion are expressed through physical symp-
symptoms related to an inability to handle toms rather than confronted directly.
stress. These physical symptoms have no
physiologic cause but are overwhelming to
the patient. Sleep disorders
of each disorder by consulting the Cheat sheet The patient with a primary sleep disorder is
on pages 374 and 375. unable to initiate or maintain sleep. Primary
sleep disorders are categorized as dyssom-
nias or parasomnias.
Somatoform disorders
Too much or not enough
The patient with a somatoform disorder com- Dyssomnias involve excessive sleep or diffi-
plains of physical symptoms and typically trav- culty initiating and maintaining sleep. Exam-
els from doctor to doctor in search of sympa- ples of dyssomnias include primary insomnia,
thetic and enthusiastic treatment. Physical ex- circadian rhythm sleep disorder, breathing-
aminations and laboratory tests, however, fail related sleep disorder, primary hypersomnia,
to uncover an organic basis for the patient’s and narcolepsy.
symptoms. Because the patient doesn’t pro-
duce the symptoms intentionally or feel a Strange things in the night
Falling asleep while sense of control over them, he’s usually un- Parasomnias are physiologic or behavioral
studying for the able to accept that his illness has a psycholog- reactions during sleep. Examples of parasom-
NCLEX doesn’t count ical cause. nias include nightmare disorder, sleep terror
as a sleep disorder. disorder, and sleepwalking disorder.
From mind to body
Psychosomatic is a term used to describe You’re getting sleepy…
conditions in which a psychological state con- Sleep can be broken down into five distinct
tributes to the development of a physical stages, rapid-eye-movement (REM) sleep
illness. and four stages of non-rapid-eye-movement
(NREM) sleep (stages 1, 2, 3, and 4):
An expression of emotional stress • Stage 1 NREM sleep is a transition from
Somatization is the manifestation of physical wakefulness to sleep and occupies about 5% of
symptoms that result from psychological dis- time spent asleep in healthy adults.
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374 Somatoform & sleep disorders
et
heat she
C
Somatoform & sleep disorders refresher
CONVERSION DISORDER PAIN DISORDER
Key sign or symptom Key signs and symptoms
• La belle indifférence (a lack of concern about • Acute and chronic pain not associated with a
the symptoms or limitation on functioning) physiologic cause
Key test result • Anger, frustration, and depression
• The absence of expected diagnostic findings • Drug-seeking behavior in an attempt to relieve
can confirm the disorder. pain
• History of frequent visits to multiple doctors to
Key treatment
seek pain relief
• Individual therapy
• Insomnia
Key interventions
Key test result
• Establish a supportive relationship that commu-
• Test results don’t support patient complaints.
nicates acceptance of the patient but keeps the
focus away from symptoms. Key treatments
• Review all laboratory and diagnostic study re- • Individual therapy
sults. • Tricyclic antidepressants: amitriptyline (Elavil),
imipramine (Tofranil), doxepin (Sinequan)
HYPOCHONDRIASIS Key interventions
Key signs and symptoms • Acknowledge the patient’s pain.
• Abnormal focus on bodily functions and sen- • Encourage the patient to recognize situations
sations that precipitate pain.
• Anger, frustration, and depression
• History of frequent visits to doctors and special- DYSSOMNIAS
ists despite assurance from health care providers Key signs and symptoms
that the patient is healthy Primary insomnia
• Intensified physical symptoms around sympa- • History of light or easily disturbed sleep or diffi-
thetic people culty falling asleep
• Rejection of the idea that the symptoms are • Insomnia
stress related Breathing-related sleep disorder
• Use of symptoms to avoid difficult situations • Abnormal breathing events during sleep, in-
Key treatments cluding apnea, abnormally slow or shallow respi-
• Individual therapy rations, and hypoventilation (abnormal blood oxy-
• Tricyclic antidepressants: amitriptyline (Elavil), gen and carbon dioxide levels)
imipramine (Tofranil), doxepin (Sinequan), • Dull headache on awakening
phenelzine (Nardil) • Fatigue
• Snoring
Key interventions
Primary hypersomnia
• Evaluate the patient’s level of knowledge about
• Confusion on awakening
how emotional issues can affect physiologic
• Difficulty awakening
functioning.
• Poor memory
• Encourage emotional expression.
Narcolepsy
• Respond to the patient’s symptoms in a matter-
• Cataplexy (bilateral loss of muscle tone trig-
of-fact way.
gered by strong emotion)
• Generalized daytime sleepiness
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Somatoform & sleep disorders refresher (continued)

DYSSOMNIAS (continued) PARASOMNIAS
• Hypnagogic hallucination (intense dreamlike images) Key signs and symptoms
• Irresistible attacks of refreshing sleep Nightmare disorder
Key test result • Dream recall
• Polysomnography is diagnostic for individual sleep disorder. • Mild autonomic arousal on awakening (sweating, tachycardia,
Key treatment tachypnea)
• Hypnotic: zolpidem (Ambien) Sleep terror disorder
• Autonomic signs of intense anxiety (tachycardia, tachypnea,
Key interventions
flushing, sweating, increased muscle tone, dilated pupils)
For primary insomnia and circadian rhythm disturbance • Inability to recall dream content
• Encourage the patient to discuss concerns that may be pre- • Screaming or crying
venting sleep. Sleepwalking disorder
• Schedule regular sleep and awakening times. • Amnesia of the episode or limited recall
For breathing-related sleep disorder • Sitting up, talking, walking, or engaging in inappropriate behav-
• Administer continuous positive nasal airway pressure. ior during episode
For primary hypersomnia and narcolepsy
Key test result
• Administer medications as prescribed.
• Develop strategies to manage symptoms and integrate them • Polysomnography is diagnostic for individual sleep disorder.
into the patient’s daily routine, such as taking naps during lunch Key interventions
or work breaks. • Lock the windows and doors if sleepwalking occurs.
• Provide emotional support.
• Stage 2 NREM sleep, which is character- sleep and generally includes measurement of
ized by specific EEG waveforms (sleep spin- EEG activity, electro-oculographic activity
dles and K complexes), occupies about 50% of (electrographic tracings made by movement
time spent asleep. of the eye), and electromyographic activity
• Stages 3 and 4 NREM sleep (also known (electrographic tracings made by skeletal
collectively as slow-wave sleep) are the deep- muscles at rest).
est levels of sleep and occupy about 10% to Additional polysomnographic measures
20% of sleep time. may include oral or nasal airflow, respiratory
• REM sleep, during which the majority of effort, chest and abdominal wall movement,
typical storylike dreams occur, occupies oxyhemoglobin saturation, or exhaled carbon
about 20% to 25% of total sleep. dioxide concentration. These measures are
used to monitor respiration during sleep and
Patterns after dark to detect the presence and severity of sleep
Stages of sleep have a characteristic temporal apnea. Measurement of peripheral electro-
organization. NREM stages 3 and 4 tend to myographic activity may be used to detect ab-
occur in the first one-third to one-half of the normal movements during sleep.
night. REM sleep occurs in cycles throughout
the night, alternating with NREM sleep about You can do it during the daytime,
every 80 to 100 minutes. REM sleep periods too!
increase in duration toward the morning. Most polysomnographic studies are per-
formed during the patient’s usual sleeping
Sparks in the night hours—that is, at night. However, daytime
Polysomnography is the monitoring of mul- polysomnographic studies are also used to
tiple electrophysiologic parameters during quantify daytime sleepiness.
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NURSING DIAGNOSES
Polish up on patient • Ineffective coping
• Anxiety
care • Chronic low self-esteem
Major somatoform disorders include conver- TREATMENT

sion disorder, hypochondriasis, and pain dis- • Individual therapy
order. Sleep disorders include dyssomnias
(primary insomnia, circadian rhythm sleep Drug therapy
disorder, breathing-related sleep disorder, pri- • Benzodiazepines: lorazepam (Ativan), alpra-
mary hypersomnia, and narcolepsy) and para- zolam (Xanax)
Absence means somnias (nightmare disorder, sleep terror dis-
presence. The absence order, and sleepwalking disorder). INTERVENTIONS AND RATIONALES
of expected diagnostic • Ensure and maintain a safe environment to
findings can confirm protect the patient.
conversion disorder. Conversion disorder • Establish a supportive relationship that
communicates acceptance of the patient but
The patient with conversion disorder exhibits keeps the focus away from symptoms to help
symptoms that suggest a physical disorder, him learn to recognize and express anxiety.
but evaluation and observation don’t reveal a • Encourage the patient to identify any emo-
physiologic cause. The onset of symptoms is tional conflicts that began before the physical
preceded by psychological trauma or conflict, symptoms to make the relationship between the
and the physical symptoms are a manifesta- conflict and the symptoms more clear.
tion of the conflict. • Promote social interaction to decrease the
patient’s level of self-involvement.
CONTRIBUTING FACTORS • Identify constructive coping mechanisms to
• Psychological conflict encourage the patient to use practical coping
• Overwhelming stress skills and relinquish the role of being sick.

• Aphonia (inability to produce sound) • Setting limits on the patient’s sick role be-
• Blindness havior while continuing to provide support
• Deafness • Using stress-reduction methods
• Dysphagia
• Impaired balance and impaired coordi-
nation Hypochondriasis
• La belle indifférence (a lack of concern
Memory about the symptoms or limitation on function- With hypochondriasis, the patient is preoccu-
jogger ing) pied by fear of a serious illness, despite med-
When • Loss of touch sensation ical assurance of good health. The patient
thinking of • Lump in the throat with hypochondriasis interprets all physical
conversion disorder, • Paralysis sensations as indications of illness, impairing
think of the term • Seizures his ability to function normally.
convert, which • Urinary retention
means “to change
from one form or CONTRIBUTING FACTORS
function to anoth- DIAGNOSTIC FINDINGS • Death of a loved one
er.” Patients with • Test results are inconsistent with physical • Family member with a serious illness
conversion disorder findings. • Previous serious illness
convert stress into • The absence of expected diagnostic find-
physical ailments. ings can confirm the disorder.
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DATA COLLECTION FINDINGS • Initiating conversations that focus on some-

• Abnormal focus on bodily functions and thing other than physical maladies
sensations
• Anger, frustration, and depression
• History of frequent visits to doctors and Pain disorder
specialists despite assurance from health care
providers that the patient is healthy With pain disorder, the patient experiences
• Intensified physical symptoms around sym- pain in which psychological factors play a sig-
pathetic people nificant role in the onset, severity, exacerba-
• Rejection of the idea that the symptoms are tion, or maintenance of the pain. The pain is-
stress related n’t intentionally produced or feigned by the
• Use of symptoms to avoid difficult situa- patient. The pain becomes a major focus of
tions life, and the patient is often unable to function
• Vague physical symptoms socially or at work. The patient may have a
physical ailment but shouldn’t be experienc-
DIAGNOSTIC FINDINGS ing pain at the level he describes.
• The test results are inconsistent with the pa-
tient’s complaints and physical findings. CONTRIBUTING FACTORS
• A traumatic, stressful, or humiliating
NURSING DIAGNOSES experience
• Deficient knowledge (treatment plan)
• Ineffective coping DATA COLLECTION FINDINGS
• Ineffective health maintenance • Acute and chronic pain not associated with
a physiologic cause
TREATMENT • Anger, frustration, and depression
• Individual therapy • Drug-seeking behavior in an attempt to re-
lieve pain
Drug therapy • History of frequent visits to multiple doc-
• Benzodiazepines: lorazepam (Ativan), alpra- tors to seek pain relief
zolam (Xanax) • Insomnia
• Tricyclic antidepressants: amitriptyline
(Elavil), imipramine (Tofranil), doxepin DIAGNOSTIC FINDINGS
(Sinequan), phenelzine (Nardil) • Test results don’t support patient com-
plaints.
INTERVENTIONS AND RATIONALES • With psychotherapy, the patient may recall
• Evaluate the patient’s level of knowledge a past traumatic event.
about how emotional issues can affect physio-
logic functioning to promote understanding of NURSING DIAGNOSES
the condition. • Acute or chronic pain
• Encourage the patient to express his emo- • Ineffective coping
tions to avoid emotional repression, which can • Anxiety
have physical consequences.
• Respond to the patient’s symptoms in a TREATMENT
matter-of-fact way to reduce secondary gain • Individual therapy
the patient achieves from talking about
symptoms. Drug therapy
• Anxiolytics (benzodiazepines): lorazepam
Teaching topics (Ativan), alprazolam (Xanax)
• Using relaxation and assertiveness tech-
niques
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Acknowledging
• Tricyclic antidepressants: amitriptyline Dyssomnias
the patient’s pain (Elavil), imipramine (Tofranil), doxepin
helps to discourage (Sinequan) Dyssomnias are primary disorders of initiat-
him from striving to ing or maintaining sleep or excessive sleepi-
convince you the INTERVENTIONS AND RATIONALES ness. These disorders are characterized by a
pain is real. • Ensure a safe, accepting environment for disturbance in the amount, quality, or timing
the patient to promote therapeutic communi- of sleep.
cation. Primar y insomnia is characterized by dif-
• Acknowledge the patient’s pain to discour- ficulty initiating or maintaining sleep that lasts
age the patient from striving to convince you for at least 1 month. Alternatively, the patient
that the pain is real and to reinforce a thera- may report that sleep isn’t refreshing. A key
peutic relationship. symptom of primary insomnia is the patient’s
• Encourage the patient to recognize situa- intense focus and anxiety about not getting
tions that precipitate pain to foster an under- sleep. Commonly, the patient reports being a
standing of the disorder. “light sleeper.”
With circadian rhythm sleep disorder,
Teaching topics there’s a mismatch between the internal
• Promoting social interaction sleep-wake circadian rhythm and timing and
• Establishing constructive coping mecha- the duration of sleep. The patient may report
nisms insomnia at particular times during the day
• Using problem-solving techniques and excessive sleepiness at other times. Caus-
• Attempting to use nonpharmacologic pain es can be intrinsic, such as delays in the sleep
management, such as guided imagery, mas- phases, or extrinsic, such as in jet lag or shift
sage, therapeutic touch, relaxation, heat, and work.
cold Another class of sleep disorder identified in
the Diagnostic and Statistical Manual of Men-
Nursing care for a tal Disorders, 4th ed., Text Revision, is
pain disorder may breathing-related sleep disorder. Specific
focus on pain disorders in this class include central sleep
management apnea syndrome, central alveolar hypoventila-
techniques, such as tion syndrome, and obstructive sleep apnea
relaxation and syndrome. Obstructive sleep apnea syndrome
meditation. is the most commonly diagnosed breathing-
related sleep disorder.
With breathing-related sleep disorder, a dis-
turbance in breathing leads to a disruption in
sleep that results in excessive sleepiness or
insomnia. Excessive sleepiness is the most
common complaint of patients. Naps usually
aren’t refreshing and may be accompanied by
a dull headache. These patients often mini-
mize the problem by bragging that they can
sleep anywhere and at any time.
With primar y hypersomnia, the patient
experiences excessive sleepiness lasting at
least 1 month. The patient may take daytime
naps or sleep extended periods of time at
night. People with primary hypersomnia typi-
cally sleep 8 to 12 hours per night. They fall
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Drugs that affect sleep

When caring for a patient with a sleep disorder, keep in mind that certain medications can affect
sleep. Review the patient’s medication list to see whether he’s receiving any such medications.
Examples are listed here.
INCREASE TOTAL SLEEP TIME
• Barbiturates
• Benzodiazepines
• Alcohol (during the first half of the night)
• Phenothiazines
DECREASE TOTAL SLEEP TIME
• Amphetamines
• Alcohol (during the second half of the night)
• Caffeine
ALTER DREAMING AND REM SLEEP
• Beta-adrenergic blockers: decreased rapid-eye-movement (REM) sleep, possible nightmares
• Levodopa: vivid dreams and nightmares
• Amphetamines: decreased REM sleep
• Tricyclic antidepressants and monoamine oxidase inhibitors: decreased REM sleep
• Barbiturates: decreased REM sleep
• Benzodiazepines: decreased REM sleep
INCREASE WAKING AFTER SLEEP ONSET
• Steroids
• Opioids
• Beta-adrenergic blockers
DECREASE WAKING AFTER SLEEP ONSET
• Benzodiazepines
• Barbiturates
With narcolepsy,
the patient develops
an overwhelming urge
to sleep at any time
asleep easily and sleep through the night but CONTRIBUTING FACTORS of the day.
often have trouble awakening in the morning. Primary insomnia
Some mornings they awake confused and • Illness (especially pheochro-
combative. These patients have great difficul- mocytoma or hyperthyroidism)
ty with morning obligations. • Many illegal drugs
With narcolepsy, the patient develops an • Older than age 65
overwhelming urge to sleep at any time of the • Stress
day regardless of the amount of previous • Use of certain legal drugs
sleep. The patient may fall asleep two to six (see Drugs that affect sleep)
times a day during inappropriate times, such
as while driving a car or attending a class. Circadian rhythm sleep
The patient’s sleepiness typically decreases disorder
after a sleep attack, only to return several • Delayed sleep phase
hours later. The sleep attacks must occur dai- • Jet lag
ly over a period of 3 months to confirm the di- • Shift work
agnosis.
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Breathing-related sleep disorder Narcolepsy

• Instability in the respiratory control center, • Cataplexy (bilateral loss of muscle tone trig-
which causes periods of apnea gered by strong emotion)
• Obstruction or collapse of the airway, which • Frequent, intense, and vivid dreams that
causes periods of apnea may occur during nocturnal sleep
• Slow or shallow breathing, which causes ar- • Generalized daytime sleepiness
terial oxygen desaturation • Hypnagogic hallucination (intense dream-
like images)
Primary hypersomnia • Irresistible attacks of refreshing sleep
• Autonomic nervous system dysfunction
• Genetic predisposition DIAGNOSTIC FINDINGS
Primary insomnia
Narcolepsy • Polysomnography shows poor sleep conti-
• Genetic predisposition nuity, increased stage 1 sleep, decreased
stages 3 and 4 sleep, increased muscle ten-
DATA COLLECTION FINDINGS sion, or increased amounts of EEG alpha ac-
Primary insomnia tivity during sleep.
• Anxiety related to sleep loss • Psychophysiologic testing may show high
• Fatigue arousal (increased muscle tension or exces-
• Haggard appearance sive physiologic reactivity to stress).
• History of light or easily disturbed sleep or
difficulty falling asleep Circadian rhythm sleep disorder
• Insomnia • Polysomnography shows short sleep laten-
• Poor concentration cy (length of time it takes to fall asleep), re-
• Tension headache duced sleep duration, and sleep continuity
disturbances. (Results may vary depending
For a patient with Circadian rhythm sleep disorder on the time of day testing is performed.)
primary insomnia or • Cardiovascular and GI disturbances, such
circadian rhythm as palpitations, peptic ulcer disease, and Breathing-related sleep disorder
disturbance, plan gastritis • Polysomnography measures of oral and
activities that • Fatigue nasal airflow are abnormal, and oxyhemoglo-
require him to wake • Haggard appearance bin saturation is reduced.
at a regular hour and • Poor concentration
stay out of bed Primary hypersomnia
during the day. Breathing-related sleep disorder • Polysomnography demonstrates a normal
• Abnormal breathing events during sleep, in- to prolonged sleep duration, short sleep laten-
cluding apnea, abnormally slow or shallow cy, normal to increased sleep continuity, and
respirations, and hypoventilation (abnormal normal distributions of REM and NREM
blood oxygen and carbon dioxide levels) sleep. Some individuals may have increased
• Dull headache on awakening amounts of slow-wave sleep.
• Fatigue
• Gastroesophageal reflux Narcolepsy
• Large neck circumference • Polysomnography shows sleep latencies of
• Mild systemic hypertension with elevated less than 10 minutes and frequent REM peri-
diastolic blood pressure ods, frequent transient arousals, decreased
• Snoring sleep efficiency, increased stage 1 sleep, in-
creased REM sleep, and increased eye move-
Primary hypersomnia ments within the REM periods. Periodic limb
• Confusion on awakening movements and episodes of sleep apnea are
• Difficulty awakening also often noted.
• Poor memory
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NURSING DIAGNOSES during the day to reinforce natural circadian

• Insomnia rhythms.
• Fatigue
• Impaired home maintenance Breathing-related sleep disorder
• Administer continuous positive nasal airway
TREATMENT pressure to treat obstructive sleep disorders.
• Hypnosis
• Relaxation techniques Primary hypersomnia and narcolepsy
• Sleep restrictions (patients are instructed to • Administer medications as prescribed to
avoid napping and to stay in bed only when help the patient stay awake and to maintain
sleeping) patient safety.
• Develop strategies to manage symptoms
Drug therapy and integrate them into the patient’s daily rou-
For primary insomnia or circadian rhythm tine, such as taking naps during lunch or
sleep disorder work breaks, to help maintain patient safety
• Antidepressant: trazodone (Desyrel) and promote normal functioning.
• Benzodiazepines: lorazepam (Ativan), alpra-
zolam (Xanax) Teaching topics
• Hypnotic: zolpidem (Ambien) For primary insomnia and circadian rhythm
• Sleep aid: diphenhydramine (Benadryl) disorder
• Using relaxation techniques and other mea-
For primary hypersomnia or narcolepsy sures to promote sleep, such as consuming
• Stimulants: caffeine, methylphenidate (Rita- warm milk before bedtime and using the bed-
lin), pemoline (Cylert), dextroamphetamine room only for sleep, not for watching televi-
(Dexedrine), modafinil (Provigil) sion or reading
• Limiting caffeine, alcohol, and spicy foods
INTERVENTIONS AND RATIONALES • Avoiding exercise within 3 hours before
• Monitor the patient and document his sleep bedtime
disturbance symptoms to gain information for • Identifying ways to reduce stressors
developing a care plan.
For breathing-related sleeping disorder
Primary insomnia and circadian rhythm • Using a positive nasal airway pressure de-
disturbance vice at home
• Encourage the patient to discuss concerns
that may be preventing sleep. Active listening For primary hypersomnia and narcolepsy
helps elicit underlying causes of sleep distur- • Integrating a nap period into the daily rou-
bance such as stress. tine
• Help him establish a sleep routine to pro-
mote relaxation and sleep.
• Schedule regular sleep and awakening Parasomnias
times for the patient to help ensure that
progress is maintained after he leaves the facili- Parasomnias are characterized by abnormal
ty. behavior that occurs during sleep. They in-
• Administer medications as prescribed to include nightmare disorder, sleep terror disor-
duce sleep and to reduce anxiety. der, and sleepwalking disorder.
• Provide warm milk at bedtime. L-trypto- Nightmare disorder is characterized by
phan, found in milk, is a precursor to sero- the recurrence of frightening dreams that
tonin, a neurotransmitter necessary for sleep. cause the patient to awaken from sleep. When
• Plan activities that require the patient to the patient awakens, he’s fully alert and expe-
wake at a regular hour and stay out of bed riences persistent anxiety or fear. Typically,
920113.qxd 8/7/08 3:04 PM Page 382
the patient can recall details of a dream that These awakenings usually occur during the
involved physical danger. second half of the night. Heart rate and respi-
Sleep terror disorder is characterized by ratory rate may increase or show increased
episodes of sleep terrors that cause distress variability before the awakening.
or impairment of social or occupational func-
tioning. The patient may sit up in bed scream- Sleep terror disorder
ing or crying with a frightened expression • Polysomnography reveals that sleep terrors
and signs of intense anxiety. During such begin during deep NREM sleep characterized
episodes, the patient is difficult to awaken by slow-frequency EEG activity.
and, if he does awaken, is generally confused
or disoriented. The patient has no recollection Sleepwalking disorder
of the dream content. • Polysomnography reveals episodes of sleep-
With sleepwalking disorder, the patient walking that begin within the first few hours
arises from bed and walks about. The patient of sleep, usually during NREM stage 3 or 4
has limited recall of the event on awakening. sleep.
CONTRIBUTING FACTORS NURSING DIAGNOSES

• Severe psychosocial stressors • Insomnia
• Genetic predisposition • Fatigue
• Sleep deprivation • Ineffective role performance
• Fever
TREATMENT
DATA COLLECTION FINDINGS • Hypnosis
Nightmare disorder
•Anxiety Drug therapy
•Depression • Benzodiazepines: lorazepam (Ativan), alpra-
•Dream recall zolam (Xanax)
•Excessive sleepiness
•Irritability INTERVENTIONS AND RATIONALES
•Mild autonomic arousal on awakening •Monitor the patient and document his sleep
(sweating, tachycardia, tachypnea) disturbance symptoms to aid in formulating a
•Poor concentration treatment plan.
• Lock the windows and doors if the patient
Don’t go
Sleep terror disorder walks in his sleep to maintain patient safety.
to sleep yet!
You still have •Autonomic signs of intense anxiety (tachy- • Provide emotional support to allay the pa-
to pump up on cardia, tachypnea, flushing, sweating, in- tient’s anxiety.
practice creased muscle tone, dilated pupils) • Establish a sleep routine to promote relax-
questions. •Inability to recall dream content ation and sleep.
•Screaming or crying • Schedule regular sleep and awakening
times so that the patient can learn specific
Sleepwalking disorder planning strategies for managing sleep.
• Amnesia of the episode or limited recall • Administer medications as prescribed to
• Episode possibly includes sitting up, talk- promote sleep.
ing, walking, or engaging in inappropriate
behavior Teaching topics
• Employing safety measures (in the case of
DIAGNOSTIC FINDINGS sleepwalking disorder)
Nightmare disorder • Identifying ways to reduce stressors
• Polysomnography demonstrates abrupt
awakenings from REM sleep that correspond
to the individual’s report of nightmares.
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experiencing circadian rhythm sleep disorder

related to which factor?
1. History of recent fever
2. Shift work
3. Hyperthyroidism
4. Pheochromocytoma
Answer: 2. The client is experiencing circadi-
an rhythm sleep disorder (palpitations, GI dis-
turbances, fatigue, haggard appearance, and
poor concentration), which is typically caused
by shift work, jet lag, or a delayed sleep
phase. Fever is a contributing factor in para-
somnias. Hyperthyroidism and pheochromo-
Pump up on practice cytoma are causative factors for primary in-
somnia.
questions Client needs category: Psychosocial
integrity
1. A client complains of experiencing an over- Client needs subcategory: None
whelming urge to sleep. He states that he’s Cognitive level: Analysis
been falling asleep while working at his desk.
He reports that these episodes occur about 3. A client comes to the clinic complaining of
five times daily. This client is most likely expe- the inability to sleep over the past 2 months.
riencing which sleep disorder? He states that his inability to sleep is ruining
1. Breathing-related sleep disorder his life because “getting sleep” is all he can
2. Narcolepsy think about. This client is most likely experi-
3. Primary hypersomnia encing which sleep disorder?
4. Circadian rhythm disorder 1. Circadian rhythm sleep disorder
Answer: 2. Narcolepsy is characterized by ir- 2. Breathing-related sleep disorder
resistible attacks of refreshing sleep that oc- 3. Primary insomnia
cur two to six times per day and last for 5 to 4. Primary hypersomnia
20 minutes. The client with breathing-related Answer: 3. The client with primary insomnia
sleep disorder suffers from interruptions in experiences difficulty initiating or maintaining
sleep that leave him excessively sleepy. With sleep. Key symptoms of primary insomnia are
hypersomnia, the client suffers from exces- the client’s intense focus and anxiety about
sive sleepiness and reports prolonged periods not getting sleep. The client diagnosed with
of nighttime sleep or daytime napping. With circadian rhythm sleep disorder reports peri-
circadian rhythm disorder, the client has periods of insomnia at particular times during a
ods of insomnia followed by periods of in- 24-hour period and excessive sleepiness at
creased sleepiness. other times. Excessive sleepiness is the most
Client needs category: Psychosocial common complaint of clients affected by
integrity breathing-related sleep disorder. The client
Client needs subcategory: None experiencing primary hypersomnia typically
Cognitive level: Application sleeps 8 to 12 hours per night. He falls asleep
easily and sleeps through the night but com-
2. The nurse is caring for a client who commonly has trouble awakening in the morning.
plains of fatigue, inability to concentrate, and Client needs category: Psychosocial
palpitations. The client states that he has been integrity
experiencing these symptoms for the past 6 Client needs subcategory: None
months. The nurse suspects that the client is Cognitive level: Analysis
920113.qxd 8/7/08 3:04 PM Page 384
4. The nurse is helping prepare a teaching 3. Degenerative dementia

plan for a client diagnosed with primary in- 4. Echolalia
somnia. Which teaching topic should be in- Answer: 2. Somatoform disorders are charac-
cluded in the plan? terized by recurrent and multiple physical
1. Eating unlimited spicy foods and limit- symptoms that have no organic or physiologic
ing caffeine and alcohol base. Exhibitionism involves public exposure
2. Exercising 1 hour before bedtime to of genitals. Degenerative dementia is charac-
promote sleep terized by deterioration of mental capacities.
3. Importance of sleeping whenever the Echolalia is a repetition of words or phrases.
client tires Client needs category: Safe, effective
4. Drinking warm milk before bed to in- care environment
duce sleep Client needs subcategory: Coordinated
Answer: 4. A client diagnosed with primary in- care
somnia should be taught that drinking warm Cognitive level: Analysis
milk before bedtime can help induce sleep.
He should also be taught the importance of
limiting spicy foods, alcohol, and caffeine. He
should avoid exercise within 3 hours before
bedtime, establish a routine bedtime, and
avoids naps.
integrity
6. The nurse is caring for a client who be-

lieves he has cancer. He has visited several
oncologists and undergone many tests. Thus
far, no evidence of cancer has been found.
The client remains convinced he’s gravely ill
and tells the nurse he doesn’t expect to live
much longer. What specific type of disorder is
the client exhibiting?
1. Hypochondriasis
2. Dependency
5. The nurse is caring for a client hospital- 3. Denial
ized on numerous occasions for complaints of 4. Confabulation
chest pain and fainting spells, which he attrib- Answer: 1. Hypochondriasis is marked by the
utes to his deteriorating heart condition. No client’s persistent fear or belief that he has a
relatives or friends report ever actually seeing serious illness. Dependency involves expecta-
a fainting spell. After undergoing an extensive tions that another person should do all the
cardiac, pulmonary, GI, and neurologic work- work to change the client from relative illness
up, he’s told that all test results are negative. to health. Denial is lack of awareness and is
The client remains persistent in his belief that usually an unconscious defense mechanism.
he has a serious illness. What diagnosis may Confabulation is a reaction in which the client
be appropriate for this client? invents answers, attempting to fill in memory
1. Exhibitionism gaps.
2. Somatoform disorder
920113.qxd 8/7/08 3:04 PM Page 385
Client needs category: Psychosocial discuss these possible factors initially. If the
integrity client has a weight problem, suffers from
Client needs subcategory: None sleep apnea, or reports sexual problems,
Cognitive level: Knowledge these also can affect sleep; however, consider-
ation of life stressors occurs first.
7. The nurse is caring for a client who ex- Client needs category: Psychosocial
hibits signs of somatization. Which statement integrity
is most relevant? Client needs subcategory: None
1. Clients with somatization are cognitive- Cognitive level: Application
ly impaired.
2. Anxiety rarely coexists with somatiza-
tion.
3. Somatization exists when medical evi-
dence supports the symptoms.
4. Clients with somatization often have
lengthy medical records.
Answer: 4. Clients with somatization are prone
to “doctor shop” and have extensive medical
records as a result of their multiple proce-
dures and tests. Clients with somatization
aren’t usually cognitively impaired. These
clients have coexisting anxiety and depres-
sion and no medical evidence to support a 9. The nurse is caring for a client who dis-
clear-cut diagnosis. plays gait disturbances, paralysis, pseudo-
Client needs category: Psychosocial seizures, and tremors. These symptoms may
integrity be manifestations of what psychiatric disor-
Client needs subcategory: None der?
Cognitive level: Analysis 1. Pain disorder
2. Adjustment disorder
8. The nurse is caring for a client who reveals 3. Delirium
symptoms of a sleep disorder during the ad- 4. Conversion disorder
mission assessment. The client also admits Answer: 4. Conversion disorders are most fre-
that he has “broken down and cried for no ap- quently associated with psychologically medi-
parent reason.” Which criteria is most impor- ated neurologic deficits, such as those men-
tant for the nurse to consider initially to gain tioned. Pain disorders and adjustment disor-
insight into the client’s patterns of sleep and ders aren’t generally expressed in terms of
feelings of depression? neurologic deficits. Delirium is associated
1. Stressors in the client’s life with cognitive impairment.
2. The client’s weight Client needs category: Psychosocial
3. Periods of apnea integrity
4. Sexual activity Client needs subcategory: None
Answer: 1. Recognizing that sleep distur- Cognitive level: Analysis
bances are commonly symptoms of stress, de-
pression, and anxiety, the nurse is prudent to
920113.qxd 8/7/08 3:04 PM Page 386
10. The nurse is caring for a client who com- Answer: 1. Psychosocial factors should be sus-
plains of chronic pain. Given this complaint, pected when pain persists beyond the normal
why would the nurse simultaneously evaluate tissue healing time and physical causes have
both general physical and psychosocial prob- been investigated. The other choices may or
lems? may not be correct but certainly aren’t credi-
1. Depression is commonly associated ble in all cases.
with pain disorders and somatic com- Client needs category: Psychosocial
plaints. integrity
2. Combining evaluations will save time Client needs subcategory: None
and allow for quicker delivery of health Cognitive level: Analysis
care.
3. Most insurance plans won’t cover evalu-
ation of both as separate entities.
4. The physician doesn’t have the training
to evaluate for psychosocial considera-
tions.
You’ve finished the

chapter on sleep
disorders. Now, you
may want to nap
before the next
chapter.
920114.qxd 8/7/08 3:04 PM Page 387
14 Anxiety & mood

disorders
Two common patterns of bipolar disorder
In this chapter,
you’ll review:
Brush up on key include:
• bipolar I, in which depressive episodes al-
✐ basic concepts of
anxiety and mood dis-
concepts ternate with full manic episodes (hyperactive
behavior, delusional thinking, grandiosity, and
orders Anxiety disorders are characterized by ex- often hostility)
✐ common anxiety and treme anxiety and avoidant behavior. Patients • bipolar II, characterized by recurrent de-
mood disorders. are overwhelmed by feelings of impending pressive episodes and occasional manic
catastrophe, guilt, shame, and worthlessness. episodes.
Patients with extreme anxiety cling to mal-
adaptive behaviors in an attempt to alleviate CONTRIBUTING FACTORS
their distress, but these behaviors only in- • Concurrent major illness
crease their symptoms. • Environment
Mood disorders are characterized by de- • Heredity
pressed or elevated moods that alter the pa- • History of psychiatric illnesses
tient’s ability to cope with reality and to func- • Seasons and circadian rhythms that affect
tion normally. mood
At any time, you can review the major points • Sleep deprivation
of each disorder by consulting the Cheat sheet • Stressful events, which may produce limbic
on pages 388 and 389. system dysfunction

During periods of mania
Polish up on patient • Bizarre and eccentric appearance and be-
havior
care • Cognitive manifestations, such as difficulty
concentrating, flight of ideas, delusions of
Major mood disorders include bipolar disor- grandeur, and impaired judgment
der and major depression. Major anxiety dis- • Decreased sleep
orders include generalized anxiety, obsessive- • Delusions, paranoia, and hallucinations
compulsive disorder, panic disorder, phobias, • Deteriorated physical appearance
and posttraumatic stress disorder. • Euphoria and hostility
• Feelings of grandiosity
• Impulsiveness
Bipolar disorder • Increased energy (feeling of being charged
up)
Also known as manic depression, bipolar dis- • Increased sexual interest and activity
order is a severe disturbance in affect, mani- • Increased social contacts
fested by episodes of extreme sadness alter- • Inflated sense of self-worth
nating with episodes of euphoria. Severity and • Lack of inhibition
duration of episodes vary. The exact biologi- • Rapid, jumbled speech
cal basis of bipolar disorder remains un- • Recklessness
known. (Text continues on page 390.)
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388 Anxiety & mood disorders
et
heat she
C
Anxiety & mood disorders refresher
BIPOLAR DISORDER GENERALIZED ANXIETY DISORDER
During periods of mania • Easy startle reflex
• Euphoria and hostility • Excessive worry and anxiety
• Feelings of grandiosity • Fatigue
• Inflated sense of self-worth • Fears of grave misfortune or death
• Increased energy (feeling of being charged up) • Motor tension
During periods of depression • Muscle tension
• Altered sleep patterns Key test result
• Anorexia and weight loss • Laboratory tests rule out physiologic causes.
• Helplessness
Key treatments
• Irritability
• Individual therapy focusing on coping skills
• Lack of motivation
• Anxiolytics: alprazolam (Xanax), lorazepam (Ati-
• Low self-esteem
van), clonazepam (Klonopin), buspirone (BuSpar)
• Sadness and crying
Key interventions
Key test result
• Help the patient identify and explore coping
• EEG is abnormal during the depressive
mechanisms used in the past.
episodes of bipolar I disorder and major
• Observe for signs of mounting anxiety.
depression.
Key treatments MAJOR DEPRESSION
• Individual therapy Key signs and symptoms
• Family therapy • Altered sleep patterns
• Antimanic agents: lithium carbonate (Eskalith), • Anorexia and weight loss
lithium citrate (Cibalith-S) • Helplessness
Key interventions • Irritability
Don’t get frazzled During manic phase • Lack of motivation
if you don’t have time • Decrease environmental stimuli by behaving • Low self-esteem
to study the whole • Sadness and crying
consistently and supplying external controls.
chapter. Just peek at
• Ensure a safe and supportive environment. Key test result
the Cheat sheet.
• Define and explain acceptable behaviors and • Beck depression inventory indicates depres-
then set limits. sion.
• Monitor drug levels, especially lithium. Key treatments
During depressive phase • Selective serotonin reuptake inhibitors (SSRIs):
• Ensure a safe and supportive environment for paroxetine (Paxil), fluoxetine (Prozac), sertraline
the patient. (Zoloft), escitalopram (Lexapro), bupropion (Well-
• Evaluate the risk of suicide and formulate a butrin), citalopram (Celexa), venlafaxine (Effexor)
safety contract with the patient, as appropriate. • Tricyclic antidepressants (TCAs): imipramine
• Observe the patient for medication compliance (Tofranil), desipramine (Norpramin), amitriptyline
and adverse effects. (Elavil), clomipramine (Anafranil), doxepin
• Encourage the patient to identify current prob- (Sinequan), nortriptyline (Pamelor)
lems and stressors. • Other antidepressants: mirtazapine (Remeron,
nefazodone (Serzone)
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Anxiety & mood disorders refresher (continued)

MAJOR DEPRESSION (continued) Key interventions
Key interventions During panic attacks
• Ensure a safe and supportive environment for the patient. • Distract the patient from the attack.
• Evaluate the risk of suicide and formulate a safety contract • Approach the patient calmly and unemotionally.
with the patient. • Use short, simple sentences.
• Observe the patient for medication compliance and adverse PHOBIAS
effects.
OBSESSIVE-COMPULSIVE DISORDER • Panic when confronted with the feared object
Key signs and symptoms • Persistent fear of specific things, places, or situations
• Compulsive behavior (which may include repetitive touching or Key test results
counting, doing and undoing small tasks, or any other repetitive • No specific test is available to diagnose phobias.
activity) Key treatments
• Obsessive thoughts (which may include thoughts of contami- • Family therapy
nation, repetitive worries about impending tragedy, or repeating • Supportive therapy
and counting images or words) • Benzodiazepines: alprazolam (Xanax), lorazepam (Ativan),
Key test result clonazepam (Klonopin)
• Positron emission tomography shows increased activity in the Key interventions
frontal lobe of the cerebral cortex. • Provide a safe and supportive environment.
Key treatments • Collaborate with the patient to identify the feared object or
• Behavioral therapy situation.
• Individual therapy • Assist in desensitizing the patient.
• Benzodiazepines: alprazolam (Xanax), lorazepam (Ativan),
clonazepam (Klonopin) POSTTRAUMATIC STRESS DISORDER
• SSRIs: fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine Key signs and symptoms
(Paxil), sertraline (Zoloft) • Anxiety
Key interventions • Flashbacks of the patient’s traumatic experience
• Encourage the patient to express his feelings. • Nightmares about the traumatic experience
• Encourage the patient to identify situations that produce anxi- • Poor impulse control
ety and precipitate obsessive-compulsive behavior. • Social isolation
• Work with the patient to develop appropriate coping skills. • Survivor guilt
Key test results
PANIC DISORDER • No specific tests are available to identify or confirm post-
Key signs and symptoms traumatic stress disorder.
• Diminished ability to focus, even with direction from others Key treatments
• Edginess or impatience • Individual therapy
• Loss of objectivity • Group therapy
• Severely impaired rational thought • Systematic desensitization
• Uneasiness and tension • Benzodiazepines: alprazolam (Xanax), lorazepam (Ativan),
Key test result clonazepam (Klonopin)
• Medical tests rule out physiologic causes. • TCAs: imipramine (Tofranil), amitriptyline (Elavil)
Key treatments Key interventions
• Individual therapy • Work with the patient to identify stressors.
• Benzodiazepines: alprazolam (Xanax), lorazepam (Ativan), • Provide a safe and supportive environment.
clonazepam (Klonopin) • Encourage the patient to explore the traumatic event and the
meaning of the event.
• Assist the patient with problem solving and resolving guilt.
920114.qxd 8/7/08 3:04 PM Page 390
During periods of depression INTERVENTIONS AND RATIONALES

• Altered sleep patterns During manic phase
Bipolar disorder
isn’t indicated by • Anorexia and weight loss • Decrease environmental stimuli by behav-
mood swings alone. It • Confusion and indecisiveness ing consistently and supplying external con-
involves extreme • Constipation trols to promote the patient’s ability to relax
behavior during both • Decreased alertness and sleep.
manic and depressive • Delusions and hallucinations •Ensure a safe and supportive environment
phases. • Difficulty thinking logically to protect the patient from himself.
• Flat affect • Define and explain acceptable behaviors
• Guilt and set limits to begin a process in which the
• Helplessness patient will eventually define and set his own
• Hisory of amenorrhea limits.
• Impotence and lack of interest in sex • Monitor drug levels, especially lithium
• Inability to experience pleasure levels.
• Irritability
• Lack of motivation During depressive phase
• Low self-esteem • Ensure a safe and supportive environment
• Pessimism for the patient to protect him from self-inflicted
• Poor hygiene harm.
• Poor posture • Evaluate the risk of suicide and formulate a
• Sadness and crying safety contract with the patient, as appropri-
ate, to ensure well-being and open lines of com-
DIAGNOSTIC FINDINGS munication.
• Abnormal dexamethasone suppression test • Observe the patient for medication compli-
results indicate bipolar I disorder. ance and adverse effects; without compliance,
• Cortisol secretion increases during manic there’s little hope of progress.
episodes of bipolar I disorder. • Encourage the patient to identify current
• EEG is abnormal during the depressive problems and stressors so that he can begin
episodes of bipolar I disorder and major de- therapeutic treatment.
pression. • Promote opportunities for increased in-
volvement in activities through a structured,
NURSING DIAGNOSES daily program to help the patient feel comfort-
• Disturbed thought processes able with himself and others.
• Bathing or hygiene self-care deficit • Select activities that ensure success and ac-
• Insomnia complishment to increase self-esteem.
• Help the patient to modify negative expecta-
TREATMENT tions and think more positively because posi-
• Electroconvulsive therapy (ECT), if drug tive thinking will help the patient begin a heal-
therapy fails ing process.
• Individual therapy • Spend time with the patient, even if the pa-
• Family therapy tient is too depressed to talk, to enhance the
therapeutic relationship.
Drug therapy
• Anticonvulsant agents: carbamazepine Teaching topics
(Tegretol), divalproex sodium (Depakote) • Following the pharmacologic regimen
• Antimanic agents: lithium carbonate (Es- faithfully and recognizing that therapeutic re-
kalith), lithium citrate (cibalith-S) sults may take 1 to 3 weeks
• Selective serotonin reuptake inhibitors (SS- • Thinking more positively
RIs): paroxetine (Paxil), fluoxetine (Prozac) • Participating in therapy
• Obtaining follow-up laboratory tests as indi-
cated
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Generalized anxiety disorder • Antihypertensive: clonidine (Catapres)

• Monoamine oxidase inhibitors (MAOIs):
A patient with generalized anxiety disorder phenelzine (Nardil), tranylcypromine (Par-
worries excessively and experiences extreme nate)
anxiety almost daily. The worry lasts for • SSRIs: paroxetine (Paxil), sertraline
longer than 6 months and is usually dispro- (Zoloft), fluoxetine (Prozac)
portionate to the situation. Both adults and • Tricyclic antidepressants (TCAs): imip-
children can be diagnosed with generalized ramine (Tofranil), desipramine (Norpramin)
anxiety disorder, although the content of the
worry may differ. INTERVENTIONS AND RATIONALES
• Help the patient identify and talk about how
CONTRIBUTING FACTORS he uses coping mechanisms. Establishing a
• Family history of anxiety baseline for the level of current functioning will
• Preexisting psychiatric problems, such as enable you to help the patient build his knowl-
social phobia, panic disorder, and major de- edge.
pression • Observe the patient for signs of mounting
anxiety to direct measures to moderate it.
DATA COLLECTION FINDINGS • Negotiate a contract with the patient to
• Autonomic hyperactivity work on goals that give him control of his own
• Distractibility situation.
• Easy startle reflex • Alter his environment to reduce his anxiety
• Excessive attention to surroundings and meet his needs.
• Excessive worry and anxiety • Monitor his diet and nutrition and encour-
• Fatigue age him to decrease his caffeine intake to re-
• Fears of grave misfortune or death duce anxiety.
• Motor tension
• Muscle tension Teaching topics
• Pounding heart • Recognizing sources of anxiety
• Repetitive thoughts • Altering diet when receiving MAOIs (caf-
• Sleep disorder feine can cause arrhythmias; foods containing
• Strained expression tyramine, such as fava beans, yeast-containing Each patient and
• Tingling of hands or feet and fermented foods, and avocados, can each depression is
• Vigilance and scanning cause a hypertensive crisis) unique, so finding the
• Understanding the medication regimen and most effective drug
DIAGNOSTIC FINDINGS recognizing that therapeutic results may take and dosage is
typically a process of
• Laboratory tests rule out physiologic 2 to 3 weeks
trial and error.
causes.
NURSING DIAGNOSES Major depression

• Anxiety
• Ineffective coping Major depression is a syndrome of persistent
• Deficient knowledge (treatment plan) sad, dysphoric mood that’s accompanied by
disturbances in sleep and appetite from
TREATMENT lethargy and an inability to experience plea-
• Individual therapy focusing on coping skills sure.
Major depression can profoundly alter so-
Drug therapy cial functioning, but the most severe compli-
• Anxiolytics: alprazolam (Xanax), lorazepam cation of major depression is the potential for
(Ativan), clonazepam (Klonopin), buspirone suicide.
(BuSpar)
• Beta-adrenergic blocker: propranolol (In- CONTRIBUTING FACTORS
deral) • Current substance abuse
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• Deficiencies in the receptor sites for some • SSRIs: paroxetine (Paxil), fluoxetine
neurotransmitters: norepinephrine, serotonin, (Prozac), sertraline (Zoloft), escitalopram
Treatment for dopamine, and acetylcholine (Lexapro), bupropion (Wellbutrin), citalo-
depression usually • Family history of depressive disorders pram (Celexa), venlafaxine (Effexor)
requires collaboration • Hormonal imbalances • TCAs: imipramine (Tofranil), desipramine
with the patient to • Lack of social support (Norpramin), amitriptyline (Elavil),
find an effective • Nutritional deficiencies clomipramine (Anafranil), doxepin
program of drug • Prior episode of depression (Sinequan), nortriptyline (Pamelor)
therapy and • Significant medical problems • Other antidepressants: mirtazapine (Re-
psychotherapy. • Stressful life events meron), nefazodone (Serzone)
DATA COLLECTION FINDINGS INTERVENTIONS AND RATIONALES

• Altered sleep patterns • Ensure a safe and supportive environment
• Amenorrhea for the patient to protect him from self-inflicted
• Anorexia and weight loss harm.
• Confusion and indecisiveness • Evaluate the patient’s risk of suicide and for-
• Constipation mulate a safety contract with him, as appropri-
• Decreased alertness ate, to ensure his well-being and open lines of
• Delusions and hallucinations communication.
• Difficulty thinking logically • Reorient the patient undergoing ECT as
• Flat affect needed. Patients receiving ECT commonly
• Guilt have temporary memory loss.
• Helplessness • Observe the patient for medication compli-
• Impotence or lack of interest in sex ance and adverse effects; without compliance,
• Inability to experience pleasure there’s little hope of progress.
• Irritability • Encourage the patient to identify his cur-
• Lack of motivation rent problems and stressors so that he can be-
• Low self-esteem gin therapeutic treatment.
• Pessimism • Promote opportunities that increase the pa-
Memory • Poor hygiene tient’s involvement in activities through a
jogger • Poor posture structured, daily program to help him feel
When deal- • Sadness and crying comfortable with himself and others.
ing with • Select activities that ensure his success and
depressive patients, DIAGNOSTIC FINDINGS accomplishment to increase his self-esteem.
think COMPARE: • Thyroid test results are abnormal in major • Help the patient to modify his negative ex-
Consult with staff. depression. pectations and think more positively because
• Beck depression inventory indicates de- positive thinking helps him begin the healing
Observe the suici- pression. process.
dal patient. • Spend time talking with the patient, even if
Maintain personal NURSING DIAGNOSES he’s too depressed to talk, to enhance the ther-
contact. • Hopelessness apeutic relationship.
Provide a safe envi- • Impaired social interaction • Involve family members in patient care to
ronment. • Chronic low self-esteem help them develop coping skills.
Assess for clues to TREATMENT Teaching topics
suicide.
• ECT • Learning relaxation and sleep methods
Remove dangerous • Individual therapy • Complying with therapy
objects. • Family therapy • If taking MAO inhibitors, avoiding tyra-
Encourage expres- • Phototherapy mine-containing foods, such as wine, beer,
sion of feelings. cheeses, and preserved fruits, meats, and
Drug therapy vegetables
• MAOIs: phenelzine (Nardil)
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• Understanding medication regimen and rec- • MAOIs: phenelzine (Nardil), tranylcypro-

ognizing that therapeutic results may take 2 mine (Parnate)
to 3 weeks • SSRIs: fluoxetine (Prozac), fluvoxamine
(Luvox), paroxetine (Paxil), sertraline
(Zoloft)
Obsessive-compulsive • TCAs: imipramine (Tofranil), desipramine
(Norpramin), clomipramine (Anafranil)
disorder
Obsessive-compulsive disorder, also known • Encourage the patient to express his feel-
as OCD, is characterized by recurrent obses- ings to decrease his level of stress.
sions (intrusive thoughts, images, and impuls- • Help the patient to recognize how his com-
es) and compulsions (repetitive behaviors in pulsive behaviors affect his functioning. The
response to an obsession). The obsessions patient needs to realistically evaluate the con-
and compulsions cause intense stress and im- sequences of his behavior.
pair the patient’s functioning. Some patients • Encourage the patient to identify situations
have simultaneous symptoms of depression. that produce anxiety and precipitate obses-
sive-compulsive behavior to help him evaluate
CONTRIBUTING FACTORS and cope with his condition.
• Brain lesions • Work with the patient to develop appropri-
• Childhood trauma ate coping skills to reduce anxiety.
• Lack of role models to teach coping skills
• Multiple stressors Teaching topics
• Understanding anxiety and obsessive-
DATA COLLECTION FINDINGS compulsive disorder
• Compulsive behavior (which may include
repetitive touching or counting, doing and un-
doing, or any other repetitive activity) Panic disorder
• Obsessive thoughts (which may include
thoughts of contamination, repetitive worries While everyone experiences some level of
about impending tragedy, or repeating and anxiety, patients with panic disorder experi-
counting images or words) ence a nonspecific feeling of terror and dread Don’t worry.
• Social impairment accompanied by symptoms of physiologic Dreading the NCLEX
stress. This level of anxiety makes it difficult, doesn’t mean you’ve
developed panic
DIAGNOSTIC FINDINGS if not impossible, for the patient to carry out
disorder.
• Positron emission tomography shows in- the normal functions of everyday life.
creased activity in the frontal lobe of the cere-
bral cortex. CONTRIBUTING FACTORS
• Agoraphobia (fear of being alone or in pub-
NURSING DIAGNOSES lic places)
• Anxiety • Asthma
• Ineffective coping • Cardiovascular disease
• Chronic low self-esteem • Familial pattern
• GI disorders
TREATMENT • History of anxiety disorders
• Behavioral therapy • History of depression
• Individual therapy • Neurologic abnormalities: abnormal activity
on the medial portion of the temporal lobe in
Drug therapy the parahippocampal area and significant
• Benzodiazepines: alprazolam (Xanax), lo- asymmetrical atrophy of the temporal lobe
razepam (Ativan), clonazepam (Klonopin) • Neurotransmitter involvement
• Stressful lifestyle
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DATA COLLECTION FINDINGS Drug therapy

• Abdominal discomfort or pain, nausea, • Benzodiazepines: alprazolam (Xanax), lo-
heartburn, or diarrhea razepam (Ativan), clonazepam (Klonopin)
• Avoidance (the patient’s refusal to en- • MAOIs: phenelzine (Nardil); in patients
counter situations that may cause anxiety) with severe panic disorder, tranylcypromine
• Chest pressure, lump in throat, or choking (Parnate)
sensation • SSRIs: paroxetine (Paxil), fluoxetine
• Confusion (Prozac), sertraline (Zoloft)
• Decreased ability to relate to others • TCAs: imipramine (Tofranil), desipramine
• Diminished ability to focus, even with direc- (Norpramin), clomipramine (Anafranil)
tion from others
• Edginess or impatience INTERVENTIONS AND RATIONALES
• Eyelid twitching • During the patient’s panic attack, distract or
• Fidgeting or pacing redirect him from the attack to alleviate the ef-
• Flushing or pallor fects of panic.
• Generalized weakness • Discuss other methods of coping with his
• Increased or decreased blood pressure stress to make the patient aware of alterna-
• Insomnia tives.
• Itching • Approach the patient calmly and unemotion-
• Loss of appetite or revulsion toward food ally to reduce the risk of further stressing the
• Loss of objectivity patient.
• Palpitations and tachycardia • Use short, simple sentences because the pa-
• Physical tension tient’s ability to focus and to relate to others is
• Potential for dangerous, impulsive actions diminished.
• Rapid speech • Administer medications, as needed, to en-
• Rapid, shallow breathing or shortness of sure a therapeutic response.
breath
• Severely impaired rational thought Teaching topics
• Startle reaction • Recognizing sources of stress and panic
• Sudden urge and frequent urination triggers
• Sweating • Learning decision-making and problem-
• Tremors solving skills
• Uneasiness and tension • Learning relaxation techniques
DIAGNOSTIC FINDINGS
• Medical test results eliminate a physiologic Phobias
cause.
• Urine and blood test results indicate the A phobia is an intense, irrational fear that’s
presence of psychoactive agents. out of proportion to reality. This fear often
stems from early painful or unpleasant experi-
NURSING DIAGNOSES ences that involve a particular object or situa-
• Anxiety tion. Phobias are resistant to insight-oriented
• Ineffective coping therapies.
• Powerlessness
CONTRIBUTING FACTORS
TREATMENT • Biochemical, involving neurotransmitters
• Individual therapy • Familial patterns
• Group therapy • Traumatic events
• Family therapy
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• Displacement (shifting of the patient’s emo- • Learning assertiveness techniques
tions from their original object) and symbol- • Learning relaxation and coping techniques
ization • Participating in the desensitizing process
• Disruption in the patient’s social or work • Understanding medication regimen and rec-
life ognizing that therapeutic results may take 2
• Dysfunctional social interactions and rela- to 3 weeks.
tionships
• Panic when confronted with the feared ob-
ject Posttraumatic stress disorder
• Persistent fear of specific things, places, or
situations Posttraumatic stress disorder (PTSD) is a
group of symptoms that the patient develops
DIAGNOSTIC FINDINGS after a traumatic event. This traumatic event
• No specific test is available to diagnose may involve death, injury, or threat to his
phobias. physical integrity. In PTSD, ordinary coping
behaviors fail to relieve the anxiety. The pa-
NURSING DIAGNOSES tient may experience reactions that are acute,
• Anxiety chronic, or delayed.
• Fear
• Powerlessness CONTRIBUTING FACTORS
• Anxiety
TREATMENT • Low self-esteem
• Individual therapy • Personal experience of threatened injury or
• Family therapy death
• Supportive therapy • Preexisting psychopathology
• Systematic desensitization • Witnessing a traumatic event happen to a
close friend or family member
Drug therapy
• Beta-adrenergic blocker: propranolol (In- DATA COLLECTION FINDINGS
deral) for phobia related to public speaking • Anger PTSD was
• Benzodiazepines: alprazolam (Xanax), lo- • Anxiety originally called
razepam (Ativan), clonazepam (Klonopin) • Avoidance of people involved in the trauma “shell shock”
because
• MAOIs: phenelzine (Nardil), tranyl- • Avoidance of places where the trauma oc-
participation in
cypromine (Parnate) curred active combat is a
• SSRIs: paroxetine (Paxil), sertraline (Zoloft) • Chronic tension common cause of
• TCAs: imipramine (Tofranil), desipramine • Detachment this disorder.
(Norpramin) • Difficulty concentrating
• Difficulty falling or staying asleep
INTERVENTIONS AND RATIONALES • Emotional numbness
• Provide a safe and supportive environment • Flashbacks of the traumatic experience
to decrease anxiety. • History of military service
• Collaborate with the patient to identify the • Hyperalertness
feared object or situation to develop an effec- • Inability to recall details of the traumatic
tive treatment plan. event
• Assist in desensitizing the patient to dimin- • Labile affect
ish his fear. • Nightmares about the traumatic experience
• Remind the patient about resources and • Poor impulse control
personal strengths to build self-esteem. • Social isolation
• Survivor guilt
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DIAGNOSTIC FINDINGS
• No specific test is available to identify or
confirm PTSD.
NURSING DIAGNOSES
• Posttrauma syndrome
• Powerlessness
• Situational low self-esteem
TREATMENT
• Alcohol and drug rehabilitation, when indi-
cated
• Group therapy
• Progressive relaxation techniques
Pump up on practice
• Systematic desensitization questions
Drug therapy
• Benzodiazepines: alprazolam (Xanax), 1. The nurse is caring for a client who’s expe-
lorazepam (Ativan), clonazepam (Klonopin) riencing a panic attack. Which intervention
• Beta-adrenergic blocker: propranolol (In- would be most appropriate?
deral) 1. Tell the client that he’s all right and that
• MAOIs: phenelzine (Nardil), tranylcy- there’s no need to panic.
promine (Parnate) 2. Speak to the client in short, simple sen-
• SSRIs: paroxetine (Paxil), sertraline (Zoloft) tences.
• TCAs: imipramine (Tofranil), amitriptyline 3. Explain to the client that there’s no
(Elavil) need to worry because he’s safe.
4. Give the client a detailed explanation of
INTERVENTIONS AND RATIONALES his panic reaction.
• Work with the patient to identify stressors Answer: 2. The client experiencing a panic at-
to initiate effective coping. tack is unable to focus, and his ability to relate
• Provide a safe and supportive environment to others is diminished. Therefore, short, sim-
to decrease anxiety and the chance of injury. ple sentences are the most effective means of
• Encourage the patient to discuss and ex- communication. The other options minimize
plore the meaning of the traumatic event to the client’s concerns about his anxiety.
promote effective coping. Client needs category: Psychosocial
• Assist the patient with problem solving and integrity
resolving guilt to help him understand that un- Client needs subcategory: None
controllable factors probably played a larger Cognitive level: Analysis
part in the trauma than did his personal ac-
tions, decisions, or inactions. 2. The nurse is caring for a client who re-
ports that he often feels a choking sensation
Teaching topics in his throat, a racing heart, dizziness, and
• Joining a support group fearfulness. All of these symptoms have oc-
• Learning relaxation techniques curred almost daily for the past 3 months. Af-
• Promoting social interaction ter the nurse decides that a psychological
component may be causing these symptoms,
what would she anticipate administering?
1. Benzodiazepines
2. Proton pump inhibitors
3. Nitroprusside
4. Lithium carbonate
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Answer: 1. Pharmacologic management would Quitting a job is a drastic means that would be
consist of either tricyclic antidepressants or suggested only after all other therapies failed.
benzodiazepines. Proton pump inhibitors are Telling jokes wouldn’t reduce anxiety in this
used for GI disorders. Nitroprusside is a po- situation for this person; in fact, this may in-
tent vasodilator used for hypertensive emer- crease anxiety (for example, worrying about
gencies. Lithium carbonate is an antimanic telling the joke well). MAO inhibitors aren’t
agent. indicated for periods of episodic anxiety.
integrity integrity
Client needs subcategory: Pharmaco- Client needs subcategory: Pharmaco-
logical therapies logical therapies
3. The nurse is caring for a client who com- 5. The nurse is caring for a client who com-
plains of a choking sensation in his throat, a plains of palpitations, sweating, and intense
racing heart, dizziness, and fearfulness. fear when speaking in public. What would be
Which of the following conditions could cause a possible diagnosis for that client?
these symptoms? 1. Panic attack
1. Substance abuse 2. Major depression
2. Panic disorder 3. Phobia
3. Phobia 4. Malingering
4. Huntington’s chorea Answer: 3. Even though a panic attack may
Answer: 2. Panic disorder is diagnosed when have similar symptoms, phobias are charac-
associated symptoms occur more than four terized by episodic anxiety in response to a
times in 1 month. Other related symptoms in- specific precipitating event. Panic attacks may
clude rubbery legs, faintness, chest discom- not have such a specific cause. Symptoms of
fort, preoccupation with health, and a feeling major depression are long term and are asso-
of going insane. Substance abuse can cause a ciated with considerable disability. Malinger-
large spectrum of similar symptoms, but the ing occurs when an incentive for symptoms
symptoms would depend on what was ingest- exists.
ed. Phobias are generally related to a specific Client needs category: Psychosocial
phobic stimulus (heights, for instance). Hunt- integrity
ington’s chorea is a neurologic degenerative Client needs subcategory: None
disease. Cognitive level: Comprehension
integrity 6. The nurse is caring for one client with pan-
Client needs subcategory: None ic disorder and another client with a phobia.
Cognitive level: Knowledge What is one major difference between those
two disorders?
4. A client in his mid-40s complains of severe 1. Specific precipitants are present with
palpitations, sweating, and intense fear when panic disorders.
he has to speak in public. Because his job en- 2. Specific precipitants are present with
tails lecturing in auditoriums, what would the phobias.
nurse suggest? 3. The symptoms are different for each
1. Behavioral therapy and beta- disorder.
adrenergic blockers 4. Phobias are one cause of major depres-
2. Quitting his job sive states.
3. Telling jokes to reduce anxiety Answer: 2. Phobias are characterized by
4. Monoamine oxidase (MAO) inhibitors episodic anxiety in response to specific pre-
Answer: 1. Behavioral therapy and beta- cipitants, such as flying, talking in public, and
adrenergic blockers have been shown to de- insects. Both may be associated with similar,
crease anxiety related to speaking in public.
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not different, symptoms. Neither phobias nor 9. The nurse is caring for a client who has a
panic disorders cause depressive states. mood disorder. This disorder has a strong bi-
Client needs category: Psychosocial ological and genetic component. What disor-
integrity der might this client have?
Client needs subcategory: None 1. Generalized anxiety disorder
Cognitive level: Comprehension 2. Adjustment disorder with depressed
mood
7. The nurse is caring for a client who served 3. Posttraumatic stress disorder
in the military and was on duty during a 4. Bipolar disorder
bombing of an American embassy. Which Answer: 4. Formerly called manic depression,
findings would suggest PTSD? bipolar disorder has a genetic link. About 10%
1. Seizures and headaches of children who have a parent with this disor-
2. Stuttering, flashbacks, and memory der will develop it themselves. The other
loss choices have no clear-cut genetic or biological
3. Paralysis, flashbacks, and seizures link.
4. Anger, depression, and flashbacks Client needs category: Psychosocial
Answer: 4. PTSD occurs after a person experi- integrity
ences a trauma that is outside the range of Client needs subcategory: None
normal human experience. The disorder is Cognitive level: Comprehension
characterized by nightmares, flashbacks, anx-
iety, and depression. The other symptoms 10. The nurse is caring for a client who suf-
don’t apply. fers from depression. Two weeks after the
Client needs category: Psychosocial start of treatment, this client has gained 2 lb
integrity (0.9 kg), combs her hair, and is beginning to
Client needs subcategory: None participate in therapy. The nurse explains that
Cognitive level: Knowledge because she’s showing signs of improvement,
she’ll be able to choose her daily menu. She
8. The nurse is caring for a client who has tells the client that she must avoid cheese, yo-
generalized anxiety disorder. Which state- gurt, and preserved meats, fruits, and vegeta-
ment is true about this client? bles. Based on this information, the client is
1. The client has regular obsessions. most likely receiving which drug therapy to
2. Relaxation techniques and psycho- treat her depression?
therapy are necessary for cure. 1. MAO inhibitor
3. Nightmares and flashbacks are com- 2. Benzodiazepine
mon in individuals who suffer from gener- 3. SSRI
It’s okay to be alized anxiety disorder. 4. TCA
happy—you’ve finished 4. The client has experienced episodes of Answer: 1. This client is receiving an MAO
the chapter on anxiety anxiety for longer than 6 months. inhibitor, which requires her to avoid
and mood disorders!
Answer: 4. Constant patterns of anxiety that tyramine-rich foods, such as cheese, beer,
affect the client for more than 6 months and wine, yogurt, and preserved fruits, vegeta-
interfere with normal activities are character- bles, and meats. Benzodiazepines, SSRIs, and
istic of generalized anxiety disorder. Frequen- TCAs require no dietary restrictions other
tly, pharmaceutical therapy with benzodiaze- than avoiding alcoholic beverages.
pines can help. Clients having regular obses- Client needs category: Psychosocial
sions are probably suffering from obsessive- integrity
compulsive disorder. Nightmares and flash- Client needs subcategory: None
backs are typical symptoms of posttraumatic Cognitive level: Analysis
stress disorder.
integrity
920115.qxd 8/7/08 3:05 PM Page 399
15 Cognitive
disorders
withdrawal from alcohol and drugs, and toxic
In this chapter,
you’ll review:
Brush up on key substances. Toxic substances are especially
difficult to deal with because they can have
✐ factors that con-
tribute to the develop-
concepts residual effects. Drugs present another prob-
lem—a medication may be innocuous by itself
ment of cognitive dis- Cognitive disorders result from conditions but deadly when taken with another medica-
orders that alter or destroy brain tissue and, in turn, tion or food. Elderly patients are especially
✐ the difference be- impair cerebral functioning. Symptoms of susceptible to the toxic effects of medication.
tween delirium and cognitive disorders include cognitive impair-
dementia ment, behavioral dysfunction, and personality Brain defects
✐ clinical features of changes. The most common cognitive disor- Unlike delirium, dementia is caused by pri-
cognitive disorders. ders described in the Diagnostic and Statisti- mary brain pathology. Consequently, reversal
cal Manual of Mental Disorders, 4th ed., Text of cognitive defects is less likely. Dementia
Revision, are delirium, dementia, and amnesic can easily be mistaken for delirium, so the
disorders. cause needs to be thoroughly investigated.
of each disorder by consulting the Cheat sheet
on pages 400 and 401.
Catching up on cognitive disorders

Cognitive mental disorders are character-
ized by the disruption of cognitive function-
care
ing. Clinically, cognitive disorders are mani- Major cognitive disorders include Alz-
fested as mental deficits in patients who heimer’s-type dementia, amnesic disorder,
hadn’t previously exhibited such deficits. delirium, and vascular dementia.
Cognitive disorders are difficult to identify
and treat. The key to diagnosis lies in the dis-
covery of an organic problem with the brain’s Alzheimer’s-type dementia
tissue.
Cognitive disorders may result from: A patient with Alzheimer’s-type dementia suf-
• a primary brain disease fers from a global impairment of cognitive
• the brain’s response to a systemic distur- functioning, memory, and personality. The de-
bance such as a medical condition mentia develops gradually but with continu-
• the brain tissue’s reaction to a toxic sub- ous decline. Damage from Alzheimer’s-type
stance, as in substance abuse. dementia is irreversible. Because of the diffi-
culty of obtaining direct pathological evidence
Brain disruptions of Alzheimer’s disease, the diagnosis can be
Delirium is commonly caused by the disrup- made only when the etiologies for the demen-
tion of brain homeostasis. When the source of tia have been eliminated. A definitive diagno-
the disturbance is eliminated, cognitive sis can only be made with an autopsy after the
deficits generally resolve. patient’s death.
Common causes of delirium include postop- Researchers have developed different
erative conditions or metabolic disorders, scales to measure the progression of symp-
920115.qxd 8/7/08 3:05 PM Page 400
400 Cognitive disorders
et
heat she
C
Cognitive disorders refresher
ALZHEIMER’S-TYPE DEMENTIA AMNESIC DISORDER
Stage 1 (mild symptoms) • Confusion, disorientation, and lack of insight
• Confusion and short-term memory loss • Inability to learn and retain new information
• Disorientation to time and place • Tendency to remember the remote past better
• Difficulty performing routine tasks than more recent events
• Changes in personality and judgment Key test result
Stage 2 (moderate symptoms) • The Mini–Mental Status Examination shows
• Anxiety that the patient is disoriented and has difficulty
• Obvious memory loss recalling events and information.
• Suspiciousness
Key treatments
• Agitation
• Correction of the underlying medical cause
• Wandering
• Group therapy
• Difficulty recognizing family members
• Family therapy
Stage 3 (moderate to severe symptoms)
• Increasing loss of expressive language skills Key interventions
• Loss of reasoning ability • Ensure the patient’s safety.
• Loss of ability to perform activities of daily living • Encourage him to explore his feelings.
Stage 4 (severe symptoms) • Provide simple, clear medical information.
• Absent cognitive abilities DELIRIUM
• Disorientation to time and place
• Impaired or absent motor skills
• Bowel and bladder incontinence. • Altered psychomotor activity, such as apathy,
withdrawal, and agitation
Key test results
• Bizarre, destructive behavior that’s worse at
Don’t forget • The cognitive assessment scale demonstrates
about the night
cognitive impairment. • Disorganized thinking
Cheat sheet.
• The functional dementia scale shows the de- • Distractibility
gree of the dementia. • Impaired decision making
• Magnetic resonance imaging (MRI) shows ap- • Inability to complete tasks
parent structural and neuralgic changes. • Insomnia or daytime sleepiness
• The Mini–Mental Status Examination reveals • Poor impulse control
disorientation and cognitive impairment. • Rambling, bizarre, or incoherent speech
Key treatments Key test result
• Group therapy • Laboratory results indicate that the delirium is a
• Anticholinesterase agents: tacrine (Cognex), result of a physiologic condition, intoxication,
donepezil (Aricept), rivastigmine (Exelon), galan- substance withdrawal, toxic exposure, pre-
tamine (Reminyl) scribed medicines, or a combination of these fac-
Key interventions tors.
• Remove hazardous items or potential obstacles Key treatments
from the patient’s environment. • Correction of the underlying physiologic
• Communicate verbally and nonverbally with the problem
patient in a consistent, structured way. • Cholinesterase inhibitor: physostigmine (Anti-
• Increase the patient’s social interaction. lirium)
• Encourage the use of community resources. • Antipsychotic agent: risperidone (Risperdal)
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Cognitive disorders refresher (continued)

DELIRIUM (continued) • Global Deterioration Scale signifies degenerative dementia.
Key interventions • The Mini–Mental Status Examination reveals that the patient is
• Minimize excessive sensory stimuli disoriented and has difficulty recalling information.
• Create a structured, safe, and supportive environment. Key treatments
• Keep a light on in the patient’s room. • Carotid endarterectomy to remove blockages in the carotid
artery
VASCULAR DEMENTIA • Treatment of the underlying condition (hypertension, high cho-
Key signs and symptoms lesterol, or diabetes)
• Depression • Antiplatelet aggregate drugs: aspirin, ticlopidine (Ticlid)
• Difficulty following instructions Key interventions
• Emotional lability • Orient the patient to his surroundings.
• Inappropriate emotional reactions • Monitor the patient’s environment.
• Memory loss • Encourage the patient to express his feelings of sadness and
• Wandering and getting lost in familiar places loss.
Key test results
• The cognitive assessment scale shows a deterioration in cog-
nitive ability.
toms. The Clinical Dementia Rating delin- • Difficulty performing routine tasks
eates five stages in the disease. Another scale, • Changes in personality and judgment
the Global Deterioration Scale, delineates sev- • Decreased attention span
en. However, most health care providers cate-
gorize the disease in only three stages: mild, Stage 2 (moderate symptoms)
moderate, and severe. These three stages • Lasts from 2 to 10 years
may overlap, and the appearance and progres- • Anxiety
sion of symptoms may vary from one individ- • Obvious memory loss
ual to the next. • Confusion
• Suspiciousness
CONTRIBUTING FACTORS • Agitation
• Alterations in acetylcholine (a neurotrans- • Irritability
mitter) • Wandering
• Altered immune function, with autoantibody • Pacing
production in the brain • Sleep disturbances
• Family history, such as a first-degree rela- • Difficulty recognizing family members
tive with Alzheimer’s disease or Down syn-
drome Stage 3 (moderate to severe symptoms)
• Increased brain atrophy with wider sulci • Lasts from 5 to 15 years
and cerebral ventricles than seen in patients • Increasing loss of expressive language
who are aging normally skills
• Neurofibrillary tangles and beta amyloid • Loss of ability to perform activities of daily
neuritic plaques, mainly in the frontal and living
temporal lobes • Loss of reasoning ability
• Loss of appetite
DATA COLLECTION FINDINGS • Weight loss
Stage 1 (mild symptoms)
• Lasts from 1 to 3 years Stage 4 (severe symptoms)
• Confusion and short-term memory loss • Lasts from 5 to 15 years
• Disorientation to time and place • Absent cognitive abilities
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• Disorientation to time and place • Identify triggers to agitation (typically,

• Impaired or absent motor skills changes in the patient’s environment).
• Bowel and bladder incontinence • Redirect the patient’s focus, rather than ar-
guing, disagreeing, or being confrontational,
DIAGNOSTIC FINDINGS to prevent increasing agitation.
• The cognitive assessment scale demon- • Simplify the patient’s environmental tasks
strates that the patient has cognitive impair- and routines to prevent agitation.
ment. • Encourage the consumption of foods con-
• The functional dementia scale shows the de- taining folic acid, such as green, leafy vegeta-
gree of the dementia. bles, citrus fruits and juices, whole wheat
• Magnetic resonance imaging (MRI) shows bread, and dry beans, to maintain nutrition.
apparent structural and neurologic changes. • Encourage the patient and his caregiver to
• The Mini–Mental Status Examination re- initiate health care directives and decisions
veals that the patient has disorientation and while the patient still has the capacity to do
cognitive impairment. so, which can ease the burden on the caregiver
• The patient’s spinal fluid contains increased as the disease progresses.
beta amyloid. • Provide verbal and nonverbal communica-
tion that’s consistent and structured to pre-
NURSING DIAGNOSES vent added confusion.
• Bathing or hygiene self-care deficit • State expectations simply and completely to
• Impaired memory orient the patient.
• Risk for caregiver role strain • Increase the patient’s social interaction to
provide stimuli.
TREATMENT • Encourage the use of community resources
• Group therapy and make appropriate referrals to provide out-
• Palliative medical treatment side support for caregivers.
• Diet adequate in folic acid • Promote physical activity and sensory stim-
• Family support ulation to alleviate symptoms of the disorder.
• Provide an identification bracelet for the pa-
Drug therapy tient to help identify him if he wanders off.
• Anticholinesterase agents: tacrine
(Cognex), donepezil (Aricept), rivastigmine Teaching topics
Because patients (Exelon), galantamine (Reminyl) • Finding support and education (for care-
with Alzheimer’s are • Antipsychotic agents: haloperidol (Haldol), givers) (see Caring for the caregiver)
confused, risperidone (Risperdal) in low doses, olanza- • Learning stress-relief techniques (for care-
communicate with pine (Zyprexa) givers and patients)
them in a way that’s
• Benzodiazepines: alprazolam (Xanax), • Contacting the Alzheimer’s Association
consistent, direct,
and structured. lorazepam (Ativan), oxazepam (Serax)
• Vitamin E supplements
• Antidepressants: fluoxetine (Prozac), Amnesic disorder
paroxetine (Paxil), sertraline (Zoloft)
• N-methyl-D-aspartate receptor antagonist: With amnesic disorder, the patient experi-
memantine (Namenda) ences a loss of both short-term and long-term
memory. He’s unable to recall some or many
INTERVENTIONS AND RATIONALES past events. The patient’s abstract thinking,
• Remove any hazardous items or potential judgment, and personality usually remain in-
obstacles from the patient’s environment to tact. Symptoms may have a sudden or gradual
maintain a safe environment. onset and may be transient or long-lasting.
• Monitor the patient’s food and fluid intake Amnesic disorder differs from dissociative
because he may not maintain adequate nutri- amnesia in that it results from an identifiable
tion.
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Many NCLEX
Caring for the caregiver questions about
Alzheimer’s-type
Caring for a family member or friend with Alzheimer’s disease can place considerable strain on the dementia focus on
caregiver. Therefore, it’s important to encourage the caregiver to express his feelings. In many cas- caregivers, who are
es, caregivers feel confused, fearful, guilty, and grief stricken when a family member is diagnosed also significantly
with Alzheimer’s disease. Help the caregiver cope using these techniques: affected by this
• Discuss situations that are typically stressful, such as dealing with the patient’s hostility, anxiety, disorder.
and suspicion.
• Discuss resources needed to provide adequate, safe care. (The care of a patient with Alzheimer’s
disease can place financial strain on a family.)
• Work with the caregiver to develop a plan to obtain assistance from other family members, neigh-
bors, and friends.
• Reinforce the importance of the caregiver establishing a plan for maintaining personal well-being,
including recreation, rest, and exercise. (The stress of caring for a patient with Alzheimer’s disease
can leave the caregiver susceptible to illness.)
physical cause, rather than psychosocial NURSING DIAGNOSES

stressors. • Dressing or grooming self-care deficit
• Impaired memory
CONTRIBUTING FACTORS • Deficient knowledge (source of amnesia)
• Adverse effects of certain medications
• Brain surgery TREATMENT
• Cerebrovascular events • Correction of the underlying medical cause
• Encephalitis • Group therapy
• Exposure to a toxin • Family therapy
• Poorly controlled type 1 diabetes
• Substance abuse INTERVENTIONS AND RATIONALES
• Sustained nutritional deficiency • Use appropriate measures to promote the
• Traumatic brain injury patient’s safety because he may be unable to
maintain a safe environment.
DATA COLLECTION FINDINGS • Use environmental cues—for example, post
• Apathy and emotional blandness the patient’s name and schedule in his
• Confabulation in early stages room—to promote orientation.
• Confusion, disorientation, and lack of in- • Spend time with the patient and talk about
sight his health and self-care needs to encourage
• Inability to learn and retain new information greater self-understanding.
• Tendency to remember the remote past • Identify realistic short-term goals so the pa-
better than more recent events tient doesn’t become overwhelmed.
• Encourage him to explain his feelings,
DIAGNOSTIC FINDINGS which can spark memory.
• Medical tests (electrolyte levels, MRI, and • Provide simple, clear medical information to
computed tomography [CT] scan) confirm a help him understand his condition.
physical basis.
• The Mini–Mental Status Examination Teaching topics
shows the patient’s disorientation and inabili- • Understanding the underlying illness and
ty to recall events and information. its relationship to amnesic disorder
• Neuropsychological testing demonstrates
memory deficits.
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Delirium DIAGNOSTIC FINDINGS

• Laboratory results indicate that delirium is
Delirium is a condition that has a rapid onset a result of a physiologic condition, intoxica-
and is characterized by disorientation, im- tion, substance withdrawal, toxic exposure,
paired memory, changed personality, and mis- prescribed medicines, or a combination of
perceptions of the environment that can’t be these factors.
Dehydration is a attributed to preexisting dementia. Delirium
common cause of develops over a short period of time, usually NURSING DIAGNOSES
delirium, especially in hours to days, and tends to fluctuate during • Risk for injury
older patients. the course of the day. It’s potentially re- • Impaired memory
versible but can be life-threatening if not treat- • Disturbed thought processes
ed.
TREATMENT
CONTRIBUTING FACTORS • Correction of the underlying physiologic
• Cerebral hypoxia problem
• Dehydration (common cause in elderly pa- • Individual therapy
tients)
• Effects of medication Drug therapy
• Fever • Tranquilizer: droperidol (Inapsine)
• Fluid and electrolyte imbalances • Benzodiazepine: low-dose lorazepam (Ati-
• Hepatic and renal disease van)
• Infection (especially of the urinary tract and • Cholinesterase inhibitor: physostigmine
upper respiratory system) (Antilirium)
• Metabolic disorders • Antipsychotic agent: risperidone
• Neurotransmitter imbalance (Risperdal)
• Pain
• Polypharmacy, especially anticholinergics INTERVENTIONS AND RATIONALES
• Sensory overload or deprivation • Minimize excessive sensory stimuli to help
• Sleep deprivation the patient relax.
• Stress • Create a structured, safe, and supportive
• Substance intoxication environment to prevent the patient from harm-
ing himself.
DATA COLLECTION FINDINGS • Institute measures to comfort the patient to
Memory • Altered psychomotor activity, such as apa- help him relax and fall asleep.
jogger thy, withdrawal, and agitation • Keep the patient’s room lit to allay his fears
To help re- • Altered respiratory depth or rhythm and prevent visual hallucinations.
member • Bizarre, destructive behavior that worsens • Monitor the effects of medications to pre-
the difference beat night vent exacerbating symptoms.
tween delirium and • Disorganized thinking
dementia, think • Disorientation (especially to time and place) Teaching topics
DR. DID (delirium • Distractibility • Contacting community resources
reversible; dementia • Generalized seizures • Developing family coping skills
irreversible damage): • Impaired decision making • Managing the patient’s basic needs
Delirium is re- • Inability to complete tasks • Understanding the medication regimen
versible (though se- • Insomnia or daytime sleepiness
rious if not treat- • Picking at bed linen and clothes
ed). • Poor impulse control Vascular dementia
Dementia stems • Rambling, bizarre, or incoherent speech
from irreversible • Tremors Also called multi-infarct dementia, vascular
damage. • Visual and auditory hallucinations dementia impairs the patient’s cognitive func-
920115.qxd 8/7/08 3:05 PM Page 405
tioning, memory, and personality but doesn’t • Smoking cessation

Hmmm…Slurred
affect the patient’s level of consciousness. It’s • Treatment of the underlying condition speech and wandering,
caused by an irreversible alteration in brain (hypertension, high cholesterol, or diabetes) along with stroke
function that damages or destroys brain tis- symptoms? That
sue. Drug therapy sounds like vascular
• Antiplatelet aggregation drugs: aspirin, dementia.
CONTRIBUTING FACTORS ticlopidine (Ticlid)
• Cerebral emboli or thrombosis
• Diabetes INTERVENTIONS AND RATIONALES
• Heart disease • Orient the patient to his surroundings to
• High cholesterol level alleviate his anxiety.
• Hypertension (leading to stroke) • Monitor the patient’s environment to pre-
• Transient ischemic attacks vent overstimulation.
• Encourage him to express his feelings of
DATA COLLECTION FINDINGS sadness and loss to foster a healthy therapeutic
• Depression environment.
• Difficulty following instructions
• Dizziness Teaching topics
• Emotional lability • Controlling weight and diet
• Inappropriate emotional reactions • Exercising to decrease cardiovascular risk
• Memory loss factors
• Neurologic symptoms that last only a few
days
• Rapid onset of symptoms
• Slurred speech
• Syncopal episodes
• Wandering and getting lost in familiar
places
• Weakness in an extremity
DIAGNOSTIC FINDINGS
• The cognitive assessment scale shows a de-
terioration in cognitive ability.
• The global deterioration scale signifies that
the patient has degenerative dementia.
• The Mini–Mental Status Examination re-
veals that the patient is disoriented and has
Pump up on practice
difficulty recalling information.
• Structural and neurologic changes can be
questions
seen on MRI or CT scans. 1. The nurse is caring for one client diag-
• A carotid ultrasound may show stenosis. nosed with dementia and another client diag-
nosed with delirium. How does dementia dif-
NURSING DIAGNOSES fer from delirium?
• Disturbed thought processes 1. Dementia is confined to elderly people.
• Impaired memory 2. Delirium occurs only with substance
• Risk for injury abuse.
3. Delirium is an acute or subacute onset
TREATMENT of confusion.
• Carotid endarterectomy to remove block- 4. They aren’t different; their defining
ages in the carotid artery characteristics are interchangeable.
• Low-fat diet
920115.qxd 8/7/08 3:05 PM Page 406
Answer: 3. Delirium is characterized by an Client needs category: Physiological

acute or subacute onset of confusion, inter- integrity
spersed with alert and drowsy states. Neither Client needs subcategory: Reduction of
disorder is age-specific. Neither disorder is risk potential
restricted to individuals with histories of sub- Cognitive level: Analysis
stance abuse. Their defining characteristics
are different. 3. The nurse is reading the autopsy report of
Client needs category: Physiological a client who recently died. The report reveals
integrity senile plaques, neurofibril tangles, and atro-
Client needs subcategory: Reduction of phy. These changes are characteristic of
risk potential which illness?
Cognitive level: Comprehension 1. Meningitis
2. Delirium tremors
3. Neurosyphilis
4. Alzheimer’s disease
Answer: 4. Although some of these changes
can occur as part of the normal aging
process, these findings are characteristic of
Alzheimer’s disease—not of the other three
illnesses.
integrity
logical adaptation
2. The nurse is caring for a 78-year-old client Cognitive level: Knowledge
hospitalized with bilateral pneumonia. Shortly
after admission, he becomes extremely bel- 4. The nurse is caring for a client diagnosed
ligerent, confused, and hypotensive and devel- with Alzheimer’s-type dementia. Which of the
ops tachypnea. The nurse immediately admin- following medications is indicated for treat-
isters oxygen and anti-infectives and requests ment of this disorder?
that the CT scan of his head be delayed. Why? 1. Donepezil (Aricept)
1. The client’s change in mental status 2. Benazepril (Lotensin)
may be related to hypoxia, metabolic en- 3. Fosinopril (Monopril)
cephalopathy, and sepsis. 4. Lisinopril (Prinivil)
2. Taking this client to the radiology de- Answer: 1. Donepezil is an anticholinesterase
partment would jeopardize his condition. drug indicated for treatment of Alzheimer’s-
3. The client exhibited no signs of focal type dementia. Benazepril, fosinopril, and
neurologic impairment. lisinopril are angiotensin-converting enzyme
4. The client’s prognosis was poor and inhibitors that are indicated for treatment of
didn’t justify a CT scan. hypertension.
Answer: 1. Severe functional abnormalities Client needs category: Physiological
and confusion are commonly caused by non- integrity
neurologic diseases, especially in elderly Client needs subcategory: Pharmaco-
clients. Encephalopathies such as these are logical therapies
reversible if the underlying cause is treated. Cognitive level: Knowledge
The other choices—poor prognosis, absence
of signs of focal neurologic impairment, and
an unstable condition—aren’t appropriate jus-
tifications for delaying a diagnostic CT scan.
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5. The nurse is caring for a client with vascu- 3. Delirium

lar dementia. Which of the following diagnos- 4. Amnesia
tic tests or findings helps confirm the diagno- Answer: 3. Delirium is commonly a sign of un-
sis? derlying medical problems, especially in older
1. A drug screen for toxicology clients; it can be caused by hypoxia, infection,
2. The findings upon autopsy drugs, and metabolic disturbances. It’s poten-
3. MRI tially reversible. Dementia is usually charac-
4. The client’s response to electroconvul- terized by irreversible alterations in brain
sive therapy function. Although both amnesia and anxiety
Answer: 3. Vascular dementia is commonly may have some association with underlying
caused by cerebrovascular disease and very medical problems, neither is caused by such
small cerebral infarctions, which can be de- problems.
tected with an MRI. Attempts to diagnosis Client needs category: Physiological
vascular dementia wouldn’t be delayed until integrity
autopsy. A positive drug screen wouldn’t be Client needs subcategory: Physio-
helpful in diagnosing dementia caused by the logical adaptation
vascular problems. Electroconvulsive therapy Cognitive level: Comprehension
is occasionally used in the treatment for se-
lected psychiatric disorders, but it isn’t a diag-
nostic tool for dementia.
integrity
risk potential
6. The nurse is caring for a client diagnosed

with delirium. Which statement describes the
characteristics of delirium?
1. An acute onset and a duration of about
1 month. 8. The nurse is caring for a client who’s diag-
2. A slowly evolving onset and a duration nosed with delirium. What must the nurse
of about 1 week. provide for the client?
3. A slowly evolving onset and a duration 1. A safe environment
of about 1 month. 2. An opportunity to release frustration
4. An acute onset and a duration of hours 3. Prescribed medications
to a number of days 4. Medications as needed, judiciously
Answer: 4. Delirium has an acute onset and Answer: 1. Keeping the client with delirium
usually a duration of hours to a number of safe is the most important aspect of care. All
days. other choices are logical and appropriate, but
Client needs category: Physiological safety issues and meeting the client’s basic
integrity physiologic needs are of primary importance.
Client needs subcategory: Physio- Client needs category: Safe, effective
logical adaptation care environment
Cognitive level: Knowledge Client needs subcategory: Safety and
infection control
7. Which of the following can be caused by Cognitive level: Application
cerebral hypoxia, infection, drugs, or meta-
bolic disorders?
1. Dementia
2. Anxiety disorder
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9. The nurse is caring for a client experienc- 1. Encouraging the client to perform as
ing severe psychosocial stress. This condition much self-care as possible
could trigger which disorder? 2. Making the client assume responsibility
1. Wilson’s disease for physical care
2. Huntington’s disease 3. Assigning a staff member to take over
3. Amnesia the client’s physical care
4. Multiple sclerosis 4. Accepting the client’s desire to go with-
Answer: 3. Amnesia is usually triggered by se- out bathing
vere psychosocial stress, not physiologic Answer: 1. Clients with Alzheimer’s-type de-
causes. The other three choices are neurode- mentia tend to fluctuate in their capabilities.
generative disorders that commonly have Encouraging self-care to the extent possible
physiologic causes. will help increase the client’s orientation and
Client needs category: Psychosocial promote a trusting relationship with the
integrity nurse. Insisting that the client assume respon-
Client needs subcategory: None sibility for his physical care is unreasonable.
Cognitive level: Comprehension Assigning a staff member to take over care re-
stricts the client’s independence. Accepting
10. A 76-year-old client is admitted to a long- the client’s desire to go without bathing pro-
term care facility with a diagnosis of motes bad hygiene.
Alzheimer’s-type dementia. The client has Client needs category: Physiological
been wearing the same dirty clothes for sev- integrity
eral days, and the nurse contacts the family to Client needs subcategory: Reduction of
bring in clean clothing. Which intervention risk potential
would best prevent further regression in the Cognitive level: Application
client’s personal hygiene?
It’s okay to feel a

little delirious after
finishing this chapter.
Remember, you’ve taken
another step toward
conquering the NCLEX!
920116.qxd 8/7/08 3:06 PM Page 409
16 Personality
disorders
in early childhood and continue into adult-
In this chapter,
you’ll review:
Brush up on key hood, but actual diagnosis requires that the
patient be at least 18 years old and that he dis-
✐ factors that con-
tribute to the develop-
concepts played some symptoms of the disorder before
age 15.
ment of personality Personality traits are behavior patterns that
disorders reflect how people perceive and relate to oth- CONTRIBUTING FACTORS
✐ characteristics dis- ers and themselves. Personality disorders oc- • Childhood trauma
played by patients cur when these traits become rigid and mal- • Genetic predisposition
with personality dis- adaptive. According to the Diagnostic and • Physical abuse
orders Statistical Manual of Mental Disorders, 4th • Sexual abuse
✐ common personality ed., Text Revision, a personality disorder is a • Social isolation
disorders. problematic pattern occurring in two of the • Transient friendships
following areas: cognition, affectivity, interper- • Unstable or erratic parenting
sonal functioning, and impulse control. A per-
son with a personality disorder uses maladap- DATA COLLECTION FINDINGS
Be prepared for tive behavior to relate to others and to fulfill • Destructive tendencies
defensiveness. A basic emotional needs. The patient commonly • Excessively opinionated nature
patient suffering from doesn’t perceive that a problem exists, so • General disregard for the rights and feel-
a personality disorder medical treatment can be difficult. ings of others
isn’t likely to recognize At any time, you can review the major points • Impulsive actions
it in himself. of each disorder by consulting the Cheat sheet • Inability to maintain close personal or sexu-
on pages 410 and 411. al relationships
• Inflated and arrogant self-appraisal
• Lack of remorse
• Possible concurrent psychiatric disorders
Polish up on patient • Power-seeking behavior
• Previous violations of societal norms or
care rules
• Substance abuse
Major personality disorders include antisocial • Sudden or frequent changes in job, resi-
personality disorder, borderline personality dence, or relationships
disorder, dependent personality disorder, and • Superficial charm (manipulative)
paranoid personality disorder.
DIAGNOSTIC FINDINGS
• The Minnesota Multiphasic Personality In-
Antisocial personality ventory–2 reveals an antisocial personality
disorder.
disorder
NURSING DIAGNOSES
With antisocial personality disorder, the pa- • Risk for other-directed violence
tient displays disregard for the rights of oth- • Chronic low self-esteem
ers. Antisocial personality disorder can begin
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410 Personality disorders
et
heat she
C
Personality disorders refresher
ANTISOCIAL PERSONALITY DISORDER Key interventions
Key signs and symptoms • Recognize the behaviors that the patient uses
• Destructive tendencies to manipulate others.
• General disregard for the rights and feelings of • Set limits on behavior.
others • Provide a positive role model.
• Lack of remorse DEPENDENT PERSONALITY DISORDER
• Sudden or frequent changes in job, residence,
or relationships
• Clinging, demanding behavior
Key test result
• Fear and anxiety about losing the people the
• The Minnesota Multiphasic Personality Inven- patient is dependent on
tory–2 reveals an antisocial personality disorder. • Hypersensitivity to potential rejection and deci-
Key treatments sion making
• Behavioral therapy • Inability to make decisions
• Antimanic agent: lithium carbonate (Eskalith) • Low self-esteem
• Beta-adrenergic blocker: propanolol (Inderal) Key test result
for controlling aggressive outbursts • Laboratory tests rule out any underlying med-
• Selective serotonin reuptake inhibitor (SSRI): ical condition.
paroxetine (Paxil)
Key treatments
Key interventions
• Behavior modification through assertiveness
• Help the patient to identify manipulative be- training
haviors. • Individual therapy
• Establish a behavioral contract with the patient. • Benzodiazepines: alprazolam (Xanax), lor-
• Hold the patient responsible for his behavior. azepam (Ativan), clonazepam (Klonopin)
BORDERLINE PERSONALITY DISORDER • SSRIs: paroxetine (Paxil), sertraline (Zoloft)
• Destructive behavior • Support the patient in accepting increased de-
• Impulsive behavior cision making (such as balancing his checkbook,
• Inability to develop a healthy sense of self planning meals, and paying his bills).
• Inability to maintain relationships • Help him to identify his manipulative behaviors,
• Moodiness focusing on specific examples.
• Self-mutilation PARANOID PERSONALITY DISORDER
• Standard psychological tests reveal a high de- • Feelings of being deceived
gree of dissociation. • Hostility
Key treatments • Major distortions of reality
• Individual therapy • Social isolation
• Antimanic medications: valproate (Depakote), • Suspiciousness and mistrust of friends and
lithium carbonate (Eskalith) relatives
• Anxiolytic: buspirone (BuSpar) Key treatments
• SSRIs: paroxetine (Paxil), fluoxetine (Prozac), • Possible drug-free treatment to reduce the
sertraline (Zoloft) chance of causing increased paranoia
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Personality disorders refresher (continued)

PARANOID PERSONALITY DISORDER (continued) Key interventions
• Individual therapy • Establish a therapeutic relationship by listening and respond-
• Antipsychotic agents: olanzapine (Zyprexa), risperidone ing to the patient.
(Risperdal), chlorpromazine (Thorazine), thioridazine (Mellaril), • Instruct the patient in and help him to practice strategies that
fluphenazine (Prolixin), haloperidol (Haldol), quetiapine (Sero- facilitate the development of social skills.
quel)
TREATMENT Borderline personality

• Alcohol or drug rehabilitation (if appropri-
ate) disorder
• Behavioral therapy
• Group therapy Borderline personality disorder results in a
• Individual therapy pattern of instability in a person’s mood, inter-
personal relationships, self-esteem, self-
Drug therapy identity, behavior, and cognition. Impulsive-
• Antimanic agent: lithium carbonate ness is its most prominent characteristic. Al-
(Eskalith) though the exact cause isn’t knowing, it oc-
• Beta-adrenergic blocker: propranolol curs more commonly in families with a histo-
(Inderal) for controlling aggressive outbursts ry of the disorder.
• Selective serotonin reuptake inhibitor
(SSRI): paroxetine (Paxil) CONTRIBUTING FACTORS
• Brain dysfunction in the limbic system or
INTERVENTIONS AND RATIONALES frontal lobe
• Help the patient to identify manipulative be- • Decreased serotonin activity
haviors to help him counteract the perception • Early parental loss or separation
that others are extensions of himself. • Increased activity in alpha-2-noradrenergic
• Establish a behavioral contract to communi- receptors
cate to the patient that other behavior options • Major losses early in life
are available. • Physical abuse
• Avoid confrontations and power struggles to • Sexual abuse
maintain the opportunity for therapeutic com- • Substance abuse
munication. (See Dealing with antisocial per- Watch the patient
sonality disorder, page 412.) DATA COLLECTION FINDINGS with antisocial
• Hold the patient responsible for his behav- • Compulsive behavior personality disorder
ior to promote development of a collaborative • Destructive behavior for physical and verbal
relationship with the patient. • Dissociation (separating objects from their signs of agitation.
• Help the patient to manage anger, and ob- emotional significance)
serve him for physical and verbal signs of agi- • Dysfunctional lifestyle
tation. These steps will help him maintain a • Emotional reactions, with few cop-
healthy therapeutic environment. ing skills
• Extreme fear of abandonment
Teaching topics • High self-expectations
• Learning appropriate behaviors • History of substance abuse
• Continuing treatment after discharge •Impulsive behavior
• Inability to develop a healthy sense
of self
920116.qxd 8/7/08 3:06 PM Page 412
Be careful!
Patients receiving drug Dealing with antisocial personality disorder
therapy for borderline
personality disorder Aggressive behavior makes caring for the pa- • Encourage the patient to verbalize his aggres-
should take tient with antisocial personality disorder a chal- sive feelings.
medications only for lenge. Patients with this disorder are typically • Talk with him about appropriate ways to han-
targeted symptoms impulsive. They tend to lash out at those who in- dle anger such as channeling energy into social-
and only for a short terfere with their need for immediate gratifica- ly acceptable activities.
period. tion. Therefore, helping these patients express • Teach the patient coping strategies, such as
their anger in a nonviolent manner takes priority. negotiation skills, stress-reduction techniques,
The following steps may be helpful: and ways to communicate anger effectively.
• Maintain a safe environment.
• Inability to maintain relationships INTERVENTIONS AND RATIONALES

• Moodiness • Recognize the behaviors that the patient
• Paranoid ideation uses to manipulate others to avoid uncon-
• Self-directed anger sciously reinforcing these behaviors.
• Self-mutilation • Set limits on behavior to teach appropriate
• Shame interactions.
• Suicidal behavior • Provide a positive role model to help the pa-
• Viewing others as either extremely good tient identify appropriate behavior.
or bad • Respect the patient’s sense of personal
space to increase trust.
DIAGNOSTIC FINDINGS • Provide a safe and supportive environment.
• Standard psychological tests reveal a high Observe the patient frequently to prevent him
degree of dissociation. from injuring himself.
NURSING DIAGNOSES Teaching topics

• Impaired social interaction • Developing problem-solving skills
• Risk for self-directed violence • Developing therapeutic communication
• Chronic low self-esteem skills
• Implementing relaxation techniques
TREATMENT
• Alcohol and drug rehabilitation, as indi-
cated Dependent personality
• Group therapy
• Family therapy disorder
The patient with dependent personality disor-
Drug therapy der experiences an extreme need to be taken
• Antimanic medications: valproate (De- care of that leads to submissive, clinging be-
pakote), lithium carbonate (Eskalith) havior and fear of separation. This pattern be-
• Anxiolytic: buspirone (BuSpar) gins by early adulthood, when behaviors de-
• Monoamine oxidase inhibitor (MAOI): signed to elicit caring from others become
phenelzine (Nardil) predominant. These behaviors arise from the
• Narcotic detoxification adjunct agent: patient’s perception that he’s unable to func-
naltrexone (ReVia) tion adequately without others.
• SSRIs: paroxetine (Paxil), fluoxetine
(Prozac), sertraline (Zoloft)
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CONTRIBUTING FACTORS • Help the patient identify manipulative be-

• Childhood traumas haviors, focusing on specific examples, to de-
• Closed family system that discourages rela- crease the perception that others are extensions
tionships with others of himself.
• Genetic predisposition • Limit interactions with the patient to a few
• Physical abuse staff members to increase the patient’s sense of
• Separation anxiety disorder security.
• Sexual abuse
• Social isolation Teaching topics
• Expressing ideas and feelings assertively
DATA COLLECTION FINDINGS • Improving social skills and promoting social
• Clinging, demanding behavior interaction
• Exaggerated fear of losing approval • Substituting positive self-talk for negative
• Fear and anxiety about losing the people self-talk
he’s dependent on
• Hypersensitivity to potential rejection and
decision making Paranoid personality disorder
• Inability to make decisions
• Indirect resistance to occupational and so- Paranoid personality disorder is characterized
cial performance by extreme distrust of others. Paranoid peo-
• Low self-esteem ple avoid relationships in which they aren’t in
• Tendency to be passive control or have the potential of losing control.
Avoid supporting a
DIAGNOSTIC FINDINGS CONTRIBUTING FACTORS paranoid patient’s
• Laboratory tests rule out any underlying • Genetic link to schizophrenia delusions, but don’t
medical condition. • Neurochemical alteration attack his delusions
• Parental modeling of paranoid behaviors directly. This approach
NURSING DIAGNOSES only increases anxiety.
• Interrupted family processes DATA COLLECTION FINDINGS
• Ineffective coping • Bad temper
• Chronic low self-esteem • Delusional thinking
• Emotional reactions, including nervous-
TREATMENT ness, jealousy, anger, or envy
• Behavior modification through assertive- • Feelings of being deceived
ness training • Hostility
• Individual therapy • Hyperactivity
• Group therapy • Hypervigilance
• Irritability
Drug therapy • Lack of humor
• Benzodiazepines: alprazolam (Xanax), lor- • Lack of social support systems
azepam (Ativan), clonazepam (Klonopin) • Major distortions of reality
• SSRIs: paroxetine (Paxil), sertraline (Zoloft) • Need to be in control
• Refusal to confide in others
INTERVENTIONS AND RATIONALES • Self-righteousness
• Encourage activities that require decision • Social isolation
making (balancing his checkbook, planning • Sullen attitude
meals, and paying his bills) to promote inde- • Suspiciousness (mistrust of friends and rel-
pendence. atives)
• Help the patient establish and work toward
goals to foster a sense of independence.
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DIAGNOSTIC FINDINGS
• No specific test is available to diagnose
paranoid personality disorder.
NURSING DIAGNOSES
• Ineffective coping
• Risk for other-directed violence
• Social isolation
TREATMENT
• Possible drug-free treatment to reduce the
chance of causing increased paranoia
Drug therapy
Pump up on practice
• Antipsychotic agents: olanzapine (Zyprexa),
risperidone (Risperdal), chlorpromazine
questions
(Thorazine), thioridazine (Mellaril), 1. A client with a personality disorder is accu-
fluphenazine (Prolixin), haloperidol (Haldol) rately identifed when admitted to a medical-
in low doses, quetiapine (Seroquel) surgical unit after a recent surgery. The nurse
deliberately interacts with this client more
INTERVENTIONS AND RATIONALES than she interacts with another client, who
• Establish a therapeutic relationship by lis- had the same surgery. Both clients are recov-
tening and responding to the patient to initi- ering equally well. Why would the nurse do
ate therapeutic communication. this?
• Encourage the patient to take part in social 1. Other caregivers commonly minimize
interactions to introduce other people’s percep- contact with such clients.
tions and realities to him. 2. The nurse feels sorry for the client.
• Help the patient identify negative behaviors 3. One client has health insurance; the
that interfere with his relationships so he can other client doesn’t.
see how his behavior affects others. 4. The nurse suspects that the first client
• Instruct the patient in strategies that aid the isn’t recovering as well as reported.
development of social skills and help him Answer: 1. Because clients with personality
practice them. This approach can help him disorders can be demanding and difficult,
gain confidence and practice interacting with health care providers with little psychiatric
others. experience commonly try to limit their con-
• Avoid situations that the patient may per- tact with them. This tends to perpetuate be-
ceive as demeaning to decrease any hostile re- havioral problems, not improve them. This
sponse. nurse is acting to balance that trend. Sympa-
thy for a client, lack of health insurance, and
Teaching topics unfounded suspicions aren’t relevant consid-
• Learning coping strategies erations.
• Understanding the disorder (family and Client needs category: Psychosocial
patient) integrity
2. The nurse is caring for a client diagnosed

with paranoid personality disorder in an acute
care facility. Which intervention would the
nurse use to help reduce the patient’s suspi-
ciousness?
920116.qxd 8/7/08 3:06 PM Page 415
1. Keeping messages clear and consistent, 1. Personality disorder with low self-
while avoiding deception esteem
2. Providing pharmacologic therapy 2. Depression with need for counseling
3. Providing social interactions with oth- 3. Bipolar disorder with intense need for
ers on the unit pharmacologic therapy
4. Attending to basic daily needs of the 4. Suffering from lingering effects of
client on a consistent basis childhood abuse
Answer: 1. Keeping messages consistent, fos- Answer: 1. Given as much information as pre-
tering trust, and avoiding deception will help sented, a diagnosis of some type of personali-
reduce the patient’s suspiciousness. Encour- ty disorder and a nursing observation of low
aging social interaction, attending to basic dai- self-esteem are appropriate. Any of the other
ly needs, and providing pharmacologic thera- diagnoses and treatment options are possible
py are general nursing interventions appropri- concomitant problems, but further informa-
ate for patients with any psychiatric disorder. tion is needed.
Client needs category: Safe, effective Client needs category: Psychosocial
care environment integrity
Client needs subcategory: Safety and Client needs subcategory: None
infection control Cognitive level: Comprehension
5. The nurse is caring for a client who dis-
3. A client arrives on the psychiatric unit plays limited insight, a predilection for risky
from the emergency department. His diagno- behavior, and a history of trouble with the le-
sis is personality disorder, and he exhibits gal system. The client moves frequently, mak-
manipulative behavior. As the nurse reviews ing it difficult for him to maintain stable
the unit rules with him, the client asks, “Can I friendships. These characteristics are all asso-
go to the snack shop just one time, and then I ciated with which diagnosis?
will answer whatever you ask?” Which of the 1. Obsessive-compulsive disorder
following is the most appropriate response? 2. Midlife crisis
1. “Yes, but hurry, because I need to fin- 3. Cultural awareness deprivation
ish your assessment.” 4. Antisocial personality disorder
2. “Okay, but be back in 5 minutes.” Answer: 4. The characteristics described are
3. “No, you can’t go.” associated with impaired social functioning,
4. “No, you can’t go. The rules here apply a trait commonly attributed to clients with
to everyone.” antisocial personality disorder. Persons with
Answer: 4. This response sets limits with an obsessive-compulsive disorder are generally
appropriate explanation. Allowing the client to less inclined to engage in risky behavior or
go (options 1 and 2) gives in to his manipula- get in trouble with the legal system. Lack of
tive behavior. Option 3 doesn’t explain the awareness of cultural norms and midlife crisis
reason for the refusal. aren’t official psychiatric diagnoses.
Client needs category: Psychosocial Client needs category: Psychosocial
integrity integrity
Client needs subcategory: None Client needs subcategory: None
4. The nurse is caring for a client who’s a tal- 6. A nurse is teaching a client about healthy
ented, renowned neurosurgeon. He has been interpersonal relationships. Which character-
married several times and can’t manage to istic would the nurse include?
keep an employee because of his constant be- 1. Minimal self-revelation
littling and preoccupation with power and con- 2. Willingness to risk self-revelation
trol. What might be a diagnosis for this client? 3. Ego-dystonic behavior
4. Intimacy and merging of identities
920116.qxd 8/7/08 3:06 PM Page 416
Answer: 2. Willingness to risk self-revelation Answer: 4. Personality disorders are consid-

and achieving intimacy, while maintaining ered to be lifelong patterns with little relation-
separate identities, are characteristics of ship to age and developmental growth. Per-
healthy interpersonal relationships. Ego- sonality disorders are associated with low
dystonic behavior, the opposite of ego- self-esteem.
syntonic behavior, refers to thoughts, impuls- Client needs category: Psychosocial
es, attitudes, and behavior that the client feels integrity
are distressing, repugnant, or inconsistent Client needs subcategory: None
with the rest of his personality. Cognitive level: Comprehension
integrity 9. The nurse is caring for a client who has a
Client needs subcategory: None personality disorder. Which of the following
Cognitive level: Analysis findings should the nurse expect?
1. Manipulative behavior and inflated feel-
7. The nurse is caring for a client with a per- ings of self-worth
sonality disorder. What is the most significant 2. Manipulative behavior and inability to
obstacle for the nurse to overcome? tolerate frustration
1. Clients with personality disorders gen- 3. Suicidal ideation and starvation
erally lack the motivation to change. 4. Patterns of bulimia and starvation
2. In-house treatment is necessary, but Answer: 2. Manipulative behavior and inability
most insurance plans don’t cover such to tolerate frustration are important clues
measures. about personality. Low self-esteem—not inflat-
3. Appropriate pharmacologic therapy has ed feelings of self-worth—are more likely in
significant, potentially lethal adverse ef- clients with personality disorders. The other
fects. choices are more likely to be observed in
4. Neuroleptic medications aren’t always clients with eating disorders.
effective in helping the client maintain con- Client needs category: Psychosocial
I think I’m trol of his behavior. integrity
getting a Answer: 1. Lack of client motivation is the Client needs subcategory: None
borderline
most common cause of treatment failure in Cognitive level: Comprehension
anti-NCLEX
disorder! clients with personality disorders. The other
options may contribute to treatment failure in 10. The nurse is caring for a client with bor-
other psychiatric disorders but are less applic- derline personality disorder. Which interven-
able in clients with personality disorders. tion should the nurse perform?
Client needs category: Psychosocial 1. Setting limits on manipulative behavior
integrity 2. Allowing the client to set limits
Client needs subcategory: None 3. Using restraints judiciously
Cognitive level: Comprehension 4. Encouraging acting-out behavior
Answer: 1. Setting limits on manipulative be-
8. The nurse is caring for a client who has a havior provides the structure that the client
personality disorder. Which statement is true needs. Encouraging acting-out behavior and
regarding that client? allowing the client to set limits would be con-
1. Personality disorders are temporary traindicated. The need to restrain a client who
patterns of conflict within the individual. has borderline personality disorder is rare,
2. Developmental growth patterns and unless the patient has coexisting disorders.
chronological age will halt any behavior Client needs category: Psychosocial
disturbances. integrity
3. Personality disorders are associated Client needs subcategory: None
with high self-esteem. Cognitive level: Application
4. Personality disorders are lifelong be-
havior patterns.
920117.qxd 8/7/08 3:06 PM Page 417
17 Schizophrenic &
delusional disorders
Thought broadcasting
In this chapter,
you’ll review:
Brush up on key Delusions are false, fixed beliefs that aren’t
shared by other members of the patient’s so-
✐ major characteristics
of schizophrenic and
concepts cial, cultural, or religious background. Com-
monly, delusions occur in the form of thought
delusional disorders Schizophrenic and delusional disorders fall broadcasting, in which people believe that
✐ common schizo- under the diagnostic umbrella of psychosis. their personal thoughts are broadcast to the
phrenic and delusion- A psychotic illness is a brain disorder charac- external world. Many times, the patient be-
al disorders terized by an impaired perception of reality, lieves that his feelings, thoughts, or actions
✐ treatments and inter- commonly coupled with mood disturbances. aren’t his own.
ventions used in the The patient experiencing psychosis lacks in-
care of patients with sight into the unusual or bizarre thinking or Look for a theme
schizophrenic and behavior that accompanies the psychosis. Common themes characterize delusions.
delusional disorders. Psychosis can be either progressive or Delusional themes are described as persecu-
episodic. tor y, somatic, erotomanic, jealous, or
Schizophrenia is characterized by distur- grandiose. An example of a persecutory
bances (for at least 6 months) in thought con- delusion is the idea that one is being followed,
tent and form, perception, affect, sense of self, tricked, tormented, or made the subject of
volition, interpersonal relationships, and psy- ridicule. The patient with erotomanic delu-
chomotor behavior. sions falsely believes he shares an idealized
Delusional disorders are marked by false relationship with another person, usually
beliefs with a plausible basis in reality. Previ- someone of higher status such as a celebrity.
ously referred to as paranoid disorders, delu- An example of a somatic delusion is a patient
sional disorders affect less than 1% of the pop- who believes his body is deteriorating from
ulation. within. An example of jealous delusion is the
At any time, you can review the major points patient’s feeling that his or her spouse or
of each disorder by consulting the Cheat sheet lover is unfaithful. The patient with grandiose
on pages 418 and 419. delusions has an exaggerated sense of self-
importance.
Positive or negative
Symptoms of schizophrenia may be character- Hearing voices
ized as positive or negative. Positive symp- Most commonly, schizophrenics experience
toms focus on a distortion of normal func- auditor y hallucinations. When the patient
tions; negative symptoms focus on a loss of hears voices, he perceives these voices as be-
normal functions. Examples of positive symp- ing separate from his own thoughts. The con-
toms are delusions, hallucinations, disorga- tent of the voices may be threatening and
nized speech, and grossly disorganized or derogatory. Many times, the voices tell the pa-
catatonic behavior. Examples of negative tient to commit an act of violence against him-
symptoms include flat affect, alogia (poverty self or others.
of speech), and avolition (lack of self-initiated
behaviors). All over the place
When a patient has disorganized thinking
or looseness of associations, his speech
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418 Schizophrenic & delusional disorders
et
heat she
C
Schizophrenic & delusional disorders refresher
CATATONIC SCHIZOPHRENIA • Loose associations
Key signs and symptoms • Magical thinking (patient believes his
• Bizarre postures, waxy flexibility (posture held thoughts control others)
in odd or unusual fixed positions for extended pe- • Word salads
riods of time), and resistance to being moved Key test results
• Displacement (switching emotions from their • Neuropsychological and cognitive tests indi-
original object to a more acceptable substitute) cate impaired performance.
• Dissociation (separation of things from their Key treatments
emotional significance) • Milieu therapy
• Echolalia (repetition of another’s words) • Social skills training
• Echopraxia (involuntary imitation of another • Supportive psychotherapy
person’s movements and gestures) • Antipsychotics: chlorpromazine (Thorazine),
Key test results fluphenazine (Prolixin), haloperidol (Haldol), olan-
• Magnetic resonance imaging (MRI) shows pos- zapine (Zyprexa), quetiapine (Seroquel), risperi-
sible enlargement of lateral ventricles, enlarged done (Risperdal), thioridazine (Mellaril), aripipra-
third ventricle, and enlarged sulci. zole (Abilify), mesoridazine (Serentil)
• The patient shows impaired performance on Key interventions
neuropsychological and cognitive tests. • Help the patient meet his basic needs for food,
Key treatments comfort, and a sense of safety.
• Milieu therapy • During an acute psychotic episode, remove
• Supportive psychotherapy any potentially hazardous items from the pa-
• Antipsychotics: aripiprazole (Abilify), mesori- tient’s environment.
dazine (Serentil), fluphenazine (Prolixin), haloperi- • If the patient experiences hallucinations, en-
dol (Haldol), olanzapine (Zyprexa), quetiapine sure his safety and provide comfort and sup-
(Seroquel), risperidone (Risperdal), thioridazine port.
(Mellaril) • Encourage the patient with auditory halluci-
Key interventions nations to repeat what the voices are telling
• Provide skin care and reposition the patient him.
every 1 to 2 hours to prevent skin breakdown. • Encourage the patient to participate in one-
• Monitor the patient for adverse effects of an- on-one interactions, and then help him
tipsychotic drugs, such as dystonic reactions, progress to small groups.
tardive dyskinesia, and akathisia. • Provide positive reinforcement for socially ac-
• Be aware of the patient’s personal space; use ceptable behavior such as an effort to improve
gestures and touch judiciously. his hygiene and table manners.
• Provide appropriate measures to ensure the • Encourage the patient to express his feelings
patient’s safety. about the hallucinations he has experienced.
• Collaborate with the patient to identify anxious PARANOID SCHIZOPHRENIA
behaviors as well as probable causes.
DISORGANIZED SCHIZOPHRENIA • Delusions and auditory hallucinations
Key signs and symptoms • Dissociation
• Cognitive impairment • Inability to trust
• Fantasy
• Hallucinations
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Schizophrenic & delusional disorders refresher (continued)

PARANOID SCHIZOPHRENIA (continued) DELUSIONAL DISORDER
• MRI may show an enlargement of the ventricles and an en- • Delusions that are visual, auditory, or tactile
larged sulci. The presence of an enlarged sulci suggests corti- • Inability to trust
cal loss, particularly in the frontal lobe. • Projection
Key treatments Key test results
• Milieu therapy • Blood and urine tests eliminate an organic or chemical cause.
• Supportive psychotherapy • Endocrine function tests rule out hyperadrenalism, pernicious
• Antipsychotics: chlorpromazine (Thorazine), clozapine anemia, and thyroid disorders.
(Clozaril), fluphenazine (Prolixin), haloperidol (Haldol), olanza- • Neurologic evaluations rule out an organic cause.
pine (Zyprexa), risperidone (Risperdal), thioridazine (Mellaril), Key treatments
aripiprazole (Abilify), mesoridazine (Serentil) • Milieu therapy
Key interventions • Supportive psychotherapy
• Inform the patient that you’ll help him control his behavior. • Antipsychotics: chlorpromazine (Thorazine), clozapine
• Set limits on aggressive behavior and communicate your ex- (Clozaril), fluphenazine (Prolixin), haloperidol (Haldol), olanzapine
pectations to the patient. (Zyprexa), risperidone (Risperdal), thioridazine (Mellaril), aripi-
• Maintain a low level of stimuli. prazole (Abilify), mesoridazine (Serentil)
• Provide reality-based diversional activities. Key interventions
• Provide a safe environment. • Explore events that trigger delusions.
• Reorient the patient to time and place when appropriate. • Don’t directly attack the delusion.
• After the dynamics of the delusions are understood, discour-
age repetitious talk about delusions and refocus the conversa-
tion on the patient’s underlying feelings.
• Recognize the delusion as the patient’s perception of the envi-
ronment.
shifts randomly from one topic to another,

with only a vague connection between the top-
ics. While speaking, the patient may digress
to unrelated topics, make up new words (neol-
ogisms), repeat words involuntarily (persever-
care
ation), or repeat words or phrases similar in Major psychotic disorders include catatonic
sound only (clang association). schizophrenia, disorganized schizophrenia,
paranoid schizophrenia, and delusional
Loss of self disorder.
The patient may demonstrate a blunted, flat,
or inappropriate affect manifested by poor eye
contact; a distant, unresponsive facial expres- Catatonic schizophrenia
sion; and very limited body language. His
sense of self is disturbed, an experience re- A patient with catatonic schizophrenia shows
ferred to as loss of ego boundaries. This little reaction to his environment. Catatonic
loss of a coherent sense of self causes the pa- behavior involves remaining completely mo-
tient to experience difficulty in maintaining an tionless or continuously repeating one mo-
ongoing sense of identity. This may make it tion. This behavior can last for hours at a
impossible for the patient to maintain inter- time. Catatonic schizophrenia is the least
personal relationships or function at work and common type of schizophrenia.
in other life roles.
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CONTRIBUTING FACTORS • Social isolation

• A fragile ego that can’t withstand the de- • Speech resembling a word salad (string of
mands of reality words that aren’t connected in any way)
• Brain abnormalities
• Developmental abnormalities DIAGNOSTIC FINDINGS
• Genetic factors • Magnetic resonance imaging (MRI) may
• Hyperactivity of the neurotransmitter show an enlargement of lateral ventricles,
dopamine an enlarged third ventricle, and an enlarged
• An infectious agent or autoimmune re- sulci.
sponse (unproven cause) • The patient shows impaired performance
• Social or environmental stress, interacting on neuropsychological and cognitive tests.
with the person’s inherited biological makeup
NURSING DIAGNOSES
DATA COLLECTION FINDINGS • Disturbed thought processes
• Agitation that may be unexpected and dan- • Ineffective coping
gerous • Dressing or grooming self-care deficit
• Bizarre postures, waxy flexibility (posture
held in odd or unusual fixed positions for ex- TREATMENT
tended periods of time), and resistance to be- • Electroconvulsive therapy
ing moved • Family therapy
• Childlike, regressed behavior • Milieu therapy
• Clang association • Outpatient group therapy
• Displacement (switching emotions from • Psychoeducational programs
their original object to a more acceptable sub- • Social skills training
stitute) • Stress management
• Dissociation (separation of things from • Supportive psychotherapy
their emotional significance)
• Echolalia (repetition of another’s words) Drug therapy
• Echopraxia (involuntary imitation of anoth- • Antiparkinsonian agent: benztropine (Co-
A major difficulty
in treating er person’s movements and gestures) gentin) for adverse effects of antipsychotics
schizophrenia is that • Episodes of impulsiveness • Antipsychotics: aripiprazole (Abilify),
after patients’ more • Fantasy mesoridazine (Serentil), fluphenazine (Pro-
troubling symptoms • Inability to trust lixin), haloperidol (Haldol), olanzapine
recede, they believe • Little reaction to environment (Zyprexa), quetiapine (Seroquel), risperidone
they can discontinue • Mutism (Risperdal), thioridazine (Mellaril)
therapy and • Neologism
medication. • Projection INTERVENTIONS AND RATIONALES
• Purposeless overactivity or underactivity • Provide skin care and reposition the patient
• Ritualistic mannerisms every 1 to 2 hours to prevent skin breakdown.
• Monitor intake and output. Body weight may
Yet, when decrease as a result of inadequate intake.
treatment
• Monitor the patient for adverse effects of
stops, the
symptoms antipsychotic drugs, such as dystonic reac-
inevitably recur tions, tardive dyskinesia, and akathisia. Early
in full force. identification of extrapyramidal effects can help
diminish or eliminate the patient’s anxiety
about these symptoms.
• Be aware of the patient’s personal space;
use gestures and touch judiciously. Invading
the patient’s personal space can increase his
anxiety.
920117.qxd 8/7/08 3:06 PM Page 421
• When discussing the patient’s care, give • Social or environmental stress, interacting
short, simple explanations at his level of un- with the person’s inherited biological makeup
derstanding to increase cooperation.
• Provide appropriate measures to ensure the DATA COLLECTION FINDINGS Memory
patient’s safety. Explain to the patient why • Cognitive impairment jogger
you’re doing so. Implementing and explaining • Disorganized speech
safety measures can promote trust and decrease • Displacement To remem-
anxiety while increasing the patient’s sense of • Fantasy ber the
security. • Flat or inappropriate affect
major needs of
schizophrenic pa-
• Promote a trusting relationship to create a • Grimacing tients, think SDS:
safe environment in which the patient can • Hallucinations
practice social interaction skills to prepare for • Lack of coherence Structure—be-
social experiences. • Loose associations cause they tend to
• Briefly explain procedures, routines, and • Magical thinking (patient believes his
have too little in
their lives
tests to allay the patient’s anxiety. thoughts can control others)
• Collaborate with the patient to identify anx- • Word salads Diversion—to dis-
ious behavior as well as probable causes. In- tract them from
volving the patient in examination of behavior DIAGNOSTIC FINDINGS disturbing
can increase his sense of control. • MRI shows possible enlargement of the
thoughts
• Provide opportunities for the patient to ventricles and prominent cortical sulci. Stress reduction—
learn adaptive social skills in a nonthreaten- • Neuropsychological and cognitive tests indi- to minimize the
ing environment. Learning new social skills cate impaired performance. severity of the dis-
can enhance the patient’s adjustment after disorder
charge. NURSING DIAGNOSES
Teaching topics • Social isolation
• Accepting that his feelings are valid •Ineffective coping
• Understanding the importance of continu-
ing medications as prescribed TREATMENT
• Recognizing extrapyramidal effects of an- • Family therapy
tipsychotic medications • Milieu therapy
• Preventing photosensitivity reactions to the • Psychoeducational programs
drugs by avoiding exposure to sunlight • Social skills training
• Stress management
Forming a trusting
• Supportive psychotherapy
relationship is a key
Disorganized schizophrenia intervention for
Drug therapy patients with
Disorganized schizophrenics have a flat or in- • Antiparkinsonian agent: benztropine schizophrenia.
appropriate affect and incoherent thoughts. (Cogentin) for adverse effects of anti-
Patients with this disorder exhibit loose asso- psychotic medications
ciations and disorganized speech and be- • Antipsychotics: chlorpromazine (Thora-
haviors. zine), fluphenazine (Prolixin), haloperidol
(Haldol), olanzapine (Zyprexa), quetiapine
CONTRIBUTING FACTORS (Seroquel), risperidone (Risperdal), thiori-
• A fragile ego that can’t withstand the de- dazine (Mellaril), aripiprazole (Abilify),
mands of external reality mesoridazine (Serentil)
• Brain abnormalities
• Developmental involvement INTERVENTIONS AND RATIONALES
• Genetic factors • Help the patient meet his basic needs for
• Neurotransmitter abnormalities food, comfort, and a sense of safety to en-
sure the patient’s well-being and build trust.
920117.qxd 8/7/08 3:06 PM Page 422
• During an acute psychotic episode, remove mote better understanding of his experiences.
potentially hazardous items from the patient’s Allowing the patient to vent emotions reduces
environment to promote safety. anxiety.
• Briefly explain procedures, routines, and
tests to decrease the patient’s anxiety. Teaching topics
• Protect the patient from self-destructive • Learning to use distraction techniques
tendencies or aggressive impulses to ensure • Understanding the importance of following
his safety. the medication regimen
• Convey sincerity and understanding when
communicating to promote a trusting relation-
ship. Paranoid schizophrenia
• Formulate realistic goals with the patient.
Including him in formulating goals can help di- Patients with paranoid schizophrenia have
minish suspicion while increasing self-esteem delusions unrelated to reality. Patients com-
and a sense of control. monly display bizarre behavior, are easily an-
• If the patient experiences hallucinations, gered, and may act violently toward others.
don’t attempt to reason with him or challenge The prognosis for independent functioning is
his perception of hallucinations. Instead, en- typically better than the outlook for other
sure the patient’s safety and provide comfort types of schizophrenia.
and support. Attempts to reason with the pa-
tient increase anxiety, possibly making halluci- CONTRIBUTING FACTORS
nations worse. • A fragile ego that can’t withstand the de-
• Encourage the patient with auditory halluci- mands of external reality
nations to reveal what the voices are telling • Brain abnormalities
him to help prevent harm to the patient and • Developmental involvement
others. • Genetic factors
• Encourage the patient to participate in one- • Neurotransmitter abnormalities
Distraction on-one interactions, and then help him • Social or environmental stress, interacting
techniques, such as progress to small groups, which can enable with the person’s inherited biological makeup
singing along with him to practice his newly acquired social skills.
music, can alleviate • Provide positive reinforcement for socially DATA COLLECTION FINDINGS
hallucinations and acceptable behavior such as his effort to im- • Anxiety
help bring the patient
prove his hygiene and table manners. These • Argumentativeness
back to reality. Are
you two here to help steps foster improved social relationships and • Delusions and auditory hallucinations
with that? acceptance from others. • Displacement
• Encourage the patient to express his feel- • Dissociation
ings about experiencing hallucinations to pro- • Easily angered
• Inability to trust
• Potential for violence
• Projection
• Withdrawal or aloofness
DIAGNOSTIC FINDINGS
• MRI may show an enlargement of the ven-
tricles and an enlarged sulci. The presence of
the enlarged sulci suggests cortical loss, par-
ticularly in the frontal lobe.
• Neuropsychological and cognitive tests indi-
cate impaired performance.
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NURSING DIAGNOSES ple, say, “It seems that you feel you’ve been
• Disturbed thought processes treated unfairly.” Combatting delusions may in-
• Social isolation crease the patient’s feelings of persecution or Interventions for
schizophrenia promote
• Ineffective coping hostility.
the patient’s safety,
meet physical needs,
TREATMENT Teaching topics and help the patient
• Family therapy • Avoiding exposure to sunlight (to prevent deal with reality.
• Group therapy photosensitive reactions to antipsychotics)
• Milieu therapy • Reporting any adverse affects of antipsy-
• Psychoeducational programs chotic medications
• Social skills training • Understanding the importance of fol-
• Stress management lowing the medication regimen
• Supportive psychotherapy • Visiting the hospital weekly to have
blood chemistry monitored
Drug therapy
• Antiparkinsonian agent: benztropine
(Cogentin) for adverse effects of anti- Delusional disorder
psychotic drugs
• Antipsychotics: chlorpromazine (Tho- Patients with delusional disorder hold firmly
razine), clozapine (Clozaril), fluphenazine to false beliefs, despite contradictory informa-
(Prolixin), haloperidol (Haldol), olanzapine tion. They tend to be intelligent and can have
(Zyprexa), quetiapine (Seroquel), risperidone high levels of competence but also typically
(Risperdal), thioridazine (Mellaril), aripipra- have impaired social and personal relation-
zole (Abilify), mesoridazine (Serentil) ships. One indication of delusional disorder is
an absence of hallucinations.
• Inform the patient that you’ll help him con- CONTRIBUTING FACTORS
trol his behavior to promote feelings of safety. • Brain abnormalities
• Set limits on the patient’s aggressive behav- • Developmental involvement
ior and communicate your expectations to pre- • Family history of schizophrenic, avoidant,
vent injury to the patient and others. and paranoid personality disorders
• Maintain a low level of stimuli to minimize • Lower socioeconomic status
the patient’s anxiety, agitation, and suspicious- • Neurotransmitter abnormalities
ness. • Social or environmental stress that interacts
• Provide reality-based diversional activities. with the person’s inherited biological makeup
• Provide a safe environment.
• Reorient the patient to time and place when DATA COLLECTION FINDINGS
appropriate. • Antagonism
• Be flexible; allow the patient to have some • Brushes with the law
control. Let him talk about anything he wish- • Delusions that are visual, auditory, or tactile
es, but keep the conversation light and social • Denial
to avoid power struggles. • Ideas of reference (everything in the envi-
• Don’t let the patient put you on the defen- ronment takes on a personal significance)
sive, and don’t take his remarks personally. If • Inability to trust
he tells you to leave him alone, do leave but • Irritable or depressed mood
return soon. Brief contacts with the patient • Marked anger and violence
may be most useful at first. • Projection
• Don’t make attempts to combat the patient’s • Stalking behavior (as in erotomania, which
delusions with logic. Instead, respond to feel- is the belief that the patient is loved by a
ings, themes, or underlying needs. For exam- prominent person)
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DIAGNOSTIC FINDINGS Drug therapy

• Blood and urine tests eliminate an organic • Antiparkinsonian agent: benztropine
or chemical cause. (Cogentin) for adverse effects of antipsychot-
• Endocrine function tests rule out hypera- ic medications
drenalism, pernicious anemia, and thyroid • Antipsychotics: chlorpromazine (Tho-
disorders. razine), clozapine (Clozaril), fluphenazine
• Neurologic evaluations rule out an organic (Prolixin), haloperidol (Haldol), olanzapine
cause. (Zyprexa), risperidone (Risperdal), thiori-
dazine ( Mellaril), aripiprazole (Abilify),
NURSING DIAGNOSES mesoridazine (Serentil)
• Impaired social interaction
• Ineffective coping INTERVENTIONS AND RATIONALES
• Risk for other-directed violence • Formulate realistic goals with the patient.
Including the patient when setting goals may
TREATMENT help diminish suspicion and increase his self-
• Family therapy esteem and sense of control.
• Group therapy • Establish a therapeutic relationship to foster
• Milieu therapy the patient’s trust.
• Psychoeducational programs • Explore the events that trigger the patient’s
• Stress management delusions. Discuss the anxiety associated with
• Supportive psychotherapy these triggering events. Discussing the triggers
will help you understand the dynamics of the
patient’s delusional system.
• Don’t directly attack the patient’s delusions.
Differentiating
Instead, be patient in formulating a trusting
delusional disorder from
schizophrenia can be relationship. Directly attacking the patient’s
tricky. Delusions reflect delusions can increase his anxiety.
reality in a somewhat • After the dynamics of the delusions are un-
distorted way. derstood, discourage repetitious talk about
Schizophrenia is delusions. Refocus the conversation on the
indicated by scattered patient’s underlying feelings. As the patient
and incoherent identifies and explores his feelings, he will de-
thoughts unrelated to crease reliance on delusional thought.
reality. • Recognize that the delusions are the pa-
tient’s perception of the environment. Avoid
getting into arguments with him about the
content of the delusions to foster his trust.
Teaching topics
• Learning decision-making, problem-solving,
and negotiating skills
• Understanding the importance of comply-
ing with the medication regimen
• Understanding the potential adverse effects
of the medications
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Answer: 1. The scenario describes a client

who may be hallucinating. Not enough infor-
mation is available to suggest that she’s a
threat to society or to herself. Malingering
refers to a medically unproved symptom
that’s consciously motivated.
integrity
3. The nurse is caring for a client who she

suspects is paranoid. How would the nurse
Pump up on practice communicate with this client?
1. Indirect questioning
questions 2. Direct questioning
3. Lead-in sentences
4. Open-ended sentences
1. The nurse is caring for a client diagnosed Answer: 2. A direct question (such as “Do you
with schizophrenia. Which of the following is hear voices?” or “Do you feel safe right
an example of a negative symptom? now?”) is the most appropriate technique for
1. Delusions eliciting a verifiable response from a psychot-
2. Disorganized speech ic client. The other options may not elicit
3. Flat affect helpful responses.
4. Catatonic behavior Client needs category: Psychosocial
Answer: 3. Negative symptoms focus on a loss integrity
of normal functions and include flat affect, alo- Client needs subcategory: None
gia, and avolition. Positive symptoms focus on Cognitive level: Application
a distortion of normal functions and include
delusions, hallucinations, disorganized
speech, and grossly disorganized or catatonic
behavior.
integrity
2. The nurse is caring for a client who the po-

lice found huddled in her apartment. The
client stares toward one corner of the room
and seems to be responding to something
that others can’t see. She appears hyperalert 4. The nurse is caring for a client who’s expe-
and scared. How would you evaluate this situ- riencing auditory hallucinations. What would
ation? be most crucial for the nurse to evaluate?
1. The client may be hallucinating. 1. Possible hearing impairment
2. The client is suicidal. 2. Family history of psychosis
3. Nothing is wrong because the client 3. Content of the hallucinations
isn’t a threat to society. 4. Possible sella turcica tumors
4. The client is malingering.
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Answer: 3. To prevent the client from harming Client needs category: Psychosocial
himself or others, the nurse should encour- integrity
age him to reveal the content of auditory hal- Client needs subcategory: None
lucinations. Family history, although impor- Cognitive level: Knowledge
tant because of possible genetic components,
isn’t an immediate concern. Olfactory halluci- 6. The nurse is preparing to care for a client
nations, not auditory hallucinations, are asso- diagnosed with catatonic schizophrenia. In an-
ciated with sella turcica tumors. Assessing for ticipation of his arrival, what should the nurse
hearing impairment would be inappropriate. do?
Client needs category: Safe, effective 1. Notify security.
care environment 2. Prepare a magnesium sulfate drip.
Client needs subcategory: Safety and 3. Place a specialty mattress overlay on
infection control the bed.
Cognitive level: Application 4. Tell the dietary department that the
client should receive nothing by mouth.
Answer: 3. The nurse should first focus on
meeting the client’s immediate physical needs
and preventing complications related to his
catatonic state. The need for intervention
from security personnel is unlikely. A magne-
sium sulfate drip isn’t needed. The nurse
should address the client’s nutritional status
after he’s undergone a complete evaluation.
integrity
and comfort
5. The nurse is caring for a client who’s dis- Cognitive level: Application
playing signs of an acute confused state. What
are the two most common causes of such a
condition?
1. Advanced age and alcohol intake
2. Sensory deprivation and physical chal-
lenges
3. Acute schizophrenia and bipolar illness
4. Cardiac arrhythmias and stroke
Answer: 3. Acute schizophrenia and bipolar ill-
ness are the two most commonly cited causes
of acute confused states. Advanced age, alco-
hol intake, and sensory deprivation can cause
confusion, but chronic or subacute causes are
more likely. Cardiac and cerebral problems
are less likely to cause psychological symp-
toms.
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7. The nurse is caring for a client with disor- Answer: 4. Catatonic schizophrenia is the least
ganized schizophrenia. He’s responding well common type of schizophrenia.
to therapy but has had limited social contact Client needs category: Psychosocial
with others. Which intervention is most ap- integrity
propriate? Client needs subcategory: None
1. Discourage the client from interacting Cognitive level: Knowledge
with others because, if his efforts fail, the
experience will be too traumatic for him.
2. Encourage the client to attend a party
thrown for the residents of the facility.
3. Encourage the client to participate in
one-on-one interactions.
4. Encourage the client to place a personal
advertisement in the local newspaper but
not to reveal his mental disability.
Answer: 3. Encourage the client to participate
in one-on-one interactions, and then help him
progress to small groups. This enables him to
practice his newly acquired social skills.
Client needs category: Psychosocial 9. For clients with which type of schizophre-
integrity nia should the nurse expect to provide the
Client needs subcategory: None most physical care?
Cognitive level: Application 1. Disorganized type
2. Catatonic type
3. Paranoid type
4. Undifferentiated type
Answer: 2. With catatonic schizophrenia, the
client exhibits little reaction to his environ-
ment, although periods of excitement may
surface at times. Bizarre postures and the in-
ability to feed, wash, and dress himself also
occur with this type of schizophrenia. Activi-
ties of daily living may be affected in varying
degrees in clients with other types of schizo-
phrenia, but to a lesser extent.
integrity
8. What’s the least common type of schizo- Client needs subcategory: Basic care
phrenia? and comfort
1. Undifferentiated Cognitive level: Knowledge
2. Paranoid
3. Residual
4. Catatonic
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10. The nurse is caring for a client who has though thyroid disorders can be a cause of
schizophrenia. What is the first-line treatment psychotic-like symptoms, they aren’t a cause
for this client? of schizophrenia. Milieu therapy may be help-
1. Group therapy ful but isn’t a first-line treatment. Group thera-
2. Thyroid replacement therapy in select- py also wouldn’t be a first-line treatment.
ed individuals Client needs category: Physiological
3. Milieu therapy integrity
4. Antipsychotic medications Client needs subcategory: Pharmaco-
Answer: 4. Antipsychotic medications are the logical therapies
first-line treatment for schizophrenia. Al- Cognitive level: Application
If you can’t get

enough of psych
disorders, you’re in
luck. Find out more in
the next chapter.
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18 Substance-related
disorders
The monkey ON the back
In this chapter,
you’ll review:
Brush up on key Substance dependence is characterized by
physical, behavioral, and cognitive changes
✐ classes of controlled
substances
concepts resulting from persistent substance use. Per-
sistent drug use can result in tolerance and
✐ common substance The relationship between mental illness and withdrawal.
abuse disorders substance use and abuse is complex. Alcohol
✐ substance abuse as- and psychoactive drugs alter a person’s per- Just can’t get enough
sessment and treat- ceptions, feelings, and behavior. People may Tolerance is defined as an increased need for
ment. use substances for that reason. Many people a substance or a need for an increased
who suffer from emotional disorders or men- amount of the substance to achieve an effect.
tal illness turn to drugs and alcohol to self-
medicate as a coping mechanism. Yet, this The monkey OFF the back
method of self-treating is usually ineffective Withdrawal occurs when the tissue and
and may result in dependence. blood levels of the substance decrease in a
Nursing care for a substance abuser begins person who has engaged in prolonged, heavy
with identification of which substance is being use of the substance.
abused. During the acute phase, care focuses When uncomfortable withdrawal symptoms
on maintaining the patient’s vital functions persist, the person usually takes the sub-
and safety. Rehabilitation involves helping the stance to relieve the symptoms. Withdrawal
patient to realize his substance abuse prob- symptoms vary from substance to substance.
lem and find alternative methods of dealing
with stress. The nurse helps him to achieve
recovery and stay drug-free. Classes of controlled
of each disorder by consulting the Cheat sheet substances
on page 430.
Each class of controlled substance has a dif-
Social use? ferent effect on the body and thus produces
Substance intoxication is the development different reactions. Common classes of con-
of a reversible substance-specific syndrome trolled substances include:
due to ingestion of or exposure to a sub- • cannabis
stance. The clinically significant maladaptive • depressants
behavior or psychological changes vary from • designer drugs
substance to substance. • hallucinogens
• inhalants
It’s a problem • opiates and related analgesics
The essential feature of substance abuse is • phencyclidine
a maladaptive pattern of substance use cou- • stimulants.
pled with recurrent and significant adverse
consequences. CANNABIS
Tetrahydrocannabinol, the active ingredient
in hashish and marijuana, alters sensory per-
ceptions and produces a type of euphoria, in-
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430 Substance-related disorders
et
heat she
C
Substance-related disorders refresher
ALCOHOL DISORDER Key treatments
Key signs and symptoms • Detoxification
• History of alcohol intake • Rehabilitation (inpatient or outpatient)
• History of blackouts • Narcotics Anonymous
• Pathologic intoxication • Individual therapy
• Symptoms of withdrawal • Anxiolytics: lorazepam (Ativan), Alprazolam
Key test results (Xanax)
• Dopamine agent: bromocriptine (Parlodel)
• CAGE questionnaire responses indicate alco-
• SSRIs: fluoxetine (Prozac), paroxetine (Paxil)
holism.
• Michigan Alcoholism Screening test results Key interventions
indicate alcoholism. • Establish a trusting relationship with the patient.
Key treatments • Provide the patient with well-balanced meals.
• Set limits on the patient’s attempts to rationalize
• Alcoholics Anonymous
his behavior.
• Rehabilitation OTHER SUBSTANCE ABUSE DISORDERS
• Antidepressants: bupropion (Wellbutrin) Key signs and symptoms
• Anxiolytics: chlordiazepoxide (Librium), • Blaming others for problems
diazepam (Valium), lorazepam (Ativan) • Development of biological or psychological
• Disulfiram (Antabuse) to prevent relapse into al- need for a substance
cohol abuse (the patient must be alcohol-free for • Dysfunctional anger
12 hours before administering this drug) • Feelings of grandiosity
• Naltrexone (Trexan) to prevent relapse into al- • Impulsiveness
cohol abuse • Use of denial and rationalization to explain con-
• Selective serotonin reuptake inhibitors (SSRIs): sequences of behavior
fluoxetine (Prozac), paroxetine (Paxil)
Key test result
Key interventions
• A drug screening is positive for the abused sub-
• Evaluate the patient’s use of alcohol as a cop- stance.
ing mechanism.
Key treatments
• Set limits on denial and rationalization.
• Have the patient formulate goals for actions • Individual therapy
that will help him maintain a lifestyle free from • Clonidine (Catapres) for opiate withdrawal
substance abuse. symptoms
• Methadone maintenance for opiate addiction
COCAINE-USE DISORDER detoxification
• Elevated energy and mood • Ensure a safe, quiet environment free from
• Grandiose thinking stimuli.
• Impaired judgment • Monitor for withdrawal symptoms, such as
Key test result tremors, seizures, and anxiety.
• A drug screening is positive for cocaine. • Help the patient understand the consequences
of substance abuse.
• Encourage the patient to vent fear and anger.
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creased appetite, tachycardia, lack of coordi- OPIATES AND RELATED ANALGESICS

nation, and impaired judgment and memory. These substances dull the senses and bring
Marijuana is considered a “gateway drug”— about sedation and a dreamlike state, and can
a drug whose use often leads to a higher level cause respiratory depression and cardiac ar-
of drug use. rest:
• heroin
DEPRESSANTS • morphine
These substances slow down central nervous • codeine
system (CNS) functioning, causing slurred • opium
speech, impaired judgment, and mood • methadone
swings. They can cause respiratory distress • meperidine.
when taken in overdose. Common depres-
sants include: PHENCYCLIDINE
• alcohol Phencyclidine (PCP), also known as angel
• barbiturates dust, heightens the patient’s CNS function,
• benzodiazepines. distorts his perception, and has powerful anal-
gesic effects.
DESIGNER DRUGS
These substances are similar to other classes STIMULANTS
of drugs, but they’re manufactured with These substances stimulate the CNS:
chemical changes that, in some cases, make • amphetamines
them more dangerous. Common designer • cocaine (including crack cocaine)
drugs include: • caffeine
• china white (synthetic type of heroin) • nicotine.
• ecstasy.
HALLUCINOGENS
These substances produce sympathetic and
parasympathetic stimulation, hallucinations,
dissociative states, and bizarre, irrational, ag-
gressive, and sometimes violent behavior.
care
They may also cause confusion, delusions, Patients can become dependent on almost
and paranoia. Common hallucinogens any controlled substance. Though specific cir- Caffeine and
include: cumstances may vary, the causes and treat- nicotine are
• lysergic acid diethylamide (LSD) ments remain similar for each substance. classified as
stimulants because
• mushrooms (psilocybin)
of the effects they
• mescaline (from peyote cactus). have on the body.
Alcohol disorder
INHALANTS
Use of inhalants is called “huffing.” These A patient’s dependence on and abuse of alco-
substances aren’t drugs, but can alter a per- hol is considered a substance abuse disorder.
son’s sensorium after he inhales the fumes. However, the data collected and the recom-
Common inhalants include: mended treatment differ somewhat from that
• glue for other types of substance abuse. Alcohol is
• cleaning solutions a sedative, but it may also create a feeling of
• nail polish remover euphoria. The level of sedation increases with
• aerosols the amount the patient ingests. Respiratory
• petroleum products depression and coma can occur with toxicity.
• paint thinners.
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CAUSES Drug therapy

• Familial tendency • Antidepressant: bupropion (Wellbutrin)
• Gender (males have an increased likelihood • Anxiolytics: chlordiazepoxide (Librium), di-
Because alcohol of dependence) azepam (Valium), or lorazepam (Ativan) to
use is widely accepted, • History of abuse, depression, or anxiety treat withdrawal symptoms
therapeutic • Influence of nationality and ethnicity • Disulfiram (Antabuse) to prevent the pa-
communication may • Personality disorders tient’s relapse into alcohol abuse (he must be
involve dealing with a • Religious or family taboos regarding alcohol alcohol-free for 12 hours before administering
patient’s consumption this drug)
rationalizations. • Naltrexone (Trexan) to prevent relapse into
DATA COLLECTION FINDINGS alcohol abuse
• GI bleeding • Selective serotonin reuptake inhibitors
• Hallucinations (SSRIs): fluoxetine (Prozac), paroxetine
• History of alcohol intake (Paxil)
• History of blackouts
• History of liver disease INTERVENTIONS AND RATIONALES
• Irrational behavior • Provide safety measures to help prevent in-
• Korsakoff’s psychosis jury.
• Paranoid conversations • Monitor the patient for signs of withdrawal,
• Pathologic intoxication such as elevated blood pressure, tachycardia,
• Peripheral neuropathy nausea, vomiting, anxiety, and agitation. The
• Symptoms of withdrawal patient may also experience hallucinations,
tremors, and delirium.
DIAGNOSTIC FINDINGS • Evaluate the patient’s use of alcohol as a
• A drug screening is positive for alcohol. coping mechanism to formulate a therapeutic
• The responses to a CAGE questionnaire in- care plan.
dicate alcoholism. (See The CAGE question- • Encourage him to verbalize his anger, fear,
naire.) inadequacy, grief, and guilt to promote healthy
• Michigan Alcoholism Screening test results coping behaviors.
indicate alcoholism. • Set limits on denial and rationalization to
help the patient gain control and perspective.
NURSING DIAGNOSES • Have the patient formulate goals for actions
• Ineffective denial that will help him maintain a drug-free lifestyle
• Ineffective coping and avoid relapses.
• Risk for injury
Teaching topics
TREATMENT • Understanding substance abuse and relapse
• Alcoholics Anonymous prevention
• Individual therapy • Maintaining good nutrition
• Rehabilitation
The CAGE questionnaire

The CAGE questionnaire is a brief, unscored examination meant 1. Have you ever felt you should Cut down on your drinking?
to provide a standard for assessing alcohol addiction. Any two 2. Have people Annoyed you by criticizing your drinking?
positive responses to these four yes-or-no questions strongly 3. Have you ever felt bad or Guilty about your drinking?
suggest alcohol dependence. 4. Have you ever had an Eye-opener first thing in the morning
because of a hangover or just to get the day started?
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Cocaine-use disorder • Provide well-balanced meals to compensate

for nutritional deficits.
Cocaine-use disorder results from the potent • Provide a safe environment. The patient
euphoric effects of the drug. Individuals ex- may pose a risk to himself or others.
posed to cocaine develop dependence after a • Set limits on the patient’s attempts to ratio-
very short period of time. Maladaptive behav- nalize behavior to reduce inappropriate behav-
ior follows, resulting in social dysfunction. Co- ior.
caine use can also cause serious physical
complications, such as cardiac arrhythmias, Teaching topics
myocardial infarction, seizures, and stroke. • Contacting Narcotics Anonymous
• Using coping strategies
CONTRIBUTING FACTORS • Managing stress
• Genetic predisposition
• History of abuse, depression, or anxiety
• Personality disorder Other substance abuse
DATA COLLECTION FINDINGS disorders
• Elevated energy and mood
• Grandiose thinking Other substance abuse disorders include all
• Impaired judgment patterns of abuse excluding alcohol and co-
• Impaired social functioning caine. These disorders have a great deal in
• Paranoia common, though symptoms vary depending
• Violent behavior on the abused substance.
• Weight loss
DIAGNOSTIC FINDINGS • Familial tendency
• A drug screening is positive for cocaine. • Gender (females have an increased likeli-
hood of abusing prescription drugs; males
NURSING DIAGNOSES generally have an increased likelihood of de-
• Ineffective health maintenance pendence)
• Imbalanced nutrition: Less than body re- • History of abuse, depression, or anxiety During a
quirements • Influence of nationality and ethnicity psychiatric evaluation,
• Risk for other-directed violence • Personality disorders always check for drug
or alcohol use, which
TREATMENT DATA COLLECTION FINDINGS can produce
• Detoxification • Attempts to avoid anxiety and other emo- symptoms that mimic
• Rehabilitation (inpatient or outpatient) tions those of mental
• Narcotics Anonymous • Attempts to avoid conscious feelings of guilt illness.
• Individual therapy and anger
• Attempts to meet needs by influencing oth-
Drug therapy ers
• Anxiolytics: lorazepam (Ativan), alprazolam • Blaming others for problems
(Xanax) • Development of a biological or
• Dopamine agent: bromocriptine (Parlodel) psychological need for a substance
• SSRIs: fluoxetine (Prozac), paroxetine (Pax- • Dysfunctional anger
il) • Feelings of grandiosity
• Impulsiveness
INTERVENTIONS AND RATIONALES • Manipulation and deceit
• Establish a trusting relationship with the pa- • Need for immediate gratification
tient to alleviate any anxiety or paranoia. • Pattern of negative interactions
• Possible malnutrition
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• Symptoms of withdrawal
• Use of denial and rationalization to explain
consequences of behavior
DIAGNOSTIC FINDINGS
• A drug screening is positive for the abused
substance.
NURSING DIAGNOSES
• Ineffective health maintenance
• Imbalanced nutrition: Less than body
requirements
TREATMENT
Pump up on practice
• Behavior modification
• Employee assistance programs
questions
• Family counseling
• Group therapy 1. The nurse is talking to a client about am-
• Halfway houses phetamines, cocaine, and caffeine. How would
• Individual therapy the nurse classify these substances?
• Informal social support 1. Opiates
• Self-help groups 2. Analgesics
3. Stimulants
Drug therapy 4. Depressants
• Clonidine (Catapres) for opiate withdrawal Answer: 3. Amphetamines, cocaine, and caf-
symptoms feine are stimulants. Stimulation isn’t a chief
• Methadone maintenance for opiate addic- effect of drugs in the other three categories.
tion detoxification Client needs category: Physiological
integrity
INTERVENTIONS AND RATIONALES Client needs subcategory: Reduction of
• Ensure a safe, quiet environment free from risk potential
stimuli to provide a therapeutic setting and to Cognitive level: Knowledge
minimize withdrawal symptoms.
• Monitor for withdrawal symptoms, such as 2. The nurse is caring for a client who has a
delirium tremens, seizures, anxiety, elevated history of alcohol abuse. Why would the
blood pressure, nausea, and vomiting, to pro- client act as if he didn’t have a problem?
vide the most comfortable environment possible. 1. The client has never taken the CAGE
• Evaluate the patient for polysubstance questionnaire.
abuse to plan appropriate interventions. 2. Denial is a defense mechanism com-
• Help the patient understand the conse- monly used by alcoholics.
quences of his substance abuse to assist recov- 3. His thought processes are distorted.
ery. 4. Alcohol is inexpensive.
• Provide measures to induce sleep to help the Answer: 2. Denial is a defense mechanism
patient manage the discomfort of withdrawal. commonly used by alcoholics. The CAGE
• Encourage the patient to vent his fear and questionnaire is a direct method of discover-
anger so he can begin the healing process. ing whether the client is a substance abuser,
but the client is likely to deny the problem re-
Teaching topics gardless of whether he’s familiar with this as-
• Contacting addiction support agencies sessment tool. Distorted thought processes
• Learning healthy coping mechanisms
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and the cost of alcohol are less likely to have Client needs category: Physiological
an impact on the client’s use of denial. integrity
Client needs category: Psychosocial Client needs subcategory: Physio-
integrity logical adaptation
5. The nurse is interviewing a client who’s
3. The nurse is caring for a client who ex- currently under the influence of a controlled
hibits pinpoint pupils as well as decreased substance and shows signs of becoming agi-
blood pressure, pulse, respirations, and tem- tated. What should the nurse do?
perature. These symptoms may be a sign of 1. Use confrontation.
intoxication with which substance? 2. Express disgust with the client’s
1. Opiate behavior.
2. Amphetamine 3. Be aware of how to contact hospital se-
3. Cannabis curity.
4. Alcohol 4. Communicate a scolding attitude to in-
Answer: 1. Opiates, such as morphine and timidate the client.
heroin, cause these changes. Amphetamines Answer: 3. The nurse, for her own protection,
dilate pupils. Cannabis intoxication causes should be aware of how to contact hospital se-
tachycardia, dry mouth, and increased ap- curity and other assisting personnel. The oth-
petite. Alcohol intoxication causes unsteady er options may escalate the client’s agitation.
gait, lack of coordination, nystagmus, and Client needs category: Safe, effective
flushed face. care environment
Client needs category: Physiological Client needs subcategory: Coordinated
integrity care
Client needs subcategory: Physio- Cognitive level: Application
logical adaptation
Cognitive level: Application 6. Which common substances is the client
most likely to inhale to become intoxicated?
4. The nurse is caring for a client in a sub- 1. Glue, cleaning solutions, and insecti-
stance abuse clinic. The client tells the nurse cides
he needs an increased amount of heroin to 2. Glue, nail polish remover, and aerosols
produce the same effect that he experienced 3. Paint thinners, insecticides, and spray
a number of weeks ago using a smaller paint
amount. How would the nurse define this con- 4. Cleaning solutions, insecticides, and
dition? spray paint
1. Tolerance Answer: 2. Glue, nail polish remover, aerosols,
2. Dependence paint thinners, and cleaning solutions are in-
3. Withdrawal delirium halants used for a “high.” Insecticide inhala-
4. Compulsion tion would likely cause illness, and inhaling a
Answer: 1. Tolerance occurs when an in- spray paint would color the person’s face, an
creased amount of a substance is required to obvious detriment.
produce the same effect. Dependence is a Client needs category: Psychosocial
physiologic dependence on a substance. integrity
Withdrawal delirium occurs when cessation Client needs subcategory: None
of a substance produces physiologic symp- Cognitive level: Comprehension
toms. Compulsion refers to the need to com-
plete an unwanted repetitive act.
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7. The nurse is caring for a client with a his- 9. The nurse is administering disulfiram
tory of substance abuse. Depending on the (Antabuse) to a client with a history of alco-
substance abused, what might treatment in- hol abuse. Before the client receives therapy,
clude? which action is he required to do?
1. Antabuse or methadone 1. Be committed to attending Alcoholics
2. Morphine Anonymous (AA) meetings weekly
3. Demerol 2. Admit to himself and another person
4. Lithium that he’s an alcoholic
Answer: 1. Antabuse assists in recovery from 3. Remain alcohol-free for 6 hours
alcoholism; methadone maintenance is used 4. Remain alcohol-free for 12 hours
for opiate abusers. Morphine and Demerol Answer: 4. The client must be alcohol-free for
are controlled substances and aren’t used in 12 hours before initiating disulfiram therapy.
substance abuse treatment. Lithium is used to Attending AA and acknowledging alcoholism
treat bipolar disorder. aren’t necessary before the therapy.
integrity integrity
Client needs subcategory: Pharmaco- Client needs subcategory: Pharmaco-
logical therapies logical therapies
8. The nurse is using the CAGE question- 10. A client with a history of alcoholism re-
naire as a screening tool for alcohol problems. turns to the hospital 3 hours later than the
Looks like you’re What do these initials represent? time specified on his day pass. His breath
par for the course for 1. Cut down, Annoyed, Guilty, Eye-opener smells of alcohol and his gait is unsteady.
this chapter. Let’s tee 2. Consumed, Angry, Gastritis, What should the nurse say?
one up for the next Esophageal varices 1. “Why are you 3 hours late?”
one. Fore! 3. Cancer, Alcoholic liver, Gastric ulcer, 2. “How much did you drink tonight?
Erosive gastritis Drinking is against the rules.”
4. Cunning, Anger, Guilt, Excess 3. “I’m disappointed that you weren’t re-
Answer: 1. CAGE stands for “Have you felt the sponsible with your day pass.”
need to Cut down on your drinking? Have you 4. “Please go to bed now. We’ll talk in the
ever been Annoyed by criticism of your drink- morning.”
ing? Have you felt Guilty about your drinking? Answer: 4. The patient can best discuss his be-
Have you felt the need for an Eye-opener in havior when he’s no longer under the influ-
the morning?” ence of alcohol. Option 1 encourages the pa-
Client needs category: Psychosocial tient to invent excuses. Options 2 and 3 are
integrity judgmental and discourage open communica-
Client needs subcategory: None tion.
Cognitive level: Analysis Client needs category: Psychosocial
integrity
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19 Dissociative
disorders
• Sensory deprivation
In this chapter,
you’ll review:
Brush up on key • Severe stress, such as military combat, vio-
lent crime, or other traumatic events
✐ basic facts about dis- concepts DATA COLLECTION FINDINGS
sociative disorders
✐ tests used to diag- A patient with a dissociative disorder expe- • Anxiety symptoms
riences a disruption in the usual relationship • Depressive symptoms
nose dissociative dis-
between memory, identity, consciousness, • Disturbance in sense of time
orders
and perceptions. This disturbance may occur • Fear of going insane
✐ common dissociative suddenly or appear gradually. Typically, disso- • Impaired occupational functioning
disorders. ciation is a mechanism used to protect the self • Impaired social functioning
and gain relief from overwhelming anxiety. • Low self-esteem
At any time, you can review the major points • Persistent or recurring feelings of detach-
of each disorder by consulting the Cheat sheet ment from mind and body
on page 438.
DIAGNOSTIC FINDINGS
• Standard dissociative disorder tests demon-
strate a high degree of dissociation. These
Polish up on patient tests include:
– diagnostic drawing series
care – dissociative experience scale
– dissociative interview schedule
Common dissociative disorders include de- – structured clinical interview for dissocia-
personalization disorder, dissociative amne- tive disorders.
sia, and dissociative identity disorder.
NURSING DIAGNOSES
• Anxiety
Depersonalization disorder • Posttrauma syndrome
With depersonalization disorder, the patient
may feel like a detached observer, passively TREATMENT
watching his mental or physical activity as if • Individual psychotherapy
in a dream. The onset of depersonalization is
sudden and the progression of the disorder Drug therapy
may be chronic, characterized by remissions • Benzodiazepines: alprazolam (Xanax), lor-
and exacerbations. azepam (Ativan), clonazepam (Klonopin)
CONTRIBUTING FACTORS INTERVENTIONS AND RATIONALES

• History of physical and emotional abuse • Establish a trusting relationship by convey-
• History of substance abuse ing acceptance and respect to provide a safe
• Neurophysiologic predisposition environment for the patient to express distress-
• Obsessive-compulsive disorder ing feelings.
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438 Dissociative disorders
et
heat she
C
Dissociative disorders refresher
DEPERSONALIZATION DISORDER Key treatments
Key signs and symptoms • Individual therapy
• Fear of going insane • Benzodiazepines: alprazolam (Xanax), loraze-
• Impaired occupational functioning pam (Ativan)
• Impaired social functioning • Selective serotonin reuptake inhibitors (SSRIs):
• Persistent or recurring feelings of detachment paroxetine (Paxil)
from mind and body Key interventions
Key test results • Encourage the patient to verbalize feelings of
• Standard dissociative disorder tests demon- distress.
strate a high degree of dissociation. These tests • Encourage the patient to recognize that memo-
include: ry loss is a defense mechanism used to deal with
– diagnostic drawing series anxiety and trauma.
– dissociative experience scale DISSOCIATIVE IDENTITY DISORDER
– structured clinical interview for dissociative
disorders. • Guilt and shame
• Lack of recall (beyond ordinary forgetfulness)
Key treatments
• Presence of two or more distinct identities or
• Benzodiazepines: alprazolam (Xanax), loraze- personality states
pam (Ativan), clonazepam (Klonopin)
Key test results
Key interventions
• Encourage the patient to recognize that deper- strate a degree of dissociation. These tests in-
sonalization is a defense mechanism used to deal clude:
with anxiety and trauma. – diagnostic drawing series
• Assist the patient in establishing supportive re- – dissociative experience scale
lationships. – dissociative interview schedule
DISSOCIATIVE AMNESIA – structured clinical interview for dissociative
Key signs and symptoms disorders.
• EEG readings may vary markedly among the dif-
• Altered identity
ferent identities.
• Low self-esteem
• No conscious recollection of a traumatic event, Key treatments
yet colors, sounds, sites, or odors of the event • Long-term reconstructive psychotherapy
may trigger distress or depression • Benzodiazepines: alprazolam (Xanax), loraze-
• Sudden onset of amnesia and inability to recall pam (Ativan), clonazepam (Klonopin)
personal information • SSRIs: paroxetine (Paxil)
Key test results • Tricyclic antidepressants: imipramine (Tofranil),
desipramine (Norpramin)
strate a degree of dissociation. These tests in- Key interventions
clude: • Assist the patient in identifying each person-
– diagnostic drawing series ality.
– dissociative experience scale • Encourage the patient to identify emotions that
– dissociative interview schedule occur under duress.
– structured clinical interview for dissociative
disorders.
920119.qxd 8/7/08 3:08 PM Page 439
• Encourage the patient to recognize that de- – dissociative experience scale

When working with
personalization is a defense mechanism used – dissociative interview schedule a patient who has a
to deal with anxiety and trauma because the – structured clinical interview for dissocia- dissociative disorder,
patient needs to first recognize how depersonal- tive disorders. remember to keep the
ization works. focus on the
• Assist the patient in establishing supportive NURSING DIAGNOSES patient—not on
relationships because social interaction reduces • Anxiety the symptoms.
the tendency toward depersonalization. • Impaired memory
Teaching topics
• Identifying effective stress management TREATMENT
techniques • Hypnosis
Dissociative amnesia Drug therapy

• Benzodiazepines: alprazolam (Xanax),
With dissociative amnesia, acute memory lorazepam (Ativan)
loss is triggered by severe psychological • Selective serotonin reuptake inhibitors
stress. The patient may repress disturbing (SSRIs): paroxetine (Paxil)
memories or dissociate from anxiety-laden ex- • Tricyclic antidepressants: imipramine
periences. The patient may not recall impor- (Tofranil), desipramine (Norpramin)
tant life events in an attempt to avoid traumat-
ic memories. Recovery from dissociative am- INTERVENTIONS AND RATIONALES
nesia is common and recurrences are rare. • Encourage the patient to verbalize feelings
of distress to help him deal with anxiety before
CONTRIBUTING FACTORS it escalates.
• Emotional abuse • Encourage the patient to recognize that
• Past traumatic event memory loss is a defense mechanism used to
• Physical abuse deal with anxiety and trauma to help him un-
• Sexual abuse derstand his condition.

• Altered identity • Promoting positive coping skills
• Clinically significant distress or impairment • Utilizing relaxation techniques
in social functioning
• Depression
• Emotional numbness Dissociative identity disorder
• Low self-esteem
• No conscious recollection of a traumatic With dissociative identity disorder, formerly
event, yet colors, sounds, sites, or odors of known as multiple personality disorder, the
the event may trigger distress or depression patient has at least two unique identities.
• Self-mutilation, suicidal or aggressive urges Each identity can have unique behavior pat-
• Sudden onset of amnesia and inability to re- terns and unique memories, though one pri-
call personal information mary identity is usually associated with the
patient’s name. The patient may also have
DIAGNOSTIC FINDINGS traumatic memories that intrude into his
• Standard dissociative disorder tests demon- awareness. This disorder tends to be chronic
strate a degree of dissociation. These tests in- and recurrent.
clude:
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CONTRIBUTING FACTORS • Treatment for eating disorder, sleeping dis-

• Emotional, physical, or sexual abuse order, and sexual dysfunction
• Lack of nurturing experiences to assist re- Drug therapy
covery from abuse • Benzodiazepines: alprazolam (Xanax), lor-
• Low self-esteem azepam (Ativan), clonazepam (Klonopin)
• Traumatic experience before age 15 • Monoamine oxidase inhibitors: phenelzine
(Nardil), tranylcypromine (Parnate)
DATA COLLECTION FINDINGS • SSRIs: paroxetine (Paxil)
• Eating disorder • Tricyclic antidepressants: imipramine
• Guilt and shame (Tofranil), desipramine (Norpramin)
• Hallucinations (auditory and visual)
• Lack of recall (beyond ordinary forgetful- INTERVENTIONS AND RATIONALES
ness) • Establish a trusting relationship to ensure a
• Low self-esteem therapeutic environment.
• Posttraumatic symptoms (flashbacks, star- • Assist the patient in recognizing each per-
tle responses, nightmares) sonality to work toward integration.
• Presence of two or more distinct identities • Encourage the patient to identify emotions
or personality states that occur under duress to demonstrate that
• Recurrent depression extreme emotions are a normal result of stress.
• Sexual dysfunction and difficulty forming
intimate relationships Teaching topics
• Sleep disorder • Promoting positive coping skills
• Somatic pain syndromes • Identifying triggers for personality change
• Substance abuse
Help psychiatric • Suicidal tendencies
patients recognize
strengths as well as
weaknesses to bolster
DIAGNOSTIC FINDINGS
confidence as they • Standard dissociative disorder tests demon-
begin to cope with strate a degree of dissociation. These tests in-
trauma. clude:
– dissociative experience scale
– structured clinical interview for dissocia-
tive disorders.
• EEG readings may vary markedly among
the different identities.
NURSING DIAGNOSES
Pump up on practice
• Risk for self-mutilation
• Disturbed personal identity
questions
• Chronic low self-esteem 1. The nurse is caring for several clients diag-
nosed with dissociative disorders. Which
TREATMENT client has the best chance of a complete re-
• Hypnosis to revisit the trauma covery and is least likely to experience a re-
• Implementation of suicide precautions if currence of symptoms?
necessary
• Long-term reconstructive psychotherapy
• Medications, sparingly
920119.qxd 8/7/08 3:08 PM Page 441
1. A client with depersonalization disorder the client from verbalizing her feelings may
2. A client with dissociative amnesia cause anxiety to escalate. Forcing the client to
3. A client with dissociative identity disor- confront her memories will increase her anxi-
der ety. Telling the client that everything will be
4. A client with multiple personality disor- all right offers false reassurance.
der Client needs category: Psychosocial
Answer: 2. A client diagnosed with dissocia- integrity
tive amnesia usually experiences complete Client needs subcategory: None
recovery, and recurrences are rare. A client Cognitive level: Application
diagnosed with depersonalization disorder of-
ten experiences remissions and exacerba-
tions. Dissociative identity disorder tends to
be chronic and recurrent despite extensive
treatment. Multiple personality disorder is
the former name for dissociative identity
disorder.
integrity
3. The nurse is caring for a client who fre-

quently complains of vague, inconsistent
symptoms. Which nursing intervention would
be the most appropriate?
1. Screen the client for recent life changes
and symptoms of depression, while focus-
ing on physical symptoms.
2. Attempt to minimize physical symp-
toms, while screening the client for psy-
chological disorders.
2. The nurse is caring for a client diagnosed 3. Exhaust all diagnostic options in ruling
with dissociative amnesia. The client recently out disease before focusing on psychologi-
experienced a divorce. How should the nurse cal issues.
help the client deal with traumatic memories? 4. Refer the client to a psychiatrist.
1. Discourage the client from verbalizing Answer: 1. It’s important not to minimize
feelings because they’ll be too traumatic. physical symptoms so that the nurse can
2. Force the client to confront her memo- demonstrate empathy and establish rapport.
ries about the divorce in a direct, con- The nurse should simultaneously investigate
frontational manner. recent life changes and the risk of depression.
3. Tell the client that everything will be all Although tests and imaging studies may be
right. done in certain cases, review of previous med-
4. Encourage the client to verbalize feel- ical records and a physical examination
ings of distress. should first be performed to determine the
Answer: 4. Encouraging the client to verbalize likelihood of physical findings. Referral may
feelings of distress helps her deal with her be indicated, but not enough information is
anxieties before they escalate. Discouraging available.
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Client needs category: Psychosocial Answer: 4. The nurse should help the client
integrity explore the characteristics of this newly
Client needs subcategory: None emerged personality in order to work toward
Cognitive level: Analysis integration. Ridiculing the client’s outfit would
further decrease the client’s self-esteem. Not
4. The nurse is caring for a client who recalling the client by the name she requests
ports feeling “estranged and separated from would jeopardize the trusting nurse-client re-
himself.” How would the nurse describe such lationship. Ignoring the behavior doesn’t help
symptoms? the client work toward integration.
1. Intoxication Client needs category: Psychosocial
2. Antimotivational syndrome integrity
3. Existentialism Client needs subcategory: None
4. Depersonalization Cognitive level: Application
Answer: 4. Depersonalization is characterized
by feelings of separateness from oneself. In-
toxication is described as feelings of calm,
omnipotence, or euphoria. When a relative
lack of motivation occurs within an individual,
antimotivational syndrome is present. Exis-
tentialism is the philosophy that a person
finds meaning in life through experiences.
integrity
6. The nurse is caring for a client who has a

dissociative identity disorder. Which state-
ment would be true about this client?
1. The client has at least two unique iden-
tities.
2. The client has only one primary identi-
ty.
3. The physician has requested that the
client dissociate from his usual medical
5. The nurse is caring for a client named Su- caregivers and be referred to a psychia-
san who has been diagnosed with dissociative trist.
identity disorder. Usually, the client arrives to 4. The client is experiencing a gender
therapy sessions dressed in a tasteful busi- identity crisis.
ness suit. One day, the client comes to the Answer: 1. A client with a dissociative identity
clinic dressed in a gold lamé mini-dress and disorder has at least two unique identities.
insists that her name is Ruby. How should the Gender identity isn’t necessarily an issue for
nurse respond? clients with this disorder.
1. Ask the client why she’s wearing that Client needs category: Psychosocial
ridiculous outfit. integrity
2. Refuse to call the client anything but Client needs subcategory: None
Susan. Cognitive level: Knowledge
3. Ignore the client’s behavior.
4. Help the client explore the characteris-
tics of this newly emerged personality.
920119.qxd 8/7/08 3:08 PM Page 443

depersonalization disorder. Which clear and
explicit outcomes should the nurse work
toward?
1. Emphasizing strengths, rather than the
pathologic condition
2. Focusing on past accomplishments,
rather than the current condition
3. Increasing confidence and active partic-
ipation in planning and implementation of
the treatment
4. Eliciting empathetic responses from the
7. The nurse is caring for a client who seems client
to lack spontaneity, has difficulty distinguish- Answer: 3. Increasing confidence and active
ing himself from others, and has difficulty dis- participation in planning and implementation
tinguishing between internal and external of the treatment are measurable outcomes.
stimuli. The client describes a vague feeling The active involvement expected of this client
of estrangement. Which statement would de- will allow for concise documentation of this.
scribe this client? The other options are vague and inappropri-
1. He’s depressed and should be placed ate.
on antidepressants. Client needs category: Psychosocial
2. He may have a depersonalization disor- integrity
der. Client needs subcategory: None
3. He may benefit from electroconvulsive Cognitive level: Application
therapy.
4. He should be placed on suicide precau-
tions.
Answer: 2. The client has characteristics of a
depersonalization disorder. He may also suf-
fer from depression, but antidepressants
aren’t indicated given the available informa-
tion. Electroconvulsive therapy wouldn’t be
appropriate. At this point, the client’s behavior
doesn’t seem suicidal; therefore, such precau-
tions aren’t needed.
integrity
Client needs subcategory: None 9. The nurse is caring for a client who has a
Cognitive level: Analysis dissociative disorder. What should the nurse
do to assist the client in goal achievement?
1. Provide opportunities for the client to
experience success.
2. Praise the client frequently, whether it’s
warranted or not.
3. Evaluate components of the client’s self-
concept.
4. Discuss with the client three categories
of behavior commonly associated with an
altered self-concept.
920119.qxd 8/7/08 3:08 PM Page 444
Answer: 1. Providing opportunities for the Answer: 1. Amnesia in the client with a disso-
client to experience success would assist him ciative disorder can be triggered by severe
in achieving goals. Unwarranted praise will psychosocial stress. Certain pharmacologic
inevitably cause the client to question the agents given for sedation actually have an am-
caregiver’s sincerity. The other two choices nesic effect, but this doesn’t qualify as a disso-
are merely academic exercises and won’t as- ciative disorder. SIADH isn’t associated with
sist the client in achieving goals. amnesia.
integrity integrity
Cognitive level: Application Cognitive level: Analysis

dissociative disorder and is experiencing am-
nesia. What could have triggered the amne-
sia?
1. Severe psychosocial stress
2. Short-acting sedation
3. Conscious sedation
4. Syndrome of inappropriate antidiuretic
hormone (SIADH)
I’m ready to
dissociate from this
chapter. On to the
next one!
920120.qxd 8/7/08 3:08 PM Page 445
20 Sexual
disorders
In this chapter,
you’ll review:
Brush up on key • Concurrent paraphilias, especially transves-
tic fetishism
✐ basic facts about sex- concepts • Feelings of sexual inadequacy
• Generalized anxiety disorder
ual disorders
✐ common tests used to Sexual disorders described in the Diagnostic • Personality disorders
and Statistical Manual of Mental Disorders,
diagnose sexual dis-
Fourth Edition, Text Revision (DSM-IV-TR), DATA COLLECTION FINDINGS
orders
include gender identity disorder, paraphil- • Anxiety
✐ common treatments ias, and sexual dysfunctions. Gender iden- • Attempts to mask or remove sex organs
for sexual disorders. tity disorder is characterized by an intense • Cross-dressing
and ongoing cross-gender identification. Para- • Depression
philias are characterized by an intense, recur- • Disturbance in body image
ring sexual urge centered on inanimate ob- • Dreams of cross-gender identification
jects or on human suffering and humiliation. • Fear of abandonment by family and friends
Sexual dysfunctions are characterized by a • Feelings of peer ostracism
deficiency or loss of desire for sexual activity • Finding one’s own genitals “disgusting”
or by a disturbance in the sexual response • Ineffective coping strategies
cycle. • Persistent distress about sexual orientation
At any time, you can review the major points • Preoccupation with appearance
of each disorder by consulting the Cheat sheet • Self-hatred
on page 446. • Self-medication such as hormonal therapy
• Strong attraction to stereotypical activities
of the opposite sex
• Suicide attempts
Polish up on patient DIAGNOSTIC FINDINGS
care • Karyotyping for sex chromosomes (not usu-
ally indicated) may reveal an abnormality.
This section discusses care for patients with • Psychological testing may reveal cross-
gender identity disorders, paraphilias, and gender identification or behavior patterns.
sexual dysfunctions. • Sex hormones assay (not usually indicated)
may reveal an abnormality.
Gender identity disorder NURSING DIAGNOSES

Patients with gender identity disorder want to • Chronic low self-esteem
become or be like the opposite sex and are • Disturbed personal identity
extremely uncomfortable with their assigned
gender roles. This disorder can occur in TREATMENT
childhood, adolescence, or adulthood. • Group and individual psychotherapy
• Hormonal therapy
• Sex-reassignment surgery
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446 Sexual disorders
et
heat she
C
Sexual disorders refresher
GENDER IDENTITY DISORDER • Encourage the patient to identify feelings, such
Key signs and symptoms as pleasure, reduced anxiety, increased control,
• Dreams of cross-gender identification and shame, associated with sexual behavior and
• Finding one’s own genitals “disgusting” fantasies.
• Persistent distress about sexual orientation SEXUAL DYSFUNCTIONS
• Preoccupation with appearance
• Self-hatred
• Anxiety
Key test results • Decreased sexual desire (sexual desire disor-
• Psychological testing may reveal cross-gender der)
identification or behavior patterns. • Delayed or absent orgasm (orgasmic disorder)
Key treatments • Depression
• Group and individual psychotherapy • Inability to maintain an erection (sexual arousal
• Hormonal therapy disorder)
• Sex-reassignment surgery • Pain with sexual intercourse (sexual pain disor-
Key interventions der)
• Demonstrate a nonjudgmental attitude. • Premature ejaculation (orgasmic disorder)
• Help the patient to identify positive aspects of Key test results
himself. • Diagnostic tests are used to rule out a physio-
logic cause for the dysfunction.
PARAPHILIAS
Key treatments
• Development of a hobby or change in occupa-
• Hormone replacement therapy: testosterone
tion that makes the paraphilia more accessible
(Androderm)
• Recurrent paraphilic fantasies
• Sildenafil (Viagra), tadalafil (Cialis), vardenafil
(Levitra) for impotence
• Troubled social or sexual relationships
Key interventions
Key treatments
• Encourage the patient to discuss feelings and
perceptions about his sexual dysfunction.
Key interventions • Teach the patient and his partner alternative
• Demonstrate a nonjudgmental attitude. ways of expressing their affection.
• Institute safety precautions as needed accord- • Encourage the patient to seek evaluation and
ing to facility protocol. therapy from a qualified professional.
• Initiate a discussion about how emotional
needs for self-esteem, respect, love, and intima-
cy influence sexual expression.
INTERVENTIONS AND RATIONALES • Help the patient to identify positive aspects

• Demonstrate a nonjudgmental attitude to of himself to alleviate feelings of shame and
decrease feelings of low self-esteem. distress.
• Provide emotional support and empathy as • Encourage the patient to participate in sup-
the patient discusses fears and concerns to port groups so the patient can gain empathy
help him deal with anxiety.
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from others and find a safe environment to dis- • Neuroendocrine disorders

cuss concerns. • Psychosocial stressors
• Lack of knowledge about sex
Teaching topics • Sexual trauma
• Knowing treatment options
• Understanding the need for follow-up care DATA COLLECTION FINDINGS
• Anxiety
• Depression
Paraphilias • Development of a hobby or change in
occupation that makes the paraphilia more
A paraphilia is defined as a recurrent, intense accessible
sexual urge or fantasy, generally involving • Disturbance in body image
nonhuman subjects, children, nonconsenting • Guilt or shame
partners, or the degradation, suffering, and • Ineffective coping
humiliation of the patient or partners. The pa- • Purchase of books, films, or magazines
tient may report that the fantasy is always related to the paraphilia
present but that its intensity varies. The disor- • Recurrent paraphilic fantasies
der tends to be chronic and lifelong but, in • Sexual dysfunction
adults, both the fantasy and behavior com- • Signs of multiple paraphilias at the same
monly diminish with advancing age. Inappro- time
priate sexual behavior may increase in re- • Social isolation
sponse to psychological stressors, in relation • Troubled social or sexual relationships
to other mental disorders, or when opportuni-
ty to engage in the paraphilia becomes more DIAGNOSTIC FINDINGS
available. • Penile plethysmography testing may mea-
Common paraphilias include: sure sexual arousal in response to visual im-
• exhibitionism (exposing genitals and occa- agery; however, the results of this procedure
sionally masturbating in public) can be unreliable.
• fetishism (use of an object to become sexu-
ally aroused) NURSING DIAGNOSES
• frotteurism (rubbing one’s genitals on an- • Ineffective sexuality patterns
other nonconsenting person to become • Chronic low self-esteem
aroused) • Risk for other-directed violence
• pedophilia (sexual activity with a child)
• sexual masochism (being humiliated or TREATMENT
feeling pain to become aroused) • Behavior therapy Institute safety
• sexual sadism (causing physical or emotion- • Cognitive therapy precautions as needed
al pain to another to become aroused) • Individual therapy to protect the patient
• transvestic fetishism (cross-dressing) and others.
• voyeurism (watching others who are nude INTERVENTIONS AND RATIONALES
or engaging in sex to become aroused). • Demonstrate a nonjudgmental attitude to
decrease feelings of low self-esteem.
CONTRIBUTING FACTORS • Institute safety precautions ac-
• Childhood incest or sexual abuse cording to facility protocol as need-
• Concurrent mental disorders ed to protect the patient and others.
• Emotional trauma • Initiate a discussion about how
• Gender (more likely in males) emotional needs for self-esteem, re-
• Personality disorders spect, love, and intimacy influence
• Central nervous system tumors sexual expression to help the patient
• Closed head injury understand the disorder.
920120.qxd 8/7/08 3:08 PM Page 448
• Encourage the patient to identify feelings, desire for sexual activity. The patient usually
such as pleasure, reduced anxiety, increased doesn’t initiate sexual activity and may en-
control, and shame, associated with sexual gage in it only reluctantly when it’s initiated
behavior and fantasies to provide insight for by the partner. With sexual aversion disorder,
developing appropriate interventions. the patient has an aversion to and active
• Help the patient distinguish between prac- avoidance of genital sexual contact with a sex-
tices that are distressing because they don’t ual partner.
conform to social norms or personal values • sexual dysfunction due to injury, surgery,
and those that may place him or others in se- or a medical condition—Sexual dysfunction
rious emotional, medical, or legal jeopardy to may occur as a result of a physiologic prob-
reinforce the need to stop behaviors that could lem.
harm the patient or others. • sexual pain disorders—This category in-
cludes dyspareunia and vaginismus. The es-
Teaching topics sential feature of dyspareunia is genital pain
• Knowing treatment options associated with sexual intercourse. Most com-
• Understanding the need for follow-up care monly experienced during intercourse, dys-
• Contacting Sexaholics Anonymous pareunia may also occur before or after inter-
course. The disorder can occur in both males
and females. Vaginismus is recurrent or per-
Sexual dysfunctions sistent involuntary contraction of the perineal
muscles surrounding the outer third of the
Sexual dysfunctions are characterized by a vagina when vaginal penetration is attempted.
disturbance during one or more phases of the In some patients, even the anticipation of vagi-
sexual response cycle. The most common nal insertion may result in muscle spasm. The
dysfunctions are: contractions may be mild to severe.
• orgasmic disorders—The DSM-IV-TR lists • substance-induced sexual dysfunction—
female orgasmic disorder, male orgasmic dis- This term is used to describe sexual dysfunc-
order, and premature ejaculation. Male and fe- tion resulting from direct physiologic effects
male orgasmic disorders are characterized by of a substance, such as from drug abuse,
a persistent or recurrent delay in or absence medication use, or toxin exposure.
Sexual of orgasm following a normal sexual excite-
dysfunction commonly ment phase. Premature ejaculation is marked CONTRIBUTING FACTORS
accompanies other
by persistent and recurrent onset of orgasm • Anger or hostility
medical situations,
such as surgery, and ejaculation with minimal sexual stimula- • Depression
pregnancy, or tion. • Drugs or alcohol
pharmacologic • sexual arousal disorders—These include fe- • Endocrine disorders
treatment. male sexual arousal disorder and male erec- • Genital surgery
tile disorder. With female sexual arousal dis- • Genital trauma
order, the patient has a persistent or recur- • Infections
rent inability to attain or maintain adequate • Lifestyle disruptions
lubrication, swelling, and response of sexual • Medications
excitement until the completion of sexual ac- • Paraphilia
tivity. In male erectile disorder, the patient • Pregnancy
has a persistent or recurrent inability to attain • Religious or cultural taboos that reinforce
or maintain an adequate erection until com- guilt feelings about sex
pletion of sexual activity. • Stress
• sexual desire disorders—This category in-
cludes hypoactive sexual desire disorder and DATA COLLECTION FINDINGS
sexual aversion disorder. The key feature of • Anxiety
hypoactive sexual desire disorder is a defi- • Decreased sexual desire (sexual desire dis-
ciency or absence of sexual fantasies and the order)
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• Delayed or absent orgasm (orgasmic disor- to help validate his perceptions and reduce
der) emotional distress.
• Depression • Teach the patient and his partner alterna-
• Disturbance in body image tive ways of expressing sexual intimacy and
• Frustration and feelings of being unattrac- affection. Alternative expressions of intimacy
tive may raise the patient’s self-esteem.
• Inability to maintain an erection (sexual • Encourage the patient to seek evaluation
arousal disorder) and therapy from a qualified professional to
• Ineffective coping enable the patient to obtain proper diagnosis
• Pain with sexual intercourse (sexual pain and treatment.
disorder)
• Poor self-concept Teaching topics
• Premature ejaculation (orgasmic disorder) • Understanding medication use and possible
• Social isolation adverse effects.
• Understanding sexual response
DIAGNOSTIC FINDINGS • Using alternative sexual positions to pro-
• Diagnostic tests are used to rule out a phys- mote comfort
iologic cause of dysfunction. • Performing relaxation exercises
• Performing Kegel exercises to improve
NURSING DIAGNOSES urethral and vaginal tone
• Impaired social interaction • Contacting self-help groups
• Chronic low self-esteem
• Sexual dysfunction
TREATMENT
• Changing medications to decrease symp-
toms (as appropriate)
• Marital or couples therapy
• Penile implant or vacuum pump (for erectile
dysfunction)
• Sex therapy
• Treatment of underlying medical condition
• Vaginal dilators
• Vascular surgery (for erectile dysfunction)
Drug therapy
Pump up on practice
• Hormone replacement therapy: testos-
terone (Androderm), estradiol (Estrace)
questions
• Sildenafil (Viagra), tadalafil (Cialis), varde- 1. The nurse is caring for a client who’s
nafil (Levitra) for impotence experiencing hypoactive sexual desire. How
• Alprostadil (Caverject) intracavernously to would the nurse classify this condition?
induce erection 1. Sexual arousal disorder
2. Sexual pain disorder
INTERVENTIONS AND RATIONALES 3. Sexual desire disorder
• Establish a therapeutic relationship with the 4. Orgasmic disorder
patient to provide a safe and comfortable at- Answer: 3. Sexual desire disorders include
mosphere for discussing sexual concerns. both sexual aversion and hypoactive sexual
• Encourage the patient to discuss feelings desire disorder. Sexual arousal disorders in-
and perceptions about his sexual dysfunction clude male erectile and female arousal disor-
ders. Examples of sexual pain disorders in-
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clude dyspareunia and vaginismus. Orgasmic 1. “I understand your reluctance to tell the
disorders, such as premature ejaculation, af- physician, but it may have an impact on
fect both males and females and are charac- your treatment.”
terized by problems relating to orgasm, not 2. “Based on client confidentiality, I won’t
desire. tell the physician if you wish.”
Client needs category: Psychosocial 3. “Your sex change and your hormones
integrity have nothing to do with your heart attack.”
Client needs subcategory: None 4. “Tell me about your sexual preference.
Cognitive level: Application Are you attracted to men or women?”
Answer: 1. During the history and physical ex-
2. The nurse is caring for a client who was ac- amination of any female client being screened
cused of voyeurism by his neighbors. Which for thrombolytic therapy, the physician must
term most appropriately describes such be- know about the last menstrual period before
havior? the MI. Although not an absolute contraindi-
1. Paraphilia cation to thrombolytics, the possibility of
2. Depersonalization disorder pregnancy or menstruation must be docu-
3. Dissociative fugue mented. According to the ethics of client con-
4. Gender identity disorder fidentiality, information may be shared in a
Answer: 1. Paraphilia is a general diagnosis professional manner with those who require it
that encompasses such disorders as exhibi- for the client’s care. Hormones are an impor-
tionism, fetishism, pedophilia, and voyeurism. tant factor in the pathogenesis of MI. Estro-
Depersonalization disorder is characterized gen is cardioprotective, while replacement
by a feeling of detachment or estrangement hormones after a sex change operation can
from oneself. Dissociative fugue is character- have an impact on how prone a person is to
ized by sudden, unexpected travel away from MI. The client’s sexual preference is of no
home, accompanied by an inability to recall consequence in this situation.
one’s past. Gender identity disorder is a sepa- Client needs category: Physiological
rate diagnostic category and isn’t related to integrity
the paraphilias. Client needs subcategory: Reduction of
Client needs category: Psychosocial risk potential
Cognitive level: Application 4. A 42-year-old client arrives at her physi-
cian’s office crying. Her husband of 17 years
3. The nurse is caring for a female client has asked her for a divorce. She admits that
who’s about to begin thrombolytic therapy for recently she has avoided having sexual inter-
treatment of acute myocardial infarction (MI). course with him. Which response by the
When the physician questions the client nurse would be most appropriate when talk-
about her last menstrual period, she becomes ing with this client?
embarrassed and asks him to leave the room. 1. “Please stop crying so that we can dis-
She then tells the nurse that she underwent cuss your feelings about the divorce.”
sex-reassignment surgery. What would be the 2. “Once you have intercourse with him,
nurse’s most appropriate response? you’ll be able to get your relationship back
on track.”
3. “I can see how upset you are. Let’s sit
and talk about how you’re feeling.”
4. “Find a good lawyer who will look out
for your interests, and then you’ll feel bet-
ter.”
920120.qxd 8/7/08 3:08 PM Page 451
Answer: 3. This response validates the client’s 6. The nurse is caring for a client with type 1
distress and provides her the opportunity to diabetes mellitus who’s experiencing erectile
talk about her feelings. Because clients in cri- disorder related to his medical condition.
sis have difficulty making decisions, the Which statement is true about this sexual
nurse must be directive as well as supportive. dysfunction?
Option 1 doesn’t provide the client with ade- 1. It’s unrelated to psychosocial problems.
quate support. Options 2 and 4 don’t acknowl- 2. It isn’t considered a sexual disorder.
edge the client’s distress. Moreover, clients in 3. It isn’t likely to cause infertility.
crisis can’t think beyond the immediate mo- 4. It can have an impact on the client’s
ment, so discussing long-range plans isn’t psychosocial well-being.
helpful. Answer: 4. Any general medical condition that
Client needs category: Psychosocial impairs sexual function has the ability to im-
integrity pact the client’s psychosocial well-being as
Client needs subcategory: None well as the ability to conceive. Regardless of
Cognitive level: Application the cause, sexual dysfunction is considered to
be a disorder.
5. A client describes being under a lot of Client needs category: Psychosocial
stress recently because of overwhelming de- integrity
mands from work and home. She has lost in- Client needs subcategory: None
terest in sexual intercourse, which is placing Cognitive level: Comprehension
a strain on her marriage. Based on this infor-
mation, from which type of sexual dysfunction 7. A client is diagnosed with erectile disor-
does the client suffer? der. Which drug may be beneficial in treating
1. Hypoactive sexual desire disorder a client with this disorder?
2. Sexual aversion disorder 1. Methyldopa
3. Sexual pain disorder 2. Vardenafil (Levitra)
4. Paraphilia 3. Benazepril (Lotensin)
Answer: 1. Hypoactive sexual desire disorder 4. Clonidine (Catapres)
is characterized by deficiency or absence of Answer: 2. Vardenafil is indicated for erectile
desire for sexual activity. Sexual aversion dis- disorder. Methyldopa, benazepril, and cloni-
order is defined as the active avoidance of dine are antihypertensive agents that can
genital sexual contact. The client with sexual cause erectile disorder.
pain disorder experiences genital pain associ- Client needs category: Physiological
ated with sexual intercourse. Paraphilia is integrity
characterized by recurrent, intense sexual Client needs subcategory: Pharmaco-
urges or fantasies generally involving nonhu- logical therapies
man subjects, children, or nonconsenting Cognitive level: Analysis
partners or the degradation, suffering, and
humiliation of the client or his partner. 8. The nurse is caring for a male client await-
Client needs category: Psychosocial ing sex-reassignment surgery. When interact-
integrity ing with this client, it’s important that the
Client needs subcategory: None nurse:
Cognitive level: Knowledge 1. discourage the client from undergoing
the procedure.
2. demonstrate a nonjudgmental attitude.
3. discuss with the client the option of un-
dergoing hypnosis as an alternative to the
surgery.
4. tell the client that his life will be less
complicated and more peaceful after the
surgery is complete.
920120.qxd 8/7/08 3:08 PM Page 452
Answer: 2. When caring for a client with gen- 10. A 14-year-old male client who prefers to
der identity disorder, the nurse should dem- dress in female clothing is brought to the psy-
onstrate a nonjudgmental attitude. It’s the chiatric crisis room by his mother. The
client’s needs and feelings that matter most, client’s mother states, “He’s always dressing
not the nurse’s opinions. The nurse shouldn’t in female clothing. There must be something
discourage the client’s decision to go ahead wrong with him.” Which of the following re-
with the procedure. Hypnosis isn’t a treat- sponses from the nurse is most appropriate?
ment for gender identity disorder, and it isn’t 1. “Your son will be evaluated shortly.”
appropriate for the nurse to suggest alternate 2. “I will explain to your son that his be-
treatments to the client. Telling the client his havior isn’t appropriate.”
life will be less complicated and more peace- 3. “I see you’re upset. Would you like to
ful after surgery offers false reassurance. talk?”
Client needs category: Psychosocial 4. “You’re being judgmental. There’s noth-
integrity ing wrong with a boy wearing female cloth-
Client needs subcategory: None ing.”
Cognitive level: Analysis Answer: 3. Acknowledging the mother’s feel-
ings and offering her an opportunity to ver-
9. Which of the following are examples of balize her concerns provides a forum for open
paraphilias? communication. Telling the client’s mother
1. Sexual masochism, transvestic that her son will be evaluated shortly doesn’t
fetishism, voyeurism address the mother’s concerns. Telling the
2. Transvestic fetishism, voyeurism, or- client that his behavior is inappropriate isn’t
gasmic disorders therapeutic. The nurse shouldn’t offer an
3. Pedophilia, exhibitionism, orgasmic dis- opinion regarding whether the client’s behav-
orders ior is acceptable.
4. Dyspareunia, vaginismus, sexual Client needs category: Psychosocial
sadism integrity
Answer: 1. All the choices presented in option Client needs subcategory: None
1 are paraphilias. Dyspareunia, vaginismus, Cognitive level: Application
and orgasmic disorders aren’t types of para-
philias.
integrity
920121.qxd 8/7/08 3:09 PM Page 453
21 Eating
disorders
In this chapter,
you’ll review:
Brush up on key • Age (most prominent in adolescents)
• Distorted body image
✐ basic facts about eat- concepts • Gender (primarily affects females)
ing disorders
✐ common tests used to Eating disorders are characterized by severe • Low self-esteem
disturbances in eating behaviors. The two • Neurochemical changes
diagnose eating disor-
most common disorders, anorexia nervosa • Poor family relations
ders
and bulimia nervosa, put the patient at risk for • Poor self-esteem
✐ patient care for severe cardiovascular and GI complications • Preoccupation with weight and dieting
anorexia nervosa and and can ultimately result in death. • Sexual abuse
bulimia nervosa. Patients with these disorders exhibit
severe disturbances in body image and self- DATA COLLECTION FINDINGS
perception. Their behavior may include self- • Amenorrhea, fatigue, loss of libido, infer-
starvation, binge eating, and purging. The tility
causes of eating disorders aren’t fully under- • Body image disturbance
stood. • Cognitive distortions, such as overgeneral-
At any time, you can review the major points ization, dichotomous thinking, or ideas of ref-
of each disorder by consulting the Cheat sheet erence
on page 454. • Compulsive behavior, especially exercising
• Decreased blood volume, evidenced by low-
ered blood pressure and orthostatic hypoten-
sion
Polish up on patient • Dependence on others for self-worth
• Electrolyte imbalance, evidenced by muscle
care weakness, seizures, or arrhythmias
• Emaciated appearance
Here’s a review of anorexia nervosa and bu- • GI complications, such as constipation or
limia nervosa, the two most common eating laxative dependence
disorders. • Guilt associated with eating
• Impaired decision making
• Lanugo
Anorexia nervosa • Laxative or diuretic abuse
• Need to achieve and please others
With anorexia nervosa, the patient deliberate- • Obsessive rituals concerning food
ly starves herself or engages in binge eating • Overly compliant attitude
and purging. A patient with anorexia nervosa • Perfectionist attitude
always views herself as overweight no matter • Refusal to eat
how low her actual weight is. A key clinical
finding is a refusal to sustain weight at or DIAGNOSTIC FINDINGS
above minimum requirements for the pa- • Eating Attitude Test suggests an eating dis-
tient’s age and height. If left untreated, order.
anorexia nervosa may cause the patient’s
death.
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454 Eating disorders
et
heat she
C
Eating disorders refresher
ANOREXIA NERVOSA • Help the patient understand the anorectic cy-
Key signs and symptoms cle.
• Decreased blood volume, evidenced by low- BULIMIA NERVOSA
ered blood pressure and orthostatic hypotension
• Electrolyte imbalance, evidenced by muscle
• Alternating episodes of binge eating and purg-
weakness, seizures, or arrhythmias
ing
• Emaciated appearance
• Constant preoccupation with food
• Need to achieve and please others
• Disruptions in interpersonal relationships
• Obsessive rituals concerning food
• Eroded tooth enamel
• Refusal to eat
• Extreme need for acceptance and approval
Key test results • Irregular menses
I can use the • Eating Attitude Test suggests eating disorder. • Russell’s sign (bruised knuckles due to induced
Cheat sheet to study • Electrocardiogram reveals nonspecific ST- vomiting)
while I get my exercise! segment changes and a prolonged PR interval. • Sporadic, excessive exercise
• Laboratory tests show elevated blood urea ni-
Key test results
trogen level and electrolyte imbalances.
• Beck Depression Inventory may reveal depres-
• Female patients exhibit low estrogen levels.
sion.
• Male patients exhibit low serum testosterone
• Eating Attitude Test suggests eating disorder.
levels.
• Metabolic acidosis may occur from diarrhea
Key treatments caused by enemas and excessive laxative use.
• Individual therapy • Metabolic alkalosis may occur from frequent
• Nutritional counseling vomiting.
• Antianxiety agents: lorazepam (Ativan), alprazo-
Key treatments
lam (Xanax)
• Cognitive therapy to identify triggers for binge
• Antidepressants: amitriptyline (Elavil), imipra-
eating and purging.
mine (Tofranil)
• SSRIs: paroxetine (Paxil), fluoxetine (Prozac)
• Selective serotonin reuptake inhibitors (SSRIs):
paroxetine (Paxil), fluoxetine (Prozac) Key interventions
Key interventions • Explain the purpose of a nutritional contract.
• Avoid power struggles about food.
• Contract for specific amount of food to be eaten
• Prevent the patient from using the bathroom for
at each meal.
2 hours after eating.
• Provide one-on-one support before, during, and
• Provide one-on-one support before, during, and
after meals.
after meals.
• Prevent the patient from using the bathroom for
• Weigh the patient once or twice per week at
2 hours after eating.
the same time of day using the same scale.
• Help the patient identify coping mechanisms for
• Help the patient identify the cause of the disor-
dealing with anxiety.
der.
• Weigh the patient once or twice a week at the
• Point out cognitive distortions.
same time of day using the same scale.
• Electrocardiogram reveals nonspecific • Laboratory tests show elevated blood urea

ST-segment changes and a prolonged PR in- nitrogen level and electrolyte imbalances.
terval. • Female patients exhibit low estrogen levels.
• Leukopenia and mild anemia are apparent.
920121.qxd 8/7/08 3:09 PM Page 455
• Male patients exhibit low serum testos- of herself as beautiful regardless of how she
terone levels. compares with others to build self-esteem.
• Thyroid hormone levels are low. • Discuss the patient’s progress with her to
increase awareness of achievements and pro-
NURSING DIAGNOSES mote continued effort.
quirements Teaching topics
• Disturbed body image • Needing gradual weight gain
• Chronic low self-esteem • Seeking nutritional support measures
TREATMENT • Seeking support services and community
• Behavioral modification resources
• Group and family therapy
• Nutritional counseling Bulimia nervosa
Drug therapy Bulimia is characterized by episodic binge
• Antianxiety agents: lorazepam (Ativan), eating, followed by purging in the form of
alprazolam (Xanax) vomiting. The patient may also use laxatives,
• Antidepressants: amitriptyline (Elavil), enemas, diuretics, or syrup of ipecac. The pa-
imipramine (Tofranil) tient’s weight may remain normal or close to
• Selective serotonin reuptake inhibitors normal. The severity of the disorder depends
(SSRIs): paroxetine (Paxil), fluoxetine on the frequency of the binge and purge cycle Weigh the patient
(Prozac) as well as physical complications. The patient once or twice each
usually views food as a source of comfort. week but not more;
INTERVENTIONS AND RATIONALES weighing too often
reinforces the focus
• Contract for a specific amount of food to be CONTRIBUTING FACTORS on weight.
eaten at each meal to avoid conflict between • History of sexual abuse
staff members and the patient. • Low self-esteem
• Provide one-on-one support before, during, • Neurochemical changes
and after meals to foster a strong nurse-patient • Poor family relations
relationship and to ensure that the patient is
eating. DATA COLLECTION FINDINGS
• Prevent the patient from using the bath- • Alternating episodes of binge eating and
room for 2 hours after eating to break the purging
purging cycle. • Anxiety
• Encourage verbal expression of feelings to • Avoidance of conflict
foster open communication about body image. • Cognitive distortions, as in anorexia ner-
• Help the patient identify coping mecha- vosa
nisms for dealing with anxiety to promote • Constant preoccupation with food
coping techniques. • Dental abnormalities such as eroded tooth
• Weigh the patient once or twice per week at enamel
the same time of day using the same scale, • Disruptions in interpersonal relationships
and be aware of artificial means of increasing • Dissatisfaction with body image
weight such as putting heavy objects in pock- • Extreme need for acceptance and approval
ets to accurately monitor weight. • Feelings of helplessness
• Help the patient identify and understand the • Focus on changing a specific body part
anorectic cycle to prevent future anorectic be- • Frequent lies and excuses to explain behav-
havior. ior
• Discuss the patient’s perception of her ap- • Guilt and self-disgust
pearance. Explain that she has a right to think • Irregular menses
• Perfectionist attitude
920121.qxd 8/7/08 3:09 PM Page 456
• Parotid and salivary gland swelling • Provide one-on-one support before, during,
Tell the patient
that she has a right • Pharyngitis and after meals to monitor and assist the pa-
to think of herself as • Physiologic problems as in anorexia ner- tient with eating.
beautiful regardless of vosa (amenorrhea, fatigue, loss of libido, in- • Encourage the patient to express her feel-
how she compares fertility, electrolyte imbalance, GI complica- ings to facilitate conversation and promote un-
with others. tions) derstanding.
• Possible use of amphetamines or other • Weigh the patient once or twice per week at
drugs to control hunger the same time of day using the same scale to
• Problems caused by frequent vomiting monitor weight. Be aware of artificial means of
• Repression of anger and frustration increasing weight such as putting heavy ob-
• Russell’s sign (bruised knuckles due to in- jects in pockets.
duced vomiting) • Help the patient identify the cause of the
• Sporadic, excessive exercise disorder to help her gain understanding and
work toward wellness.
DIAGNOSTIC FINDINGS • Point out cognitive distortions to help identi-
• Beck Depression Inventory may reveal de- fy sources of the problem.
pression. • Discuss the patient’s perception of her ap-
• Eating Attitude Test suggests an eating dis- pearance. Explain that she has a right to think
order. of herself as beautiful regardless of how she
• Metabolic acidosis may occur from diarrhea compares with others to build self-esteem.
caused by enemas and excessive laxative use. • Discuss the patient’s progress with her to
• Metabolic alkalosis (the most common increase awareness of achievements and pro-
metabolic complication) may occur from fre- mote continued effort.
quent vomiting.
Teaching topics
NURSING DIAGNOSES • Needing to gain weight gradually
• Imbalanced nutrition: Less than body re- • Knowing treatment options
quirements • Seeking support services and community
• Anxiety resources
• Powerlessness
TREATMENT
• Cognitive therapy to identify triggers for
binge eating and purging
• Family therapy
Drug therapy
• SSRIs: paroxetine (Paxil), fluoxetine
(Prozac)
Note: Drug therapy is most effective when
combined with cognitive therapy.

• Explain the purpose of a nutritional contract
to encourage a dietary change without initiat-
Pump up on practice
ing argument or struggle.
• Avoid power struggles about food to keep
questions
the focus on establishing and maintaining a 1. The nurse is caring for a client who’s delib-
positive self-image and self-esteem. erately starving herself to become as thin as
• Prevent the patient from using the bath- possible. What’s the appropriate diagnosis for
room for 2 hours after eating to help the pa- this client?
tient avoid purging behavior.
920121.qxd 8/7/08 3:09 PM Page 457
1. Anorexia nervosa Client needs category: Physiological

2. Eating disorder integrity
3. Bulimia nervosa Client needs subcategory: Reduction of
4. Genu valgum risk potential
Answer: 1. The scenario describes anorexia Cognitive level: Application
nervosa. The term eating disorder encompass-
es both anorexia nervosa and bulimia ner-
vosa. Bulimia nervosa is episodic binge eating
and purging. Genu valgum is the medical
term for “knock knees.”
integrity
3. The nurse is caring for a client who has

been binge eating. Which description of the
client’s behavior is most appropriate?
1. The client has been slowly consuming a
large amount of food over 3 hours.
2. The client has been rapidly consuming
a large amount of food.
3. The client became extremely hungry
and then consumed a large amount of
food.
2. The nurse is monitoring a client diagnosed 4. The client is extremely thin but still
with anorexia nervosa. In addition to monitor- highly concerned about her weight.
ing the client’s eating, the nurse should per- Answer: 2. Binge eating is the rapid consump-
form which action after meals? tion of a large amount of food over a given pe-
1. Weigh the client. riod. Hunger doesn’t directly affect binge eat-
2. Prevent the client from using the bathing associated with mental health disorders.
room for 2 hours after eating. Bulimic people aren’t necessarily thin; in fact,
3. Tell the client to lie down for 2 hours af- they’re usually of normal body size and, in
ter eating. many cases, slightly overweight before onset
4. Instruct the client to get plenty of exer- of the disorder.
cise. Client needs category: Physiological
Answer: 2. After observing the client while integrity
she eats, the nurse should prevent the client Client needs subcategory: Physio-
from using the bathroom for at least 2 hours logical adaptation
to break the purging cycle. The client should Cognitive level: Comprehension
be weighed once or twice per week but not
after a meal has been consumed. Exercise
should be restricted until the client has
shown adequate weight gain, and then it
should be encouraged in moderation. It isn’t
necessary for the client to lie down for 2
hours after eating.
920121.qxd 8/7/08 3:09 PM Page 458
4. The nurse is caring for a client with bulim-

ia. What physical findings would the nurse ex-
pect?
1. Parotid and salivary gland swelling,
pharyngitis
2. Facial ecchymoses, bruised knuckles,
and excessive torso fat stores
3. Depression, parotid gland swelling
4. Depression, bruised knuckles
Answer: 1. All findings listed, except excessive
torso fat, are characteristic of bulimic clients.
Depression, however, is a psychosocial—not a
physical—finding.
integrity
logical adaptation
7. The nurse is caring for a client who has
5. The nurse is caring for a client diagnosed bulimia. Which treatment option is most ef-
with bulimia and notices Russell’s sign. What fective?
finding did the nurse observe? 1. Antidepressants
1. Dental enamel erosions 2. Cognitive therapy
2. Facial ecchymoses 3. Antidepressants and cognitive therapy
3. Pharyngitis 4. Total parenteral nutrition and antide-
4. Bruised knuckles pressants
Answer: 4. Bulimic clients commonly have Answer: 3. The combined approach of antide-
bruised knuckles due to self-induced vomit- pressants and cognitive therapy has been ef-
ing. This is called Russell’s sign. fective, even when clients don’t present with
Client needs category: Physiological depression. Total parenteral nutrition isn’t in-
integrity dicated.
Client needs subcategory: Physio- Client needs category: Physiological
logical adaptation integrity
Cognitive level: Comprehension Client needs subcategory: Pharmaco-
logical therapies
6. The nurse is caring for a client who has Cognitive level: Application
bulimia. What would be the most common
metabolic complication for this client? 8. The nurse is caring for several clients who
1. Metabolic alkalosis have eating disorders. Based on appearance,
2. Respiratory alkalosis how would the nurse distinguish bulimic
3. Respiratory acidosis clients from anorectic clients?
4. Metabolic acidosis 1. By their teeth
Answer: 1. With repeated emesis, the client 2. By body size and weight
loses stomach acids, thus becoming alkalotic. 3. By looking for Mallory-Weiss tears
Respiratory pH disturbances aren’t directly 4. The clients are indistinguishable upon
related to bulimia. physical examination
integrity
logical adaptation
920121.qxd 8/7/08 3:09 PM Page 459
Answer: 2. Behaviors of the anorectic client Client needs category: Psychosocial

and the bulimic client are commonly similar, integrity
especially because both implement rituals to Client needs subcategory: None
lose weight; however, the bulimic client tends Cognitive level: Comprehension
to eat much more, because of the binge epi-
sodes, and therefore can be of near-normal 10. The nurse is caring for a client who has
weight. Not all persons with the purge disor- an eating disorder. Which nursing interven-
der have loss of enamel on teeth, especially if tions would be appropriate for this client?
the disorder has developed recently. Mallory- 1. Weigh the client once or twice per
Weiss tears are small tears in the esophageal week, and contract for amount of food to
mucosa caused by forceful vomiting, but they be eaten.
aren’t always present in bulimic clients. 2. Weigh the client daily, and allow the
Client needs category: Physiological client to use the bathroom one-half hour af-
integrity ter eating.
Client needs subcategory: Physio- 3. Provide one-on-one support before
logical adaptation meals.
Cognitive level: Application 4. Contract amount of food to be eaten,
and weigh the client twice daily.
Answer: 1. Weighing the client more often
than once or twice per week reinforces the
the client’s excessive emphasis on weight.
Contracting for a specific amount of food to
be eaten at each meal encourages dietary
change without conflict. The client shouldn’t
be allowed to use the bathroom for at least 2
hours after eating without supervision. One-
on-one support for the client must be under-
taken before, during, and after meals—not
just before meals.
9. The nurse is caring for a bulimic client and integrity
an anorectic client. What cognitive character- Client needs subcategory: Physio-
istics would be similar in these clients? logical adaptation
1. Perfectionism, preoccupation with food Cognitive level: Application
2. Relaxed personality, preoccupation with It’s been a long,
food strange trip through
3. No similarities the mind, but you’ve
4. Preoccupation with exercise tackled the section on
Answer: 1. Cognitive distortions are similar in psych disorders!
both disorders and includes an attitude of per- Congratulations!
fectionism and a preoccupation with food.
Rarely do people with eating disorders have
relaxed personalities. The anorectic client is
more likely than the bulimic client to overex-
ercise for weight control.
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1. The nurse is caring for a client who’s sar- be stopped abruptly by the client unless ad-
castic and critical and often expresses feel- vised by the physician. Fluoxetine doesn’t
ings that are the opposite of what he’s actually cause photosensitivity.
feeling. This client is exhibiting which type of Client needs category: Physiological
behavior? integrity
1. Passive Client needs subcategory: Pharmaco-
2. Aggressive logical therapies
3. Passive-aggressive Cognitive level: Knowledge
4. Assertive
Answer: 3. A passive-aggressive person is of-
ten sarcastic and critical and expresses feel-
ings that are the opposite of what he actually
feels. He defends his rights through resis-
tance. The goal is to dominate through retalia-
tion. Passive behavior is characterized by
denying one’s own rights to please others. Ag-
gressive behavior is characterized by trying
to violate the rights of others and control
them through humiliation. Assertive behavior
is characterized by honest, direct assertion of
one’s rights through effective communication.
integrity 3. The nurse is teaching a client receiving a
Client needs subcategory: None monoamine oxidase inhibitor (MAOI) about
Cognitive level: Application his drug therapy. The client demonstrates un-
derstanding by expressing the need to avoid
2. The nurse is teaching a client about the an- tyramine-containing foods and stating that
Feel like taking a tidepressant drug fluoxetine (Prozac). Which even moderate amounts of tyramine must
swing at these 30 statement is true of this drug? be avoided to prevent hypertensive crisis.
practice questions on 1. The therapeutic effect may not be seen The nurse asks the patient to list specific
psychiatric care? for 3 to 4 weeks. tyramine-containing foods. The client would
Go for it! 2. Fluoxetine doesn’t cause orthostatic be correct in naming which of the following
hypotension. foods?
3. Fluoxetine should be stopped immedi- 1. Swiss cheese
ately if adverse reactions occur. 2. Cream cheese
4. The client should avoid exposure to the 3. Milk
sun because of photosensitivity reactions. 4. Ice cream
Answer: 1. Effects of fluoxetine may not be Answer: 1. Fermented, aged, or smoked foods
seen for 3 to 4 weeks after the initiation of tend to be high in tyramine and should be
therapy. Clients taking fluoxetine should be avoided. Cream cheese, milk, and ice cream
warned to move from a sitting to a standing are unfermented milk products that may be
position very slowly because of the risk of or- taken with MAOIs without incident.
thostatic hypotension. Fluoxetine shouldn’t
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Client needs category: Physiological tongue movements. Symptoms are potentially

integrity irreversible. Pseudoparkinsonism may also
Client needs subcategory: Pharmaco- occur in clients on antipsychotic drugs; signs
logical therapies and symptoms include drooling and a shuf-
Cognitive level: Application fling gait. Akinesia causes symptoms much
like those of pseudoparkinsonism. Both are
extrapyramidal adverse effects. Oculogyric
crisis is uncontrolled rolling back of the eyes,
which sometimes occurs in epidemic en-
cephalitis or postencephalitic parkinsonism.
integrity
logical therapies
6. Electroconvulsive therapy (ECT) is most

effective in treating which disorder?
4. When caring for a client who’s receiving 1. Schizophrenia
lithium, the nurse should monitor the client 2. Major depression
for which adverse effect? 3. Dissociative disorder
1. Hypertension 4. Seizure disorder
2. Fine hand tremors Answer: 2. ECT is most effective in clients
3. Weight loss with major depression, especially those with
4. Fluid retention associated psychosis. Treatment is initiated
Answer: 2. Fine hand tremors are an adverse only after drug therapy has been unsuccess-
effect of lithium therapy that may require a ful. ECT is sometimes effective in inducing re-
dosage adjustment. Other adverse effects in- mission in clients with schizophrenia. ECT
clude hypotension, weight gain, polyuria, and isn’t effective in treating dissociative disorder
dehydration. Hypertension, weight loss, and or seizure disorder. Brief seizure activity oc-
fluid retention aren’t adverse effects associat- curs during ECT.
ed with lithium therapy. Client needs category: Psychosocial
Client needs subcategory: Pharmaco- Cognitive level: Knowledge
logical therapies
Cognitive level: Knowledge 7. When preparing the client and his family
for ECT, the nurse should alert them about
5. A client on antipsychotic drugs begins to which adverse effect?
exhibit bizarre facial and tongue movements. 1. Permanent memory loss
Based on these findings, the client is most 2. Temporary memory loss
likely exhibiting signs and symptoms of 3. Brain damage
which disorder? 4. Increased intracranial pressure
1. Akinesia Answer: 2. Temporary memory loss and con-
2. Pseudoparkinsonism fusion commonly occur in clients who have
3. Tardive dyskinesia undergone ECT. These effects may last for
4. Oculogyric crisis weeks or months. Permanent memory loss,
Answer: 3. Clients who are on long-term an- brain damage, and increased intracranial
tipsychotic therapy are at risk for tardive pressure aren’t adverse effects of ECT.
dyskinesia, which causes bizarre facial and
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462 Psychiatric care
Client needs category: Physiological 1. Have the client weigh herself and
integrity record her weight.
Client needs subcategory: Reduction of 2. Have the client record her food intake
risk potential herself after she has eaten.
Cognitive level: Comprehension 3. Remain with the client during meal-
times and observe her for 2 hours after
eating.
4. Recommend that the client not eat
snacks so that she’ll be able to eat at meal-
time.
Answer: 3. Clients with eating disorders re-
quire supervision during and after meals to
ensure that the client eats and doesn’t try to
vomit after eating. The client may record her
weight, but the nurse must be present to
weigh the client to ensure that the weight is
recorded accurately. The client may record
8. Which nursing diagnosis would be most her intake but the nurse must be present dur-
appropriate for a client who has undergone ing the meal to ensure that the intake is
the full course of ECT? recorded correctly. The nurse should leave
1. Impaired verbal communication related snacks for the client so food is always avail-
to the effects of ECT able.
2. Noncompliance related to knowledge Client needs category: Physiological
deficit integrity
3. Disturbed thought processes related to ad- Client needs subcategory: Reduction of
verse effects of ECT risk potential
4. Fear related to the unknown Cognitive level: Application
Answer: 3. Because memory loss is a common
adverse effect of ECT, disturbed thought
processes is the most appropriate nursing di-
agnosis for this client. Impaired verbal com-
munication isn’t an effect of ECT. Noncompli-
ance isn’t an appropriate diagnosis for a client
who has undergone a full course of therapy.
Fear related to the unknown would be an ap-
propriate diagnosis for the client before ECT.
integrity 10. The nurse is evaluating an elderly client
Client needs subcategory: None for dementia. Which of the following is a pri-
Cognitive level: Analysis mary symptom of dementia?
1. Psychosis
9. Which nursing intervention is most appro- 2. Memory loss
priate when planning care for a client with 3. Neurosis
anorexia nervosa? 4. Loss of impulse control
Answer: 2. Memory loss is the primary symp-
tom of dementia. Loss of short-term memory
(retaining new information) is more common,
but long-term memory (recollection of events
that occurred in the past) may also be affect-
ed. Psychosis, neurosis, and loss of impulse
control aren’t symptoms of dementia.
920121.qxd 8/7/08 3:09 PM Page 463

integrity integrity
Cognitive level: Comprehension Cognitive level: Comprehension
13. An alcohol-dependent client is admitted

for evaluation of depression. Because the
client has no access to alcohol, the nurse
should observe for which early signs and
symptoms of alcohol withdrawal?
1. Hypotension and agitation
2. Seizures and nausea
3. Anxiety, nausea, and insomnia
4. Violent behavior and tachycardia
Answer: 3. Initial signs and symptoms of alco-
hol withdrawal include anxiety, nausea, tachy-
11. Which intervention by the nurse takes cardia, fever, agitation, and insomnia. As
top priority when caring for a client with de- symptoms progress, the client may experi-
mentia? ence hallucinations, increased blood pres-
1. Providing foods that are easy to eat sure, excessive sweating, and seizures. If un-
2. Providing the opportunity for rest and treated, this syndrome can cause serious
sleep medical complications, such as pneumonia,
3. Keeping the incontinent client clean fluid and electrolyte imbalance, and dehydra-
and dry tion. Hypotension and violent behavior aren’t
4. Creating a safe environment early signs and symptoms of alcohol with-
Answer: 4. Client safety takes top priority drawal.
when caring for the client with dementia. Pro- Client needs category: Physiological
viding foods that are easy to eat, providing integrity
rest and sleep, and keeping the incontinent Client needs subcategory: Reduction of
client clean and dry are all important when risk potential
caring for the client with dementia, but client Cognitive level: Knowledge
safety takes top priority.
Client needs category: Psychosocial 14. Which of the following is a true state-
integrity ment about cocaine?
Client needs subcategory: None 1. Cocaine is sometimes prescribed for
Cognitive level: Analysis weight control.
2. Cocaine can only be inhaled or injected.
12. The nurse is caring for a client with alco- 3. Effects of cocaine last for 1 to 8 hours.
hol dependence. When talking to the client 4. Cocaine is occasionally used as a local
about his treatment options, the nurse states anesthetic.
that the most effective treatment for alcohol Answer: 4. Cocaine is occasionally used as an
dependence is: anesthetic before nasal surgery. It isn’t pre-
1. attending Alcoholics Anonymous (AA). scribed for weight control. Individuals who
2. psychotherapy. abuse cocaine may inject it I.V., inhale it, or
3. limiting alcohol consumption to one smoke it. Cocaine’s duration of action is 15
drink each day. minutes to 2 hours.
4. total abstinence. Client needs category: Physiological
Answer: 4. Total abstinence is the most effec- integrity
tive treatment for alcohol dependence. Psy- Client needs subcategory: Pharmaco-
chotherapy and AA are effective ways to help logical therapies
the client maintain total abstinence. Cognitive level: Knowledge
920121.qxd 8/7/08 3:09 PM Page 464
ascorbic acid deficiencies aren’t implicated in

Wernicke’s encephalopathy.
integrity
risk potential
17. A client with alcohol dependence has

completed a rehabilitation program and now
attends AA meetings three times per week.
Which statement by the client best reflects an
15. A client with a history of alcohol abuse understanding of AA’s philosophy?
successfully completes a few days of absti- 1. “I have to attend these meetings until I
nence. The client may benefit from which can control my drinking.”
drug that interferes with the metabolism of 2. “The organization will see that I get
the alcohol? therapy if I begin to drink again.”
1. Chlordiazepoxide (Librium) 3. “AA will help me remain sober.”
2. Diazepam (Valium) 4. “AA will help me find shelter and a job.”
3. Disulfiram (Antabuse) Answer: 3. AA is a self-help organization that
4. Sertraline (Zoloft) helps attendees maintain sobriety through
Answer: 3. Disulfiram interferes with alcohol mutual support. Total abstinence is the most
metabolism, causing the client to experience effective treatment for alcohol abuse. Social
a throbbing headache, tachycardia, tachy- drinking isn’t possible for the alcoholic. AA
pnea, and sweating within 5 to 15 minutes of doesn’t provide therapy, shelter, or jobs.
alcohol consumption. Nausea and vomiting Client needs category: Psychosocial
may follow within an hour. Chlordiazepoxide integrity
and diazepam are antianxiety drugs that are Client needs subcategory: None
sometimes used to ease the client through Cognitive level: Analysis
the withdrawal process. Sertraline is indicat-
ed for the treatment of depression. 18. The nurse is interviewing a client admit-
Client needs category: Physiological ted to the facility with a diagnosis of schizo-
integrity phrenia. The client states, “I run apple, train,
Client needs subcategory: Pharmaco- grass, window.” This response by the client is
logical therapies known as:
Cognitive level: Knowledge 1. echopraxia.
2. a word salad.
16. The nurse is caring for a client with Wer- 3. flight of ideas.
nicke’s encephalopathy. When developing a 4. a neologism.
teaching plan for the client and his family, the Answer: 2. A word salad is an illogical word
nurse should stress the importance of includ- grouping. Echopraxia is an involuntary repeti-
ing which vitamin in his diet? tion of movements. Flight of ideas is a rapid
1. Niacin succession of unrelated ideas. Neologisms
2. Riboflavin are bizarre words that have meaning only to
3. Ascorbic acid the client.
4. Thiamine Client needs category: Psychosocial
Answer: 4. Wernicke’s encephalopathy, a neu- integrity
rologic disorder seen in clients with chronic Client needs subcategory: None
alcohol abuse, results from thiamine deficien- Cognitive level: Knowledge
cy. The client should be encouraged to eat a
diet rich in thiamine. Niacin, riboflavin, and
920121.qxd 8/7/08 3:09 PM Page 465
real external stimuli. Illusions are mispercep-

tions of real external stimuli.
integrity
21. A client tells the nurse that a voice keeps

telling him to crawl on his hands and knees
like a dog. Which response by the nurse is
the most appropriate for this client?
1. “They’re just imaginary voices and
19. The nurse is caring for a client who ex- they’ll go away.”
hibits magical thinking. Which best describes 2. “If it makes you feel better, do what the
magical thinking? voices tell you.”
1. Strong positive and negative feelings 3. “I don’t hear them, but I understand
that cause conflict that you do.”
2. Returning to earlier developmental 4. “Even though I don’t hear the voices, I
stage understand that you do.”
3. Meaningless repetition of words Answer: 4. By telling the client that she
4. The belief that thoughts or wishes can doesn’t hear the voices, the nurse lets the
control other people or events client know that the voices aren’t real to her.
Answer: 4. When a client exhibits magical The nurse follows with a validation of the
thinking, he believes that his thoughts or client’s statement that opens a line of commu-
wishes can control others or events. For ex- nication and encourages the client to talk
ample, the client may believe that through about his hallucinations. Options 1 and 2 are
wishing he can make a plane fall from the sky. nontherapeutic communications that invali-
Ambivalence is the coexistence of positive date the client’s statement. By using the
and negative thoughts. Returning to an earlier words “they” and “them” in describing the
stage of development is termed regression. A voices, the nurse is reinforcing the client’s
meaningless repetition of words is called perception that they actually exist.
echolalia. Client needs category: Psychosocial
Client needs subcategory: None Cognitive level: Analysis
22. During the admission process, a client
20. A client tells the nurse that he can’t eat who has a panic disorder begins to hyperven-
because his food has been poisoned. This tilate and says, “I’m going to die if I don’t get
statement is an indication of which of the fol- out of here right now!” Which response by
lowing? the nurse would be best?
1. Paranoia 1. “Just calm down. You’re getting overly
2. Delusion of persecution anxious.”
3. Hallucination 2. “What do you think is causing your pan-
4. Illusion ic attack?”
Answer: 1. Paranoia is described as extreme 3. “You can rest alone in your room until
suspicion of others and their intentions. Delu- you feel better.”
sions of persecution are feelings that others 4. “You’re having a panic attack. I’ll stay
intend harm or persecution. A hallucination is here with you.”
a false sensory perception associated with Answer: 4. During a panic attack, the nurse’s
best approach is to orient the client to what’s
920121.qxd 8/7/08 3:09 PM Page 466
happening and provide reassurance that the 24. A client with a history of panic attacks
client won’t be left alone. The client’s anxiety seeks to increase social interaction. Each time
level is likely to increase—and the panic at- the client tries to go to the day room, she be-
tack is likely to continue—if the client is told gins to perspire and becomes short of breath.
to calm down, asked the reasons for the at- Which action by the nurse will help ease the
tack, or left alone. client’s feelings of panic?
Client needs category: Psychosocial 1. Have other clients volunteer to accom-
integrity pany the client.
Client needs subcategory: None 2. Tell the client she has to overcome her
Cognitive level: Application fear.
3. Allow the client to stay in her room.
4. Walk with the client and stay with her
while she’s in the day room.
Answer: 4. The client may find security in the
presence of a trusted person. Her fears are
very real and she’ll need the emotional sup-
port of caring professionals, not other clients,
to overcome them. Telling the client she has
to overcome her fears minimizes her feelings.
Allowing the client to stay in her room doesn’t
help her overcome her feelings of panic.
integrity
23. A client is admitted to the hospital in the Client needs subcategory: None
manic phase of bipolar disorder. When plac- Cognitive level: Application
ing a diet order for the client, which foods
would be most appropriate? 25. During the night, a 50-year-old client with
1. A bowl of soup, crackers, and a dish of posttraumatic stress disorder wakens shaking
peaches and saying that someone is trying to smother
2. A cheese sandwich, carrot sticks, fresh him. What’s the appropriate response for the
grapes, and cookies nurse in this situation?
3. Roast chicken, mashed potatoes, and 1. “It was a bad dream. You’re safe. I’ll
peas stay here with you until you go back to
4. A tuna sandwich, an apple, and a dish of sleep.”
ice cream 2. “We can talk about it tomorrow. Try to
Answer: 2. The client may have a difficult time see if you can get back to sleep.”
sitting long enough to eat his meal; therefore, 3. “It was only a dream. There’s nothing
finger foods that can be eaten easily are most to be frightened about.”
appropriate. The other foods require the 4. “I’ll call the physician and see whether I
client to sit and eat, a task that he’ll be unable can get you medication to help you go
to perform at this time. back to sleep.”
Client needs category: Physiological Answer: 1. It’s important to help the client feel
integrity safe. Staying with him until he can sleep again
Client needs subcategory: Basic care or listening to him if he wants to talk is the
and comfort most appropriate action for the nurse to take
Cognitive level: Application in this situation. Talking about the dream in
the morning won’t comfort the client when
he’s most upset. Stating that it was only a
dream trivializes his experience. Calling the
physician for a sleeping aid doesn’t help the
client cope with stress.
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integrity integrity
Cognitive level: Application Cognitive level: Knowledge
26. A 45-year-old client complains of constant

dizziness and weakness. The client has been
referred to specialists for evaluation. All tests
have been negative. The physician has con-
cluded that the client has a somatic disorder.
How should the nurse deal with this client?
1. Review the test results with the client
so she understands there’s nothing physi-
cally wrong with her.
2. Tell the client that if she develops more
outside interests she won’t focus on her
physical symptoms so much. 28. The nurse is performing an admission in-
3. Accept the fact that the physical com- terview with a client who exhibits signs of an-
plaints are real to the client. tisocial personality disorder. Which behavior
4. Ignore the client’s complaints. pattern is most characteristic of this disorder?
Answer: 3. The nurse should accept the 1. The client expresses feelings of being
client’s problem despite the fact that it isn’t or- deceived.
ganic. To deny the client’s physical com- 2. The client displays hostility toward oth-
plaints is nontherapeutic and prevents the de- ers.
velopment of a trusting, therapeutic relation- 3. The client displays a general disregard
ship. for the rights and feelings of others.
Client needs category: Psychosocial 4. The client is suspicious of his friends
integrity and relatives.
Client needs subcategory: None Answer: 3. The client with antisocial personali-
Cognitive level: Application ty disorder exhibits a general disregard for
the rights and feelings of others. The other
27. The nurse is caring for a client recently three characteristics are behavior patterns of
diagnosed with borderline personality disor- paranoid personality disorder.
der. Which characteristic is most notable in a Client needs category: Psychosocial
client with this disorder? integrity
1. Changes actions quickly and has an in- Client needs subcategory: None
tense affect Cognitive level: Knowledge
2. Does a poor job on things that he
doesn’t like to do 29. A client with borderline personality disor-
3. Avoids responsibilities by saying that der has been asked to spend 1 hour in his
he forgot room. The client asks the nurse for permis-
4. Resents useful suggestions sion to go to another client’s room to borrow
Answer: 1. A client with borderline personality a book. What behavior pattern is this client
disorder can change actions within a matter demonstrating?
of minutes, hours, or days and commonly ex- 1. Manipulation
hibits an intense affective tone such as anger. 2. Rationalizing
The other responses are characteristics of 3. Impulsivity
passive-aggressive personality disorder. 4. Distancing
Answer: 1. Manipulation is a technique used
by the person with borderline personality to
achieve whatever result he wants. Rationaliz-
920121.qxd 8/7/08 3:09 PM Page 468
ing is the substitution of acceptable reasons Answer: 3. The client’s behavior indicates that
for the actual reasons motivating behavior. he has difficulty adhering to limits and re-
Impulsivity is poor impulse control. Distanc- specting boundaries. The nurse must place
ing is becoming angry and hostile to keep an- limits on the client’s manipulative behavior.
other at a distance. Taking the client outside for a smoke is inap-
Client needs category: Psychosocial propriate because the nurse is allowing the
integrity client to manipulate her. Referring the client
Client needs subcategory: None to the technician is incorrect because the
Cognitive level: Knowledge nurse isn’t addressing the client’s manipula-
tive behavior. Option 4 is an abrupt response
30. A male client approaches the nurse and that may cause the client to act defensively.
says, “Hey cutie, can you take me outside for Client needs category: Psychosocial
a smoke?” The nurse is aware that the client integrity
isn’t supposed to go out to smoke for another Client needs subcategory: None
15 minutes. Which response by the nurse is Cognitive level: Application
most therapeutic?
1. “Sure, I’m not busy right now.”
2. “You can ask the technician. I’m busy
right now.”
3. “You’ll be able to smoke in 15 minutes.
Calling me cutie is disrespectful.”
4. “You know the rules. It isn’t time yet for
you to go out to smoke.”
You’ve made it
through your review of
psychiatric disorders.
Good job!
920122.qxd 8/7/08 3:09 PM Page 469
Part IV Maternal-neonatal care

22 Antepartum care 471
23 Intrapartum care 495
24 Postpartum care 519
25 Neonatal care 531

920122.qxd 8/7/08 3:09 PM Page 470
920122.qxd 8/7/08 3:09 PM Page 471
22 Antepartum
care
Probably is
In this chapter,
you’ll review:
Brush up on key Probable signs of pregnancy include:
• ballottement (passive fetal movement in re-
✐ basics of antepartum concepts sponse to tapping of the lower portion of the
uterus or cervix)
care
✐ antepartum tests and Antepartum care refers to care of a mother • Braxton Hicks contractions (painless uter-
before childbirth. Knowledge of the physio- ine contractions that occur throughout preg-
procedures
logic changes that accompany pregnancy and nancy)
✐ common antepartum
of fetal development is essential to under- • Chadwick’s sign (color of the vaginal walls
disorders and compli- standing patient care during the antepartum changes from normal light pink to deep vio-
cations. period. let)
At any time, you can review the major points • Goodell’s sign (softening of the cervix)
of this chapter by consulting the Cheat sheet • Hegar’s sign (softening of the lower uterine
on pages 472 to 474. segment) may be present at 6 to 8 weeks’ ges-
tation
• positive pregnancy test results
Normal antepartum period • abdominal enlargement.
Nursing care during the normal antepartum Definitely is

period includes taking a thorough maternal Positive signs of pregnancy include:
history, performing a complete physical ex- • detection of fetal heartbeat by electronic
amination, and educating the patient about an- doppler (by 10 to 12 weeks’ gestation)
tepartum health. • detection of fetal heartbeat by fetoscope(by
17 to 20 weeks’ gestation)
SIGNS AND SYMPTOMS OF • detection of fetal movements (after 16
PREGNANCY weeks’ gestation)
The patient may experience presumptive, • ultrasonography finding of the fetus (as ear-
probable, or positive signs of pregnancy. ly as 6 weeks’ gestation).
Could be PHYSIOLOGIC ADAPTATIONS

Presumptive signs of pregnancy include: Here’s a review of how body systems adapt to
• amenorrhea or slight, painless spotting of pregnancy.
unknown cause in early gestation
• breast enlargement and tenderness My ever changin’ heart
• fatigue Cardiovascular system changes include:
• increased skin pigmentation • cardiac hypertrophy from increased blood
• nausea and vomiting volume and cardiac output
• quickening (first recognizable movement of • displacement of the heart upward and to the
fetus) left from pressure on the diaphragm
• urinary frequency and urgency. • progressive increase in blood volume, peak-
ing in the third trimester at 40% to 50% of lev-
els before pregnancy

920122.qxd 8/7/08 3:09 PM Page 472
472 Antepartum care
et
heat she
C
Antepartum care refresher
ACQUIRED IMMUNODEFICIENCY SYNDROME DIABETES MELLITUS
• Diarrhea • Glycosuria
• Fatigue • Ketonuria
• Kaposi’s sarcoma • Polyuria
• Mild flulike symptoms Key test results
• Opportunistic infections, such as toxoplasmo- Gestational diabetes is diagnosed if the patient
sis, oral and vaginal candidiasis, herpes simplex, has two or more of the following results:
Pneumocystis carinii, and Candida esophagitis • Fasting blood sugar level equals or exceeds
• Weight loss 95 mg/dl
Key test results • Three-hour glucose tolerance test reveals
• CD4⫹ T-cell level is less than 200 cells/µl. 1-hour level at or above 180 mg/dl
• Enzyme-linked immunosorbent assay shows • Three-hour glucose tolerance test reveals
positive human immunodeficiency virus antibody 2-hour level at or above 155 mg/dl
titer. • Three-hour glucose tolerance test reveals
• Western blot test is positive. 3-hour level at or above 140 mg/dl.
Key treatments Key treatments
• If patient is newly diagnosed, zidovudine (Retro- • 1,800- to 2,200-calorie diet divided into three
vir) or didanosine (Videx) treatment initiated be- meals and three snacks; diet should also include
tween weeks 14 and 34 of gestation low fat and cholesterol and high fiber
Key interventions • Administration of insulin or glyburide (DiaBeta)
Don’t forget, • Determine whether the patient will be able to after the first trimester
pregnancy itself is care for her infant after delivery. Key interventions
NOT a disorder. • Encourage adherence to dietary regulations.
Effective nursing care ADOLESCENT PREGNANCY
• Encourage the patient to exercise moderately.
usually involves Key signs and symptoms • Prepare the patient for antepartum fetal surveil-
listening to and
• Denial of pregnancy, which may deter the pa- lance testing, including oxytocin challenge test-
reassuring healthy
tient from seeking medical attention early in preg- ing, nipple stimulation stress testing, amniotic flu-
mothers.
nancy id index, biophysical profile, and nonstress test.
Key test results
ECTOPIC PREGNANCY
• Pregnancy test is positive.
Key treatments
• Irregular vaginal bleeding and dull abdominal
• Diet with caloric intake that supports the grow-
pain on the affected side early in pregnancy
ing adolescent and her developing fetus
• Positive Cullen’s sign (bluish discoloration
Key interventions around the umbilicus)
• Monitor the patient’s weight gain. • Rupture of tubes, causing sudden and severe
• Advise the patient of her options, including ter- abdominal pain, syncope, and referred shoulder
minating the pregnancy, continuing the pregnan- pain as the abdomen fills with blood
cy and giving up the infant for adoption, and con- Key test results
tinuing the pregnancy and keeping the infant.
• Human chorionic gonadotropin (HCG) titers are
abnormally low when compared to a normal
pregnancy.
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Antepartum care refresher (continued)

ECTOPIC PREGNANCY (continued) Key test results
Key treatments • HCG levels are much higher than normal.
• Laparotomy to ligate the bleeding vessels and remove or repair • Ultrasound fails to reveal a fetal skeleton.
damaged fallopian tube Key treatments
• If the tube hasn’t ruptured, methotrexate (Trexall) followed by • Therapeutic abortion (suction and curettage) if a spontaneous
leucovorin (Wellcovorin) to stop the trophoblastic cells from abortion doesn’t occur
growing (therapy continues until negative HCG levels are • Weekly monitoring of HCG levels until they remain normal for 3
achieved) consecutive weeks
Key interventions • Periodic follow-up for 1 to 2 years because of increased risk of
• Monitor for signs of rupturing ectopic pregnancy, such as se- neoplasm
vere abdominal pain, orthostatic hypotension, tachycardia, and Key interventions
dizziness. • Monitor vaginal bleeding.
• Maintain I.V. fluid replacement. • Send contents of uterine evacuation to the laboratory for
• Monitor blood product administration. analysis.
HEART DISEASE HYPEREMESIS GRAVIDARUM
• Crackles at the base of the lungs • Continuous, severe nausea and vomiting
• Diastolic murmur at the heart’s apex • Dehydration
• Dyspnea • Oliguria
• Fatigue • Significant weight loss
• Tachycardia Key test results
Key test results • Arterial blood gas analysis reveals metabolic alkalosis.
• Echocardiography, electrocardiography, and chest X-ray may • Hemoglobin level and hematocrit are elevated.
reveal cardiac abnormalities, arrhythmias, impaired cardiac • Serum potassium level reveals hypokalemia.
function, increased workload on the heart, and cardiovascular Key treatments
decompensation.
• Restoration of fluid and electrolyte balance
Key treatments
Key interventions
For class III and class IV disease
• Monitor fundal height and the patient’s weight.
• Anticoagulants such as heparin
• Provide small, frequent meals.
• Antiarrhythmics, such as digoxin (Lanoxin), procainamide
• Maintain I.V. fluid replacement and total parenteral nutrition.
(Pronestyl), and beta-adrenergic blockers
• Thiazide diuretics and furosemide (Lasix) to control heart failure HYPERTENSION IN PREGNANCY
if activity restriction and reduced sodium intake don’t prevent it Key signs and symptoms
Key interventions Gestational hypertension
• Monitor cardiovascular and respiratory status. • Systolic blood pressure 140 to 159 mm Hg or diastolic blood
• Administer oxygen by nasal cannula or face mask during labor. pressure 90 to 109 mm Hg
• Position the patient on her left side with her head and shoul- • No proteinuria
ders elevated during labor. Preeclampsia
• Systolic blood pressure ≥ 140 mm Hg or diastolic blood pres-
HYDATIDIFORM MOLE
sure ≥ 90 mm Hg
Key signs and symptoms • Proteinuria
• Intermittent or continuous bright red or brownish vaginal • Weight gain more than 2 lb (0.9 kg) per week
bleeding by the 12th week of gestation • Headaches, blurred vision, hyperreflexia, nausea, vomiting, irri-
• Absence of fetal heart tones tability, cerebral disturbances, and epigastric pain
(continued)
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474 Antepartum care
Antepartum care refresher (continued)

HYPERTENSION IN PREGNANCY (continued) MULTIFETAL PREGNANCY
• Presence of HELLP syndrome (hemolysis, elevated liver en- Key signs and symptoms
zymes, and low platelet count) • More than one set of fetal heart sounds
Key test results • Uterine size greater than expected for dates
• Blood chemistry reveals increased blood urea nitrogen, creati- Key test results
nine, and uric acid levels and elevated liver function studies • Alpha-fetoprotein levels are elevated.
Key treatments • Ultrasonography is positive for multifetal pregnancy.
• Bed rest in a left lateral position Key treatments
• Delivery: with mild preeclampsia, when the fetus is mature and • Bed rest if early dilation occurs or at 24 to 28 weeks’ gestation
safe induction is possible; with severe preeclampsia, regardless • Biweekly nonstress test to document fetal growth, beginning
of gestational age with the 28th week of gestation
• High-protein diet with restriction of excessively salty foods • Increased intake of calories, iron, folate, and vitamins
• With chronic hypertension: methyldopa or labetalol (Trental) • Ultrasound examinations monthly to document fetal growth
• With severe preeclampsia: hydralazine (Apresoline) or la- Key interventions
betalol (Normodyne) to control blood pressure, betamethasone
• Monitor fetal heart sounds.
(Celestone) to accelerate fetal lung maturation, and magnesium
• Monitor maternal vital signs and weight.
sulfate to reduce the amount of acetylcholine produced by motor
• Monitor cardiovascular and pulmonary status.
nerves, thereby preventing seizures
Key interventions PLACENTA PREVIA
For all patients Key signs and symptoms
• Evaluate the patient for edema and proteinuria. • Painless, bright red vaginal bleeding, especially during the
• Maintain seizure precautions in hospitalized patients. third trimester
• Encourage bed rest in a left lateral recumbent position. Key test results
• Monitor blood pressure. • Early ultrasound evaluation reveals the placenta implanted in
For severe preeclampsia the lower uterine segment.
• Monitor maternal blood pressure every 4 hours or more fre-
Key treatments
quently if unstable.
• Depends on gestational age, when first episode occurs, and
• Be prepared to obtain a blood sample for typing and cross-
amount of bleeding
matching.
• If gestational age less than 34 weeks, hospitalizing the patient
• Keep calcium gluconate (antidote to magnesium sulfate) near-
and restricting her to bed rest to avoid preterm labor
by for administration at first sign of magnesium sulfate toxicity
• Surgical intervention by cesarean delivery depending on pla-
(elevated serum levels, decreased deep tendon reflexes, muscle
cental placement and maternal and fetal stability
flaccidity, central nervous system depression, and decreased
respiratory rate and renal function). Key interventions
• Avoid rectal or vaginal examinations unless equipment is avail-
able for vaginal and cesarean delivery.
• resting pulse rate fluctuations, with increas- • increased femoral venous pressure caused
es ranging from 15 to 20 beats/minute at by impaired circulation from the lower ex-
term tremities (resulting from the pressure of the
• pulmonic systolic and apical systolic mur- enlarged uterus on the pelvic veins and inferi-
murs resulting from decreased blood viscosi- or vena cava), which can lead to supine hy-
ty and increased blood flow otensive syndrome when the patient is in the
supine position.
920122.qxd 8/7/08 3:09 PM Page 475
• increased fibrinogen levels (up to 50% at Hormonal changes

term) from hormonal influences Endocrine system changes include:
• increased levels of blood coagulation factors • increased basal metabolic rate (up 25% at
VII, IX, and X, leading to a hypercoagulable term) caused by demands of the fetus and
state uterus and by increased oxygen consumption
• increase of about 33% in total red blood cell • increased iodine metabolism from slight hy-
(RBC) volume in patients taking iron supple- perplasia of the thyroid caused by increased
ments estrogen levels
• increase of about 50% in plasma volume • slight hyperparathyroidism from increased
• hematocrit (HCT) decrease of about 7% requirement for calcium and vitamin D
• increase of 12% to 15% in total hemoglobin • elevated plasma parathyroid hormone lev-
(Hb) level; this is less than the overall plasma els, peaking between 15 and 35 weeks’ gesta-
volume increase, thus reducing Hb concentration
tion and leading to physiologic anemia of • enlarged pituitary gland
pregnancy • increased production of prolactin by the pi-
• leukocyte production equal to or slightly tuitary gland late in pregnancy
greater than blood volume increase (average • increased estrogen levels and hypertrophy
leukocyte count is 10,000 to 11,000/µl; peaks of the adrenal cortex
at 25,000/µl during labor, possibly through an • increased cortisol levels to regulate protein
estrogen-related mechanism). and carbohydrate metabolism
• possibly decreased maternal blood glucose
Cravings and more levels
GI system changes include: • decreased insulin production early in preg-
• gum swelling from increased estrogen lev- nancy
els; gums may be spongy and bleed easily • increased production of estrogen, proges-
• lateral and posterior displacement of the in- terone, and human chorionic somatomam-
testines motropin by the placenta and increased levels
• superior and lateral displacement of the of maternal cortisol, which reduce the moth-
stomach er’s ability to use insulin, thus ensuring an ad-
• delayed intestinal motility and gastric and equate glucose supply for the fetus and pla-
gallbladder emptying time from smooth- centa.
muscle relaxation caused by high placental
progesterone levels, causing heartburn Altered breathing
• nausea and vomiting (usually subside after Respirator y system changes include:
the first trimester) • increased vascularization of the respiratory
The future is
• hemorrhoids late in pregnancy from venous tract caused by increased estrogen levels clear. Pregnancy will
pressure • shortening of the lungs caused by the en- affect nearly every
• constipation from increased progesterone larging uterus body system.
levels, resulting in increased water absorption • upward displacement of the diaphragm by
from the colon the uterus, causing dyspnea
• displacement of the appendix from McBur- • increased tidal volume, causing slight hy-
ney’s point (making diagnosis of appendicitis perventilation
difficult) • increased chest circumference (by about
• bile saturation with cholesterol and bile sta- 23⁄8 [6 cm])
sis due to progesterone’s smooth-muscle re- • altered breathing, with abdominal breathing
laxation effect, sometimes leading to gall- replacing thoracic breathing as pregnancy
stone formation. progresses
• slight increase (2 breaths/minute) in respi-
ratory rate
• lowered threshold for carbon dioxide due to
increased levels of progesterone.
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476 Antepartum care
What causes weight gain in pregnancy?

These factors are responsible for the weight • breasts (3 lb [1.4 kg])
gain that occurs during pregnancy: • blood volume (2 to 4 lb [0.9 to 1.8 kg])
• fetus (7.5 lb [3.4 kg]) • extravascular fluid and fat reserves (4 to 9 lb
• placenta and membranes (1.5 lb [0.7 kg]) [1.8 to 4.1 kg])
• amniotic fluid (2 lb [0.9 kg])
• uterus (2.5 lb [1.1 kg])
Everything increases cy; elevated GFR until delivery, but a near-

Metabolic system changes include: normal RPF by term
• increased water retention caused by higher • increased clearance of urea and creatinine
levels of steroidal sex hormones, decreased from increased renal function
serum protein levels, and increased intracapil- • decreased blood urea and nonprotein nitro-
lary pressure and permeability gen values from increased renal function
• increased levels of serum lipids, lipopro- • glucosuria from increased glomerular filtra-
teins, and cholesterol tion without an increase in tubular reabsorp-
• increased iron requirements caused by fetal tive capacity
demands • decreased bladder tone, causing urinary ur-
• increased carbohydrate needs gency and frequency
• increased protein retention from hyperpla- • increased sodium retention from hormonal
sia and hypertrophy of maternal tissues influences
• weight gain of 25 to 35 lb (11.3 to 16 kg) • increased dimensions of uterus
(see What causes weight gain in pregnancy?). • hypertrophied uterine muscle cells (5 to 10
times normal size)
Is it getting hot in here? • increased vascularity, edema, hypertrophy,
Integumentar y system changes include: and hyperplasia of the cervical glands
• hyperactive sweat and sebaceous glands • increased vaginal secretions with a pH of
• changing pigmentation from the increase of 3.5 to 6.0
melanocyte-stimulating hormone caused by • discontinued ovulation and maturation of
increased estrogen and progesterone levels new follicles
(darkened line from symphysis pubis to um- • thickening of vaginal mucosa, loosening of
bilicus known as linea nigra) vaginal connective tissue, and hypertrophy of
– darkened nipples, areola, cervix, vagina, small-muscle cells. (See Estimating delivery
and vulva dates and gestational age.)
– pigmentary changes on nose, cheeks, and
Memory forehead known as facial chloasma Not just pickles and ice cream
jogger • striae gravidarum, commonly known as Nutritional needs also change during preg-
For preg- stretch marks, caused by weight gain and nancy. For example:
nant pa- enlarged uterus. • Calorie requirements during pregnancy ex-
tients, remember ceed prepregnancy needs by 300 calories/day
3, 12, 12: Time to go (often) (from 2,100 to 2,400 kcal/day).
Maternal weight gain Changes to the genitourinar y system in- • Protein requirements during pregnancy ex-
is commonly esti- clude: ceed prepregnancy needs by 30 g/day (from
mated at 3, 12, and • dilated ureters and renal pelvis caused by 46 to 76 g/day).
12 pounds for the progesterone and pressure from the enlarg- • Intake of all vitamins should increase, and a
first, second, and ing uterus, increasing the risk of urinary tract prenatal vitamin is recommended.
third trimesters. infection • Folic acid intake is particularly important to
• increased glomerular filtration rate (GFR) help prevent fetal anomalies such as neural
and renal plasma flow (RPF) early in pregnan- tube defect. Intake should be increased from
920122.qxd 8/7/08 3:09 PM Page 477
Estimating delivery dates and gestational age

• Nägele’s rule determines the estimated date of • Fetal crown-to-rump measurements, deter-
delivery by subtracting 3 months from the first mined by ultrasonography, can be used to as-
day of the last menses and adding 7 days; for ex- sess the fetus’s age until the head can be de-
ample, October 5 ⫺ 3 months ⫽ July 5 ⫹ 7 days fined.
⫽ July 12. • Biparietal diameter is the widest transverse di-
• Quickening is described as light fluttering fetal ameter of the fetal head. Measurements can be
movement felt by the mother and is usually felt made by about 12 to 13 weeks’ gestation.
between 16 and 22 weeks’ gestation. • McDonald’s rule uses fundal height in centi-
• Fetal heart sounds can be detected with a meters to determine the duration of pregnancy
Doppler ultrasound at 10 to 12 weeks’ gestation in weeks. To use this rule, place a tape measure
and can be auscultated with a fetoscope at 16 to at the symphysis pubis and measure up and over
20 weeks’. the fundus. Fundal height in centimeters ⫻ 8⁄7 ⫽
duration of pregnancy in weeks.
400 to 800 mg/day. Dietary sources of folic The moment of truth

acid include green, leafy vegetables and Conception, or fertilization, occurs with the
whole-grain breads. fusion of a spermatozoon and an ovum
• Intake of all minerals, especially iron, (oocyte) in the ampulla of the fallopian tube.
should be increased. (See Battling discomforts • The fertilized egg is called a zygote.
of pregnancy, page 478.) • The diploid number of chromosomes (a pair
• Intake of fiber and fluid should be in- of each chromosome; 44 autosomes and 2 sex
creased. chromosomes) is restored when the zygote is
formed.
• A male zygote is formed if the ovum is fer-
Fetal development and tilized by a spermatozoon carrying a Y chro-
mosome.
structures • A female zygote is formed if the ovum is fer-
Attending to the
patient’s increased
tilized by a spermatozoon carrying an X chro- nutritional needs can
Structures unique to the fetus include fetal mosome. help prevent
membranes, the umbilical cord, the placenta, complications.
and amniotic fluid. A place to stay Nutritional care is
Implantation occurs when the cellular wall especially important
His and her cells of the blastocyst (trophoblast) implants itself for pregnant
adolescents.
Intrauterine development begins with game- in the endometrium of the anterior or posteri-
togenesis, the production of specialized sex or fundal region, about 7 to 9 days after fertil-
cells called gametes. ization.
• The male gamete (spermatozoon) is pro- • Primary villi appear within weeks
duced in the seminiferous tubules of the after implantation.
testes during spermatogenesis. • After implantation, the endometri-
• The female gamete (ovum) is produced in um is called the decidua.
the graafian follicle of the ovary during
oogenesis. The beginning of the placenta
• As gametes mature, the number of chromo- During placental formation, chori-
somes they contain is halved (through meio- onic villi invade the decidua and be-
sis) from 46 to 23. come the fetal portion of the future
placenta. By the 4th week of gesta-
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478 Antepartum care
Battling discomforts of pregnancy

Education plays an important role in helping the for at least 1 hour after eating; and use antacids
patient deal with discomforts. that don’t contain sodium bicarbonate.
FIRST-TRIMESTER DISCOMFORTS Constipation
Encourage the patient to exercise daily, increase
Nausea and vomiting
fluid and dietary fiber intake, and maintain regu-
Symptoms may occur at any time during preg-
lar elimination patterns.
nancy but are most prevalent during the first
trimester. Teach the patient to avoid greasy, Hemorrhoids
highly seasoned foods; to eat small, frequent Tell the patient to avoid constipation, prolonged
meals; and to eat dry toast or crackers before standing, and constrictive clothing, and advise
May I suggest you
arising in the morning. Instruct the patient to rise her to use topical ointments, warm soaks, and
eat small, frequent
slowly from a lying or sitting position. anesthetic ointments to relieve symptoms.
meals and avoid fatty
and fried foods. Nasal stuffiness, discharge, or obstruction Backache
Advise the patient to use a cool-mist vaporizer. Teach the patient how to use proper body me-
chanics and maintain good posture. Also tell her
Breast enlargement and tenderness
to avoid wearing high heels.
Tell the patient to wear a well-fitting support bra.
Leg cramps
Urinary frequency and urgency
Instruct the patient to increase calcium and
Instruct the patient to decrease fluid intake
phosphorus intake, frequently rest with legs ele-
in the evening to prevent nocturia; to avoid
vated, wear warm clothing and, during a leg
caffeine-containing fluids; and to respond to the
cramp, pull the toes up toward the leg while
urge to void immediately to prevent bladder dis-
pressing down on the knee.
tention and urinary stasis. Also teach the patient
how to perform Kegel exercises, and tell her to Shortness of breath
promptly report signs of urinary tract infections. Encourage the patient to maintain proper pos-
ture, especially when standing, and to sleep in
Fatigue
semi-Fowler’s position.
Tell the patient to rest periodically throughout
the day and to get at least 8 hours of sleep each Ankle edema
night. Advise the patient to wear loose-fitting gar-
ments, elevate the legs during rest periods, and
Increased leukorrhea
ensure dorsiflexion of the feet if standing or sit-
Advise the patient to bathe daily and wear ab-
ting for prolonged periods.
sorbent cotton underwear.
Insomnia
SECOND- AND THIRD-TRIMESTER Encourage the patient to use relaxation tech-
DISCOMFORTS niques. Tell her to lie on her left side, using pil-
Heartburn lows to support her legs and abdomen.
Encourage the patient to eat small, frequent
meals; avoid fatty or fried foods; remain upright
tion, a normal fetus begins to show noticeable • The amnion is the thin, tough, inner fetal
signs of growth. membrane that lines the amniotic sac.
Fetal linings Construction under way

Two fetal membranes are unique to the fetus: Embryonic germ layers generate these fetal
• The chorion is the fetal membrane closest tissues:
to the uterine wall; it gives rise to the placen- • The ectoderm generates the epidermis,
ta. nervous system, pituitary gland, salivary
920122.qxd 8/7/08 3:09 PM Page 479
glands, optic lens, lining of the lower portion • transfers passive immunity by way of mater-
of the anal canal, hair, and tooth enamel. nal antibodies.
• The endoderm generates the epithelial lin-
ing of the larynx, trachea, bladder, urethra, Fetal protection
prostate gland, auditory canal, liver, pancreas, The amniotic fluid prevents heat loss, pre-
and alimentary canal. serves constant fetal body temperature, cush-
• The mesoderm generates the connective ions the fetus, and facilitates fetal growth and
and supporting tissues; the blood and vascu- development. Amniotic fluid is replaced every
lar system; the musculature; teeth (except 3 hours.
enamel); mesothelial lining of the pericardial, At term, the uterus contains 800 to 1,200 ml
pleural, and peritoneal cavities; and kidneys of amniotic fluid, which is clear and yellowish
and ureters. and has a specific gravity of 1.007 to 1.025 and
a pH of 7.0 to 7.25. Maternal serum provides
The lifeline amniotic fluid in early gestation, with increas-
The umbilical cord serves as the lifeline ing amounts derived from fetal urine late in
from the embryo to the placenta. At term, it gestation. Amniotic fluid contains:
measures from 20 to 22 (51 to 56 cm) in • albumin
length and about 3⁄4 (2 cm) in diameter. The • bilirubin
umbilical cord contains two arteries, one vein, • creatinine
and Wharton’s jelly (which prevents kinking • enzymes
of the cord in utero). Blood flows through the • fat
cord at about 400 ml/minute. • lanugo
• lecithin
Red on the outside, gray on the • leukocytes
inside • sphingomyelin
The placenta, weighing about 1 to 11⁄4 lb • urea.
(454 to 567 g) and measuring from 6 to 10
(15 to 25 cm) in diameter, contains 15 to 20 Blood movers
subdivisions called cotyledons and is 1 to 11⁄4 Fetal circulation structures include:
(2.5 to 3 cm) thick at term. Rough in texture, • one umbilical vein, which carries oxygenat-
the placenta appears red on the maternal sured blood to the fetus from the placenta If this is the
patient’s first
face and shiny and gray on the fetal surface. • two umbilical arteries, which carry deoxy-
pregnancy, she’ll be
The placenta: genated blood from the fetus to the placenta referred to as a
• functions as a transport mechanism be- • the foramen ovale, which serves as the sep- primigravida;
tween the mother and the fetus tal opening between the atria of the fetal heart otherwise, she’s
• has a life span and function that depends on • the ductus arteriosus, which connects the referred to as a
oxygen consumption and maternal circula- pulmonary artery to the aorta, allowing blood multigravida.
tion; circulation to the fetus and placenta im- to shunt around the fetal lungs
proves when the mother lies on her left side • the ductus venosus, which
• receives maternal oxygen by way of diffu- carries oxygenated blood
sion from the umbilical vein to
• produces hormones, including human the inferior vena cava, by-
chorionic gonadotropin, human placental lac- passing the liver.
togen, gonadotropin-releasing hormone,
thyrotropin-releasing factor, corticotropin, es-
trogen, and progesterone
• supplies the fetus with carbohydrates, wa-
ter, fats, protein, minerals, and inorganic salts
• carries end products of fetal metabolism to
the maternal circulation for excretion
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480 Antepartum care
transabdominal insertion of a spinal needle

Keep abreast of into the uterus to aspirate amniotic fluid. This
procedure helps determine:
diagnostic tests • gestational age by way of a lecithin-
sphingomyelin ratio
Here’s a brief review of tests performed as • fetal lung maturity by analyzing lecithin-
part of antepartum care. sphingomyelin ratio, two key components
of surfactant
The routine • creatinine levels.
These routine laboratory tests can confirm Amniocentesis is performed to diagnose ge-
pregnancy and reveal maternal complications: netic disorders, such as chromosomal aberra-
• blood type, Rh, and abnormal antibod- tions, sex-linked disorders, inborn errors of
ies to identify the fetus at risk for erythroblas- metabolism, and neural tube defect. It may
tosis fetalis or hyperbilirubinemia also be performed to diagnose and evaluate
• immunologic tests such as rubella titer isoimmune disorders, including Rh sensitiza-
(antibodies) to determine immunity to rubel- tion and ABO blood type incompatibility.
la, rapid plasma reagin to detect untreated
syphilis, hepatitis B surface antigen to detect Nursing actions
hepatitis B, and human immunodeficiency Before the procedure
virus (HIV) antibodies to detect HIV infection • Make sure informed, written consent is ob-
• urine tests to detect urinary tract infection tained.
and to measure human chorionic gonadotro- After the procedure
pin (HCG) to confirm pregnancy • Monitor the fetal heart rate and uterine ac-
• hematologic studies, in which blood sam- tivity with an external fetal monitor for several
ples are used to analyze and measure RBCs, hours.
white blood cells (WBCs), erythrocyte sedi- • Monitor for maternal hemorrhage, infec-
mentation rate, platelets, Hb, and HCT tion, premature labor, fetal hemorrhage, and
• coagulation studies, in which a blood amnionitis.
sample is used to analyze and measure pro- • Administer RhO(D) immune globulin
thrombin time (PT), partial thromboplastin (Rho[D] IGIM)to Rh-negative mothers to pre-
After time (PTT), and international normalized ra- vent fetal isoimmunization.
amniocentesis, tio (INR)
monitor the patient • genital cultures, such as a gonorrhea Tissue sample
for hemorrhage, smear and chlamydia test, to detect sexually Chorionic villi sampling can be performed
infection, premature
transmitted disease as early as the eighth week of gestation. It in-
labor, and amnionitis.
• Papanicolaou (Pap) test to screen for volves removal and analysis of a small tissue
cervical cancer specimen from the fetal portion of the placen-
• triple screen between 15 and 20 weeks’ ta. This test helps determine the genetic
gestation to identify a fetus at increased risk makeup of the fetus, providing earlier diagno-
for Down syndrome and neural tube defect sis and allowing earlier and safer abortion if
• alpha-fetoprotein, which involves using a the fetus carries the risk of spontaneous abor-
blood sample to measure alpha-fetoprotein tion, infection, hematoma, fetal limb defects,
levels (high maternal serum levels may sug- and intrauterine death.
gest fetal neural tube defects, such as spina
bifida and anencephaly). Nursing actions
After the procedure
Check your fluid? • Administer RhI[G] to Rh-negative mothers
Amniocentesis may be performed after the to prevent sensitization.
14th week of gestation, when amniotic fluid is • Monitor the fetal heart rate and uterine ac-
sufficient and the uterus has moved into the tivity with an external fetal monitor for several
abdominal cavity. This procedure involves hours.
920122.qxd 8/7/08 3:09 PM Page 481
Sound picture nonreactive NST result, requires I.V. adminis-

You guessed
Ultrasonography, a painless, noninvasive tration of oxytocin in increasing doses every it…the
procedure, uses ultrasonic waves reflected by 15 to 20 minutes until three high-quality uter- nonstress test
tissues of different densities to visualize deep ine contractions are obtained within 10 min- doesn’t bother
structures of the body. Reflected signals are utes. me at all.
then amplified and processed to produce a vi- The OCT is performed on a patient at risk
sual display, providing immediate results for uteroplacental insufficiency or fetal com-
without harm to fetus or mother. It may be promise from diabetes, heart disease, hyper-
performed vaginally, if necessary. Ultrasound tension, or renal disease or on a patient with a
can detect fetal death, malformation, or malp- history of stillbirth. The OCT isn’t indicated
resentation; placental abnormalities; multiple for those with previous classic cesarean deliv-
gestation; and hydramnios or oligohydram- ery or third-trimester bleeding or for those at
nios. It’s used to monitor fetal growth and es- high risk for preterm labor.
timate gestational age.
Nursing actions
Nursing actions During and after the procedure
Before the procedure • Monitor fetal heart rate and maternal con-
• Instruct the patient to drink a glass of water tractions.
every 15 minutes, beginning 11⁄2 hours before
the procedure. Breast test
• Instruct the patient not to void until immedi- The nipple stimulation stress test induces
ately after the procedure. contractions by activating sensory receptors
• If the vaginal approach is necessary, in- in the areola, triggering the release of oxy-
struct the patient to void before the proce- tocin by the posterior pituitary gland. The re-
dure and to avoid fluids. ceptors are activated by rolling the nipple
manually or by applying a warm washcloth.
Stress-free This test has the same reactive pattern as the
The nonstress test (NST) is used to detect reactive NST result.
fetal heart accelerations in response to fetal
movement. This noninvasive test provides Nursing actions
simple, inexpensive, immediate results with- During and after the procedure
out contraindications or complications. It may • Monitor fetal heart rate and uterine contrac-
be indicated for a patient at risk for uteropla- tions on external fetal monitor.
cental insufficiency or for altered fetal move-
ments. Good vibrations
The NST can be performed between 32 and The vibroacoustic stimulation test uses vi-
34 weeks’ gestation. A nonreactive test result bration and sound to induce fetal reactivity
Vibroacoustic
indicates the possibility of fetal hypoxia, fetal during an NST. Vibration is produced by an stimulation…I dig it!
sleep cycle, or the effects of drugs. The re- artificial larynx or a fetal acoustic stimulator
sults may be inconclusive if the patient is ex- (over the fetus’s head for 1 to 5 seconds).
tremely obese. This test is noninvasive, quick, and conve-
nient.
Nursing actions
Before the procedure Nursing actions
• Explain the process to the patient. During and after the procedure
• Advise the patient to eat a snack before • Monitor fetal heart rate.
testing.
Six profiles in one
Contraction action The biophysical profile assesses four to six
The oxytocin challenge test (OCT) evalu- parameters—fetal breathing movements,
ates fetal ability to withstand an oxytocin- body movements, muscle tone, amniotic fluid
induced contraction. This test, given after a volume, heart rate reactivity, and placental
920122.qxd 8/7/08 3:09 PM Page 482
482 Antepartum care
grade—using real-time ultrasound. This test per day. Decreased movement may indicate
is noninvasive and quick and can detect cen- fetal compromise.
tral nervous system (CNS) depression. A
score of 8 to 10 indicates fetal well-being. Nursing actions
• Teach the patient to record fetal movement
Nursing actions for 30 minutes three times per day.
During and after the procedure • Instruct the patient to report fewer than 10
• Monitor fetal heart rate. movements in 2 hours.
How does the flow go?

Fetal blood flow studies use umbilical or
uterine Doppler velocimetry to evaluate vas-
cular resistance, especially in patients with
Catch up on
hypertension, diabetes, isoimmunization, or
lupus. These studies are useful when congeni-
complications
tal anomalies or cardiac arrhythmias are sus- Potential antepartum complications and ac-
pected. companying conditions include acquired im-
Put it together. munodeficiency syndrome (AIDS), adoles-
Determination and Nursing actions cent pregnancy, diabetes mellitus, ectopic
knowledge. That’s Before and during the procedure pregnancy, heart disease, hydatidiform mole,
what you need to pass • Before the procedure, obtain a baseline fe- hyperemesis gravidarum, hypertension in
the NCLEX. tal heart rate. pregnancy, multifetal pregnancy, and placenta
• During the procedure, continue to monitor previa.
the patient and the fetus for signs of prob-
lems, such as changes in vital signs or fetal
heart rate or continuation of uterine contrac- Acquired immunodeficiency
tions.
syndrome
Risky business
Percutaneous umbilical blood sampling A female patient may be first identified as pos-
(PUBS) is an invasive procedure that involves itive for HIV antibodies during pregnancy or
inserting a spinal needle into the umbilical when the neonate’s HIV status is identified.
cord to obtain fetal blood samples or to trans- Because of the effects of pregnancy on im-
fuse blood to the fetus in utero. munosuppression, the progression from HIV
Usually performed during the second or infection to full-blown AIDS may be expedited
third trimester, PUBS is indicated when the during pregnancy.
fetus is at risk for congenital and chromoso-
mal abnormalities, congenital infection, or CAUSES
anemia. It carries a 1% to 2% risk of fetal loss. • Exposure to HIV through blood transfu-
sions, contaminated needles, or handling
Nursing actions of blood
During and after the procedure • Exposure to semen or vaginal secretions
• Monitor fetal and maternal status through- containing HIV
out the procedure.
• Administer RhI[G] to an Rh-negative moth- DATA COLLECTION FINDINGS
er after PUBS to prevent sensitization. • Diarrhea
• Fatigue
Every kick counts • HIV-associated dementia
Fetal movement count identifies the pres- • Kaposi’s sarcoma
ence and frequency of fetal movement. Nor- • Mild flulike symptoms
mally, fetal movement occurs about 280 times • Opportunistic infections, such as toxoplas-
mosis, oral and vaginal candidiasis, herpes
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Catch up on complications 483
simplex, Pneumocystis carinii, and Candida • Counseling the patient to help her decide
esophagitis whether to terminate the pregnancy
• Weight loss
DIAGNOSTIC FINDINGS Adolescent pregnancy

• Blood chemistry shows increased transami-
nase, alkaline phosphatase, and gamma glob- A teenage mother is at risk for such complica-
ulin level and decreased albumin level. tions as hypertension in pregnancy, cephalo-
• CD4⫹ T-cell level is less than 200 cells/µl. pelvic disproportion, anemia, and nutritional
• Enzyme-linked immunosorbent assay deficiencies. Teenagers also have a high in-
shows positive HIV antibody titer. cidence of sexually transmitted diseases
• Hematology shows decreased WBC, RBC, (STDs), posing a concern for both the mother
and platelet counts. and the neonate.
• Western blot test is positive. Infants born to teenage mothers are at risk
for such complications as prematurity and low
NURSING DIAGNOSES birth weight.
• Ineffective protection
• Anxiety CONTRIBUTING FACTORS
• Ineffective coping • Desire to gain love, adulthood, and indepen-
dence through pregnancy
TREATMENT • Fear of reporting sexual activity to parents
• Care during pregnancy and delivery same • High level of adolescent sexual activity
as that for any other patient with HIV • Lack of appropriate role models
• If patient is newly diagnosed, zidovudine • Limited access to contraceptives
(Retrovir)or didanosine (Videx) treatment is • Low level of education correlated with in-
typically initiated between weeks 14 and 34 of correct use of contraceptives
gestation • Sporadic use of contraceptives
• Fetus monitored closely; serial ultrasounds • Naiveté about ability to become pregnant
performed to identify intrauterine growth re-
strictions; NST performed weekly after 32 DATA COLLECTION FINDINGS
weeks • Amenorrhea
• Denial of pregnancy, which may deter the
INTERVENTIONS AND RATIONALES patient from seeking medical attention early Be aware! Teenage
• Provide routine care for patients with AIDS. in pregnancy mothers are at risk
• Monitor for fever, chest tightness, and for insufficient or
delayed medical care.
shortness of breath to evaluate for possible re- DIAGNOSTIC FINDINGS
current acute pneumonia or pulmonary tuber- • Pregnancy test is positive.
culosis, which may indicate AIDS. • Ultrasound confirms presence of fetus.
• Provide emotional support to the patient
and her family to allay the patient’s fears. NURSING DIAGNOSES
• Determine whether the patient will be able • Deficient knowledge (pregnancy and
to care for her infant after delivery to evaluate care options)
the need for additional support services. • Imbalanced nutrition: Less than body
requirements
Teaching topics • Interrupted family processes
• Preventing the spread of infection TREATMENT
• Decreasing risk of transmission to the fetus • Diet with caloric intake sufficient to
by avoiding unsafe sex practices, avoiding support the growing adolescent and her
breast-feeding, or discontinuing I.V. drug use developing fetus
• Prenatal care
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484 Antepartum care
Drug therapy The patient with gestational diabetes has an

• Antibiotics for STDs, if necessary increased risk of developing diabetes melli-
• Prenatal vitamins tus.
INTERVENTIONS AND RATIONALES RISK FACTORS

• Monitor the patient’s weight gain to deter- • Family history of diabetes
mine nutritional deficiencies. • Gestational diabetes during previous preg-
• Collect data on the patient’s knowledge of nancies
her pregnancy to determine need for further • Maternal age older than 25
teaching. • Obesity
• Collect data about the patient’s family and
available support to determine need for refer- DATA COLLECTION FINDINGS
rals. • Glycosuria
• Provide nutritional support and encourage- • Ketonuria
ment to promote well-being of mother and fetus. • Polyuria
• Stress the importance of attending sched- • Possible monilial infection (vaginal yeast in-
uled prenatal appointments to promote well- fection)
being of mother and fetus. • Possible urinary tract infection
• Advise the patient of her options, including
terminating the pregnancy, continuing the DIAGNOSTIC FINDINGS
pregnancy and giving up the infant for adop- Gestational diabetes is diagnosed if the pa-
tion, and continuing the pregnancy and keep- tient has two or more of the following results:
ing the infant, to promote informed decision • Fasting blood sugar level equals or exceeds
making. 95 mg/dl
• Allow the patient to express her feelings • Three-hour glucose tolerance test reveals
about her pregnancy and herself to promote 1-hour level at or above 180 mg/dl
mental and emotional well-being. • Three-hour glucose tolerance test reveals
2-hour level at or above 155 mg/dl
Teaching topics • Three-hour glucose tolerance test reveals
• Encouraging attendance at prenatal and 3-hour level at or above 140 mg/dl.
birthing classes and infant care classes
• Recognizing the importance of prenatal NURSING DIAGNOSES
care • Imbalanced nutrition: More than body re-
quirements
• Risk for injury
Diabetes mellitus • Ineffective coping
With gestational diabetes mellitus, the pa- TREATMENT

tient’s pancreas, stressed by the normal adap- • 1,800- to 2,200-calorie diet, divided into
tations to pregnancy, can’t meet the increased three meals and three snacks that should also
demands for insulin. include low fat and cholesterol and high fiber
A patient may have preexisting diabetes or • Administration of insulin or glyburide (Dia-
may develop gestational diabetes while she’s Beta) after the first trimester
pregnant. Gestational diabetes is associated • Other oral antidiabetic agents contraindicat-
with an increased risk of congenital anom- ed because of adverse effects on the fetus
alies, hydramnios, macrosomia, hypertension
in pregnancy, spontaneous abortion, and fetal INTERVENTIONS AND RATIONALES
death. Additionally, the infant of a patient with • Encourage adherence to dietary regulations
diabetes is at risk for developing sacral agene- to maintain euglycemia.
sis, a congenital anomaly characterized by in-
complete formation of the vertebral column.
920122.qxd 8/7/08 3:09 PM Page 485
• Encourage the patient to exercise moder- • Positive Cullen’s sign (bluish discoloration
Severe abdominal
ately to reduce blood glucose levels and decrease around the umbilicus) pain, orthostatic
the need for insulin. • Rapid, thready pulse hypotension,
• Prepare the patient for antepartum fetal sur- • Rupture of tubes, causing sudden and se- tachycardia, and
veillance testing, including OCT, nipple stimu- vere abdominal pain, syncope, and referred dizziness may indicate
lation stress testing, amniotic fluid index, bio- shoulder pain as the abdomen fills with blood a rupturing ectopic
physical profile, and NST, to evaluate fetal • Shock with profuse hemorrhage pregnancy.
well-being. • Shoulder pain
• Encourage the patient to verbalize her feel-
ings to allay her fears. DIAGNOSTIC FINDINGS
• Provide emotional support to reduce anxiety. • HCG titers are abnormally low when
compared to a normal pregnancy.
Teaching topics • Ultrasound is positive for ruptured
• Performing serum glucose monitoring and tube and collective pelvic fluid.
insulin regulation and administration • Vaginal examination reveals a palpa-
• Performing fetal “kick counts” to monitor ble tender mass in Douglas’ cul-de-sac.
fetal well-being during the third trimester
• Learning about normal pregnancy care and NURSING DIAGNOSES
concerns • Deficient fluid volume
• Recognizing the signs and symptoms of hy- • Risk for infection
perglycemia and hypoglycemia • Acute pain
TREATMENT
Ectopic pregnancy • Laparotomy to ligate the bleeding vessels
and remove or repair damaged fallopian tube
Ectopic pregnancy is the implantation of the • Transfusion therapy: packed RBCs (if
fertilized ovum outside the uterine cavity. bleeding is uncontrolled)
Most commonly, ectopic pregnancy occurs in
a fallopian tube; other sites include the cervix, Drug therapy
ovary, and abdominal cavity. It’s the second • If the tube hasn’t ruptured, methotrexate
most frequent cause of vaginal bleeding early (Trexall) followed by leucovorin (Wellcov-
in pregnancy. orin) to stop the trophoblastic cells from
growing (therapy continues until negative
CAUSES HCG levels are achieved)
• Hormonal factors
• Malformed fallopian tubes INTERVENTIONS AND RATIONALES
• Ovulation induction drugs • Monitor vital signs and intake and output to
• Progestin-only oral contraceptives identify intense blood loss and shock.
• Tubal atony • Monitor for severe abdominal pain, ortho-
• Tubal damage from pelvic inflammatory static hypotension, tachycardia, and dizziness,
disease which may indicate rupturing ectopic preg-
• Tubal damage from previous pelvic or tubal nancy.
surgery • Maintain I.V. fluid replacement to compen-
• Tubal spasms sate for blood loss.
• Use of intrauterine devices • Monitor blood product administration to de-
tect adverse reactions.
DATA COLLECTION FINDINGS • Administer RhI[G] to combat isoimmuniza-
• Falling blood pressure tion in the patient who’s Rh-negative.
• Irregular vaginal bleeding and dull abdomi- • Provide routine preoperative and postopera-
nal pain on affected side early in pregnancy tive care if surgical intervention is necessary.
• Nausea and vomiting
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486 Antepartum care
• Provide emotional support for parents griev- DIAGNOSTIC FINDINGS

ing over the loss of the pregnancy. • Echocardiography, electrocardiography,
and chest X-ray may reveal cardiac abnormali-
Teaching topics ties, arrhythmias, impaired cardiac function,
• Reporting adverse effects of methotrexate increased workload on the heart, and cardio-
therapy, such as nausea, mouth ulceration, ab- vascular decompensation.
dominal discomfort, and altered liver enzyme
levels NURSING DIAGNOSES
• Knowing the importance of follow-up med- • Activity intolerance
ical care • Excess fluid volume
Heart disease TREATMENT

Class I and Class II
Heart disease occurs in about 1% of pregnant • Sodium restriction
patients. Pregnancy may reveal an underlying • Antibiotics: ampicillin (Omnipen-N), gen-
heart condition that previously produced no tamicin (Gentak) to prevent bacterial endo-
symptoms, or it may aggravate a known heart carditis
condition. A patient with heart disease is at
greatest risk when blood volume peaks be- Class III and Class IV
tween the 28th and 32nd week of gestation. • Anticoagulant: heparin
Successful delivery of a healthy baby de- • Antiarrhythmics: digoxin (Lanoxin), pro-
pends on the type and extent of the disease. cainamide (Pronestyl), beta-adrenergic block-
Decreased placental perfusion may lead to in- ers
trauterine growth retardation, fetal distress, • Antibiotics: ampicillin, gentamicin to pre-
and prematurity. vent bacterial endocarditis
Pregnant patients with heart disease are • Thiazide diuretics and furosemide (Lasix)
graded at a level of I to IV. to control heart failure if activity restriction
and reduced sodium intake don’t prevent it
CAUSES
• Regurgitation, which permits blood to leak INTERVENTIONS AND RATIONALES
through an incompletely closed valve, thereby • Monitor maternal and fetal vital signs to de-
increasing workload on heart chambers on termine maternal and fetal well-being.
either side of the affected valve • Monitor cardiovascular and respiratory sta-
• Valvular stenosis, which decreases blood tus to detect signs of maternal cardiac decom-
flow through a valve, increasing workload on pensation (tachycardia, tachypnea, moist
heart chambers located before the stenotic crackles, exhaustion).
valve • Administer anticoagulants, antiarrhythmics,
antibiotics, and diuretics, as prescribed, to
DATA COLLECTION FINDINGS achieve therapeutic regimens.
• Cough • Encourage the patient to monitor her calo-
• Crackles at the base of the lungs rie intake to avoid excessive weight gain.
• Diastolic murmur at the heart’s apex • Encourage the patient to limit her physical
• Dyspnea activity according to her ability and symptoms
• Fatigue to avoid overexertion.
• Hemoptysis • Encourage the patient to get 8 to 10 hours
• Nocturnal cough of sleep each night to ensure adequate rest.
• Orthopnea • Monitor I.V. fluid intake and output to main-
• Pitting edema tain proper fluid levels.
• Tachycardia
920122.qxd 8/7/08 3:09 PM Page 487
• Administer oxygen by nasal cannula or face DIAGNOSTIC FINDINGS

mask during labor to maintain fetal oxygena- • HCG levels are extremely high for early
tion. pregnancy.
• Position the patient on her left side with her • Ultrasonography fails to reveal a fetal skele-
head and shoulders elevated during labor to ton.
prevent supine hypotension syndrome.
• Continue to monitor the patient during the NURSING DIAGNOSES
postpartum period to detect signs of cardiac de- • Deficient fluid volume
compensation, even if distress is absent during • Grieving
pregnancy and labor. • Acute pain

• Achieving a healthy diet • Therapeutic abortion (suction and curet-
• Following anticoagulant therapy appropri- tage) if a spontaneous abortion doesn’t occur
ately to prevent choriocarcinoma
• Avoiding infection • Pelvic examinations and chest X-rays at reg-
• Recognizing signs and symptoms of heart ular intervals
failure • Weekly monitoring of HCG levels until they
• Receiving adequate rest remain normal for 3 consecutive weeks
• Periodic follow-up for 1 to 2 years because
of increased risk of neoplasm
Hydatidiform mole
Drug therapy
Also known as gestational trophoblastic dis- • Methotrexate (Trexall) prophylactically
ease, a hydatidiform mole is a developmental (the drug of choice for choriocarcinoma)
anomaly of the placenta that converts the
chorionic villi into a mass of clear vesicles INTERVENTIONS AND RATIONALES
(hydatid vesicles). There are two types: • Monitor and record vital signs and intake A hydatidiform
• complete mole, in which there’s neither an and output to detect changes that may indicate mole is a chorionic
tumor. The chorion is
embryo nor an amniotic sac complications.
the fetal membrane
• partial mole, in which there’s an embryo • Provide emotional support for the grieving closest to the uterine
(usually with multiple abnormalities) and an couple to demonstrate concern and understand- wall; it gives rise to
amniotic sac. ing for the patient and family. the placenta.
• Monitor vaginal bleeding to detect hemor-
CAUSES rhage.
• Possibly poor maternal nutrition or a defec- • Send contents of uterine evacuation to the
tive ovum laboratory for analysis to evaluate the presence
of hydatid vesicles.
DATA COLLECTION FINDINGS • Advise the patient to avoid pregnancy until
• Disproportionate enlargement of the uterus HCG levels are normal (may take up to 2
• Excessive nausea and vomiting years) to avoid future complications.
• Intermittent or continuous bright red or • Administer Rho(D) immunoglobulin to com-
brownish vaginal bleeding by the 12th week bat isoimmunization in the patient who’s Rh-
of gestation negative.
• Absence of fetal heart sounds
• Passage of clear, fluid-filled vesicles along Teaching topics
with vaginal bleeding • Dealing with an uncertain obstetric and
• Symptoms of hypertension in pregnancy be- medical future
fore the 20th week of gestation • Managing birth control to avoid pregnancy
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488 Antepartum care
Hyperemesis gravidarum • Obtain blood samples and urine specimens

for laboratory tests, including Hb level, HCT,
Hyperemesis gravidarum is persistent, uncon- urinalysis, and electrolyte levels.
trolled vomiting that begins in the first weeks • Monitor fundal height and the patient’s
of pregnancy and may continue throughout weight to detect complications.
pregnancy. Unlike “morning sickness,” hyper- • Provide small, frequent meals to maintain
emesis can have serious complications, inadequate nutrition.
cluding severe weight loss, dehydration, and • Maintain I.V. fluid replacement and TPN to
electrolyte imbalance. reduce fluid deficits and pH imbalances.
• Provide emotional support to help the pa-
CAUSES tient cope with her condition.
• Gonadotropin production
• Psychological factors Teaching topics
• Trophoblastic activity • Recognizing triggers of nausea and vomit-
ing
DATA COLLECTION FINDINGS • Using salt on foods to replace sodium lost
• Continuous, severe nausea and vomiting by vomiting
• Dehydration
• Dry skin and mucous membranes
• Jaundice Hypertension in pregnancy
• Nonelastic skin turgor
• Oliguria Hypertensive disorders in pregnancy are a
• Significant weight loss major cause of maternal, fetal, and neonatal
morbidity and mortality. Hypertension in
DIAGNOSTIC FINDINGS pregnancy is classified into four major disor-
• Arterial blood gas analysis reveals metabol- ders: chronic hypertension, gestational hyper-
ic alkalosis. tension, preeclampsia, and chronic hyperten-
• Hb level and HCT are elevated. sion with superimposed preeclampsia. The
• Serum potassium level reveals hypokal- hypertensive patient is at risk for cerebral he-
emia. morrhage, circulatory collapse, heart failure,
Hypertension in • Urine ketone levels are elevated. hepatic rupture, and renal failure. If delivery
pregnancy puts the • Urine specific gravity is increased. occurs before term, fetal health may be com-
patient at risk for promised because of hypoxia, acidosis, and
cerebral hemorrhage,
circulatory collapse,
NURSING DIAGNOSES immaturity.
heart failure, hepatic • Imbalanced nutrition: Less than body re-
rupture, and renal quirements RISK FACTORS FOR PREECLAMPSIA
failure. • Deficient fluid volume • Adolescent mother
• Acute pain • Diabetes mellitus
• Familial tendency
TREATMENT • First pregnancy
• Total parenteral nutrition (TPN) • Hydramnios
• Restoration of fluid and electrolyte balance • Hydrops fetalis
and acid-base balance • Hypertension
• Interpregnancy interval less than 2 years or
Drug therapy more than 10 years
• Antiemetics, as necessary, for vomiting • Malnutrition
• Maternal age older than 35
INTERVENTIONS AND RATIONALES • Multifetal pregnancy
• Monitor vital signs and fluid intake and out- • Obesity (Body mass index ≥ 35)
put to evaluate for fluid volume deficit. • Renal disease
920122.qxd 8/7/08 3:09 PM Page 489
DATA COLLECTION FINDINGS TREATMENT

Unless chronic, hypertension usually appears Chronic hypertension and gestational
between the 20th and 24th weeks of gestation hypertension
and disappears within 42 days after delivery. • Frequent fetal and maternal assessment
• Lifestyle modifications
Chronic hypertension
• BP >140 mmHg systolic or 90 mmHg dias- Preeclampsia and chronic hypertension with
tolic prior to pregnancy or before 20 weeks’ superimposed preeclampsia
gestation • Bed rest in a left lateral position
• Persists >12 weeks postpartum • Delivery: with mild preeclampsia, when the
fetus is mature and safe induction is possible;
Gestational hypertension with severe preeclampsia, regardless of gesta-
• Systolic blood pressure 140 to 159 mm Hg tional age
or diastolic blood pressure 90 to 109 mm Hg • High-protein diet with restriction of exces-
• No proteinuria sively salty foods
Preeclampsia Drug therapy

• Systolic blood pressure > 140 mm Hg or di- • With chronic hypertension: methyldopa or
astolic blood pressure > 90 mm Hg labetalol (Trandate).
• Proteinuria • With severe preeclampsia: hydralazine
• Weight gain more than 2 lb (0.9 kg) per (Apresoline) or labetalol (Normodyne) to con-
week trol blood pressure, betamethasone (Cele-
• Decreased urine output stone) to accelerate fetal lung maturation, and
• Headaches, blurred vision, hyperreflexia, magnesium sulfate to reduce the amount of
nausea, vomiting, irritability, cerebral distur- acetylcholine produced by motor nerves,
bances, seizures, and epigastric pain thereby preventing seizures
• Presence of HELLP syndrome (hemolysis,
elevated liver enzymes, and low platelet INTERVENTIONS AND RATIONALES
count) For all patients
• Evaluate for edema and proteinuria, which
Chronic hypertension with superimposed may indicate a worsening condition.
preeclampsia • Evaluate neurologic status to detect early
• Worsening hypertension signs of deterioration, which might suggest a
• New onset proteinuria after 20 weeks in a worsening condition.
woman with known hypertension • Monitor daily weight to identify sodium and
water retention. Memory
DIAGNOSTIC FINDINGS • Maintain seizure precautions in hospitalized jogger
• Blood chemistry may reveal increased patients to ensure patient safety. Some
blood urea nitrogen, creatinine, and uric acid • Promote bed rest in a left lateral recumbent women who
levels and elevated liver function studies. position to improve uterine and renal profusion. develop preeclamp-
• With preeclampsia and chronic hyperten- • Monitor blood pressure to evaluate the effec- sia also develop
sion with superimposed preeclampsia, hema- tiveness of treatment. HELLP syndrome,
tology may reveal thrombocytopenia (HELLP • Monitor fetal heart rate continuously during so be alert if you
syndrome). labor to evaluate fetal well-being. notice the following
signs:
NURSING DIAGNOSES For patients with severe preeclampsia Hemolysis
• Activity intolerance • Monitor maternal blood pressure every 4
Elevated Liver en-
• Excess fluid volume hours or more frequently if unstable to assess zyme levels
• Risk for injury for abnormalities.
• Maintain I.V. fluids as prescribed. I.V. fluids Low Platelet count.
are restricted to 60 to 150 ml/hour in the
preeclamptic patient in labor.
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490 Antepartum care
• Obtain blood samples for complete blood • Ovulation stimulation with such drugs as
count, platelet count, and liver function stud- clomiphene (Clomid)
ies and to determine serum levels of blood
urea nitrogen, creatinine, and fibrin degrada- DATA COLLECTION FINDINGS
tion products to detect complications. • More than one set of fetal heart sounds
• Be prepared to obtain a blood sample for • Uterine size greater than expected for dates
typing and crossmatching because the patient
is at risk for developing placenta previa. DIAGNOSTIC FINDINGS
• Obtain urine specimens to determine urine • Alpha-fetoprotein levels are elevated.
protein levels and specific gravity, and per- • Ultrasonography is positive for multifetal
form 24-hour urine collection for protein and pregnancy.
creatinine, as ordered, to evaluate renal func-
tion. NURSING DIAGNOSES
• Monitor urine output to evaluate fluid bal- • Anxiety
ance. • Deficient knowledge (pregnancy)
• Keep calcium gluconate (antidote to magne- • Risk for injury
sium sulfate) nearby to administer at first sign
of magnesium sulfate toxicity (elevated serum TREATMENT
levels, decreased deep tendon reflexes, mus- • Activity as tolerated with increased rest pe-
cle flaccidity, CNS depression, and decreased riods
respiratory rate and renal function). • Bed rest if early dilation occurs or at 24 to
• Promote relaxation to reduce fatigue. 28 weeks’ gestation to improve uterine blood
• Encourage the patient to verbalize her feel- flow and, possibly, increase birth weight of
ings to allay anxiety. the fetuses
• Provide a quiet environment to help prevent • Biweekly NST to document fetal growth,
complications. beginning with the 28th week of gestation
• Increased intake of calories, iron, folate, and
vitamins
Multifetal pregnancy • Prenatal visits every 2 weeks, increasing to
weekly between 24 and 28 weeks’ gestation;
A multifetal pregnancy, also known as multi- cervical examinations performed at each visit
ple gestation, occurs when two or more em- to check for premature dilation
bryos or fetuses exist simultaneously. Multi- • Ultrasound examinations monthly to docu-
fetal pregnancies are formed as follows: ment fetal growth
The nutritional • Single-ovum (monozygotic, identical) twins
needs of a patient
with a multifetal
usually have one chorion, one placenta, two INTERVENTIONS AND RATIONALES
pregnancy exceed amnions, and two umbilical cords and are of • Monitor fetal heart sounds to evaluate fetal
those of other the same sex. well-being.
pregnant patients. Try • Double-ova (dizygotic, nonidentical) twins • Monitor maternal vital signs and weight to
some calories, iron, have two chorions, two placentas, two am- evaluate maternal well-being.
folate, and vitamins. nions, and two umbilical cords and may be of • Monitor cardiovascular and pulmonary sta-
the same or different sex. tus to detect signs of hypertension in pregnancy.
• Multifetal pregnancies of three or more • Ensure adequate nutrition and increased in-
fetuses may be single-ovum conceptions, take of folate, calories, vitamins, and iron to
multiple-ova conceptions, or a combination of ensure adequate weight gain.
both. • Encourage the patient to take frequent rest
periods, especially during the third trimester,
CAUSES or to maintain bed rest, if indicated, to prevent
• In vitro fertilization fatigue.
• Family history • Provide emotional support and encourage-
• Gamete intrafallopian tube transfer ment to reduce anxiety.
920122.qxd 8/7/08 3:09 PM Page 491
• Advise the patient to return for ultrasound • Administering supplemental iron if anemia
examination and NST as scheduled to evalu- is present
ate fetal well-being. • Restricting maternal activities (for example,
no lifting heavy objects, long-distance travel,
Teaching topics or sexual intercourse)
• Notifying health care provider immediately • Transfusion of packed RBCs if Hb level and
if signs of premature labor occur HCT are low
• Refraining from coitus during the third • Treatment of choice: surgical intervention
trimester (by cesarean delivery), depending on placen-
tal placement and maternal and fetal stability
Placenta previa INTERVENTIONS AND RATIONALES

• Monitor maternal vital signs, including uter-
With placenta previa, the placenta is implant- ine activity, to evaluate maternal well-being.
ed in the lower uterine segment (low implan- • Monitor for vaginal bleeding to estimate
tation). The placenta can occlude the cervix blood loss.
partially or totally. • Monitor for signs of infection; patients with
placenta previa are at increased risk for infec-
RISK FACTORS tion.
• Maternal age older than 35 • Monitor fetal heart rate, using electronic fe-
• Multiple pregnancies tal monitoring, to detect complications.
• Placental villi torn from the uterine wall as • Avoid rectal or vaginal examinations unless
the lower uterine segment contracts and di- equipment is available for vaginal and cesar-
lates in the third trimester ean delivery to avoid stimulating uterine
• Smoking or cocaine use during pregnancy activity.
• Uterine fibroid tumors • Obtain blood samples for HCT, Hb level, PT,
• Uterine scars from surgery INR, PTT, fibrinogen level, platelet count, and
• Uterine sinuses exposed at the placental typing and crossmatching to evaluate for com-
site and bleeding plications.
• Provide routine preoperative and postopera-
DATA COLLECTION FINDINGS tive care if cesarean delivery is performed to
• Painless, bright red vaginal bleeding, espe- ensure the patient’s well-being.
cially during the third trimester (possibly in- • Monitor for postpartum hemorrhage be-
creasing with each successive incident) cause patients with placenta previa are more
likely to hemorrhage.
DIAGNOSTIC FINDINGS • Provide emotional support to reduce anxiety.
• Early ultrasound evaluation reveals the pla- • Maintain I.V. fluids as ordered to reduce flu-
centa implanted in the lower uterine segment. id loss.
• Be prepared to administer betamethasone
NURSING DIAGNOSES (Celestone) to increase fetal lung maturity if
• Fear preterm labor can’t be halted.
• Risk for injury Teaching topics
• Limiting activity
TREATMENT • Reporting increased bleeding immediately
• Depends on gestational age, when first epi- • Knowing of possible need for preterm deliv-
sode occurs, and amount of bleeding ery
• If gestational age less than 34 weeks, hospi-
talizing the patient and restricting her to bed
rest to avoid preterm labor
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492 Antepartum care
compatibility, placenta previa, or hyperemesis

isn’t increased in the diabetic client.
integrity
risk potential
3. Which finding is considered normal dur-

ing the antepartum period of pregnancy?
1. Resting pulse rate fluctuations ranging
from 15 to 20 beats/minute
2. Slight decrease in respiratory rate
Pump up on practice 3. Altered breathing pattern with thoracic
breathing replacing abdominal breathing
questions 4. HCT increase of about 7%
Answer: 1. Cardiovascular system changes
associated with pregnancy lead to resting
1. The caloric increase in nutritional require- pulse rate fluctuation with increases ranging
ments during pregnancy for a client of normal from 15 to 20 beats/minute at term. Other
weight is: pregnancy-related changes include a slight
1. 300 kcal. increase (2 breaths/minute) in respiratory
2. 400 kcal. rate; altered breathing pattern with abdominal
3. 500 kcal. breathing replacing thoracic breathing as
4. 1,000 kcal. pregnancy progresses; and a decrease in HCT
Answer: 1. The recommended daily allowance of about 7%.
(RDA)of kilocalories during pregnancy is 300 Client needs category: Health promo-
kcal greater than the RDA before pregnancy tion and maintenance
for clients of normal weight. The amount rec- Client needs subcategory: None
ommended for underweight women may be Cognitive level: Knowledge
more than 300 kcal. The RDA of kilocalories
during lactation is 500 kcal more than the 4. A client comes to the clinic for her 12-week
RDA before pregnancy. An additional 1,000 pregnancy checkup. The client asks the nurse
kcal leads to excess weight gain. when she should begin to feel her baby move.
Client needs category: Health promo- Which response by the nurse is best?
tion and maintenance 1. “You should have already felt it move.”
Client needs subcategory: None 2. “Typically women feel their baby move
Cognitive level: Knowledge for the first time when they’re 20 weeks
pregnant.”
2. During prenatal screening of a client with 3. “You’ll probably feel your baby move af-
diabetes, the nurse should keep in mind that ter your 16th week of pregnancy.”
the client is at increased risk for: 4. “Each person experiences the baby’s
1. Rh incompatibility. first movement at a different time through-
2. placenta previa. out their pregnancy.”
3. hyperemesis. Answer: 3. Although each client does detect
4. stillbirth. fetal movement at a different time, it’s typical-
Answer: 4. Clients with diabetes are at in- ly experienced just after the 16th week. If
creased risk for intrauterine fetal death after movement isn’t detected around this time,
36 weeks’ gestation. This factor must be problems with the pregnancy may exist.
weighed against the risks of delivery before
37 weeks and prematurity. The risk of Rh in-
920122.qxd 8/7/08 3:09 PM Page 493
Client needs category: Health promo- 7. A multigravida client in her 38th week of
tion and maintenance gestation has come to the emergency depart-
Client needs subcategory: None ment complaining of vaginal bleeding. She
Cognitive level: Application tells the nurse that she has recently inhaled
crack cocaine. The nurse’s top priority is to
5. A pregnant client who’s positive for HIV assess the client for:
asks the nurse about drug therapy. The nurse 1. placenta previa.
should tell the client to expect to: 2. placenta accreta.
1. start taking zidovudine (Retrovir) be- 3. malnutrition.
tween the 14th and 34th weeks. 4. hypotension.
2. delay taking zidovudine until after the Answer: 1. The use of crack cocaine during
fetus is born. pregnancy is associated with placenta previa,
3. delay taking zidovudine until the third along with hypertension, stroke, tachycardia,
trimester. hemorrhage, low birth weight, and preterm
4. delay giving zidovudine to the neonate neonates. Crack cocaine isn’t associated with
until age 6 months. placenta accreta (unusually deep attachment
Answer: 1. Zidovudine treatment should be of the placenta to the uterine myometrium) or
initiated between weeks 14 and 34 of gesta- hypotension. Although malnutrition may ex-
tion. By taking zidovudine throughout preg- ist, it isn’t life-threatening at this point.
nancy and labor, the risk of transmission to Client needs category: Physiological
the fetus is significantly decreased. Zidovu- integrity
dine therapy in the neonate should be started Client needs subcategory: Reduction of
immediately. risk potential
Client needs category: Physiological Cognitive level: Analysis
integrity
Client needs subcategory: Pharmaco- 8. A multigravida client in her 39th week of
logical therapies gestation is diagnosed with hypertension in
Cognitive level: Knowledge pregnancy and HELLP syndrome. The
nurse’s top priority is to check the client’s:
6. Which medication promotes fetal lung ma- 1. WBC count.
turity in cases of preterm labor? 2. blood glucose levels.
1. Terbutaline (Brethine) 3. serum iron levels.
2. Betamethasone (Celestone) 4. platelet count.
3. Co-trimoxazole (Bactrim) Answer: 4. Clients diagnosed with HELLP syn-
4. Clarithromycin (Biaxin) drome have hemolysis of RBCs, elevated liver
Answer: 2. Preterm labor raises concerns enzyme levels, and a low platelet count, so the
about the fetus’s respiratory potential. There- nurse should check the client’s platelet count.
fore, betamethasone is used to stimulate the This syndrome can lead to disseminated in-
development of surfactant in the lung. Terbu- travascular coagulation or hemorrhage. Moni-
taline is a beta-adrenergic agonist used to toring the client’s WBC count, blood glucose
treat preterm labor. Co-trimoxazole is a sul- levels, and serum iron levels isn’t a priority
fonamide commonly used to treat urinary for clients diagnosed with HELLP syndrome.
tract infections, and clarithromycin is an Client needs category: Physiological
antibiotic used to treat upper respiratory integrity
tract infections. Client needs subcategory: Reduction of
Client needs category: Physiological risk potential
integrity Cognitive level: Analysis
logical therapies
920122.qxd 8/7/08 3:09 PM Page 494
494 Antepartum care
9. Which finding is considered a probable 10. During her first clinic visit, a client re-
sign of pregnancy? ports that her last menses began on Septem-
1. Braxton Hicks contractions ber 12. Based on Nägele’s rule, what’s the
2. Nausea client’s estimated date of delivery?
3. Breast enlargement 1. June 1
4. Amenorrhea 2. June 19
Answer: 1. Braxton Hicks contractions, pain- 3. July 10
less uterine contractions that occur through- 4. July 29
out pregnancy, are a probable sign of preg- Answer: 2. The estimated date of delivery is
nancy. Nausea, breast enlargement, and June 19. To calculate it, start with the first day
amenorrhea are presumptive signs. of the last menses (September 12), subtract 3
Client needs category: Health promo- months (June 12), then add 7 days (June 19).
tion and maintenance Client needs category: Health promo-
Client needs subcategory: None tion and maintenance
Cognitive level: Comprehension Client needs subcategory: None
This is just the

beginning of the
pregnancy journey.
Stay tuned!
920123.qxd 8/7/08 3:56 PM Page 495
23 Intrapartum
care
Attitude refers to the fetal head’s ability to
In this chapter,
you’ll review:
Brush up on key flex or extend 45 degrees and rotate 180 de-
grees, allowing its smallest diameters to move
✐ components and concepts down the birth canal and pass through the
maternal pelvis. Pressure exerted by the ma-
stages of labor
✐ how to perform ma- Intrapartum care refers to care of the patient ternal pelvis and birth canal during labor and
during labor. In this section, you’ll find a brief delivery causes the sutures of the skull to al-
ternal and fetal evalu-
review of the signs and symptoms that indi- low the cranial bones to shift, resulting in
ations
cate the onset of labor, the patient’s physiolog- molding of the fetal head.
✐ common complica- ic and psychosocial responses to labor, basic
tions of labor and de- obstetric procedures, and methods of moni- What kind of engine?
livery, such as toring the patient and fetus. Power refers to uterine contractions, which
preterm labor and At any time, you can review the major points cause complete cervical effacement (thin-
prolapsed umbilical of this chapter by consulting the Cheat sheet ning) and dilation (expansion).
cord on pages 496 to 498.
✐ patient care for such Along for the ride
situations as preterm Other factors that affect labor are:
labor and cesarean Components of labor • accomplishment of the tasks of pregnancy
• coping mechanisms
birth.
The three major components of labor are the • mother’s ability to bear down (voluntary
passage, the passenger, and the power. These use of abdominal muscles to push during the
components must work together for labor to second stage of labor)
progress normally. • past experiences
• placental positioning
Long and winding road • preparation for childbirth
Passage refers to the maternal pelvis and soft • psychological readiness
tissues, the passageway through which the fe- • support systems.
tus exits the body. This area is affected by the
shape of the inlet, structure of the pelvis, and Let’s get this show on the road
pelvic diameters. Preliminar y signs that indicate the onset of
Memory labor include:
jogger Coach or first class? • lightening, or fetal descent into the pelvis,
To remem- Passenger refers to the fetus and its ability to which usually occurs 2 to 3 weeks before
ber the move through the passage. This ability is af- term in a primiparous patient and later or dur-
three key compo- fected by such fetal features as: ing labor in a multiparous patient
nents of labor, think • the skull • Braxton Hicks contractions, which can oc-
of the 3 Ps: • the lie (relationship of the long axis [spine] cur irregularly and intermittently throughout
Passage of the fetus to the long axis of the mother) pregnancy and may become uncomfortable
• presentation (portion of the fetus that en- and produce false labor
Passenger ters the pelvic passageway first) • cervical changes, including softening, ef-
Power. • position (relationship of the presenting part facement, and slight dilation several days be-
of the fetus to the front, back, and sides of the fore the initiation of labor
maternal pelvis). (Text continues on page 499.)
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496 Intrapartum care
et
heat she
C
Intrapartum care refresher
ABRUPTIO PLACENTAE DISSEMINATED INTRAVASCULAR
Key signs and symptoms COAGULATION
• Acute abdominal pain and rigid abdomen Key signs and symptoms
• Hemorrhage with dark red vaginal bleeding • Abnormal bleeding (petechiae, hematomas, ec-
Key test results chymosis, cutaneous oozing)
• Ultrasonography locates the placenta and may • Oliguria
reveal a clot or hematoma Key test results
Key treatments • Coagulation studies reveal decreased fibrino-
• Transfusion: packed red blood cells (RBCs), gen level, positive D-dimer test specific for dis-
platelets, and fresh frozen plasma if necessary seminated intravascular coagulation, prolonged
• Cesarean delivery prothrombin time (PT), and prolonged partial
thromboplastin time (PTT).
Key interventions
• Hematology studies reveal decreased platelet
• Avoid pelvic or vaginal examinations and ene-
count.
mas.
• Monitor administration of packed RBCs, Key treatments
platelets, or fresh frozen plasma. • Transfusion therapy: packed RBCs, fresh frozen
• Position the patient in a left lateral recumbent plasma, platelets, and cryoprecipitate
position. • Treatment of the underlying condition
• Immediate delivery of the fetus
AMNIOTIC FLUID EMBOLISM Key interventions
Key signs and symptoms • Monitor cardiovascular, respiratory, neurologic,
• Cyanosis and chest pain GI, and renal status.
• Tachypnea and sudden dyspnea • Monitor vital signs frequently.
Key test results • Closely monitor intake and output.
• Electronic fetal monitor reveals fetal distress • Monitor patient closely for signs and symptoms
(during the intrapartum period). of a transfusion reaction.
• Arterial blood gas results (ABG) reveal hypox- • Monitor the results of serial blood studies.
emia.
DYSTOCIA
Key treatments
• Oxygen therapy: face mask, cannula, or endo-
• Arrested descent
tracheal (ET) intubation and mechanical ventila-
• Hypotonic contractions
tion if respiratory arrest occurs
• Cardiopulmonary resuscitation (CPR) if patient Key test results
is apneic and pulseless • Ultrasonography shows fetal position or malfor-
• Emergency delivery using forceps or by cesare- mation.
an birth Key treatments
Key interventions • Delivery of the fetus by cesarean birth if labor
• Monitor respiratory and cardiovascular status. fails to progress and mother or fetus show signs
• Monitor fetal heart rate (FHR). of compromise
• Perform CPR if necessary. • Oxytocic agent: oxytocin (Pitocin) if contrac-
• Assist with immediate delivery of neonate. tions are ineffective
Key interventions
• Assist the patient to a left side-lying position.
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Intrapartum care refresher (continued)

DYSTOCIA (continued) • Prepare the patient and her family for the possibility of cesare-
• Monitor the effectiveness of oxytocin therapy and watch for an delivery.
complications.
FETAL DISTRESS
EMERGENCY BIRTH Key signs and symptoms
Key signs and symptoms • Change in FHR
For prolapsed umbilical cord Key test results
• Cord visible at the vaginal opening • Fetal scalp blood sampling reveals acidosis.
• Variable decelerations or bradycardia noted on fetal monitor Key treatments
strip
• Supplemental oxygen by face mask, typically at 6 to 8 L/minute
For uterine rupture
• I.V. fluid administration
• Abdominal pain and tenderness, especially at the peak of a
• Emergent fetal delivery by cesarean birth
contraction, or the feeling that “something ripped”
• Excessive external bleeding Key interventions
• Late decelerations, reduced FHR variability, tachycardia and • Monitor FHR, fetal activity, and fetal heart variability.
bradycardia, cessation of FHR • Assist the patient to a left side-lying position.
• Palpation of the fetus outside the uterus INVERTED UTERUS
For amniotic fluid embolism
• Chest pain
• Large, sudden gush of blood from the vagina
• Coughing with pink, frothy sputum
• Severe uterine pain
• Increasing restlessness and anxiety
• Sudden dyspnea Key test results
• Tachypnea • Hematology tests reveal decreased Hb levels and HCT.
Key test results Key treatments
For prolapsed umbilical cord • Fluid resuscitation with I.V. fluids and blood products
• Ultrasonography confirms that the cord is prolapsed. • Supplemental oxygen administration
For uterine rupture • Immediate manual replacement of the uterus
• Ultrasonography may reveal the absence of the amniotic cavity • Possible emergency hysterectomy
within the uterus. • Tocolytic agent: terbutaline (Brethine)
For amniotic fluid embolism Key interventions
• ABG analysis reveals hypoxemia. • Administer supplemental oxygen.
Key treatments • Monitor vital signs frequently.
• Administration of oxygen by nasal cannula or mask (ET intuba- • Closely monitor intake and output.
tion and mechanical ventilation may be necessary in the case of LACERATION
amniotic fluid embolism)
• Emergency cesarean delivery
• Increased vaginal bleeding after delivery of placenta
Key interventions
Key test results
• Monitor maternal vital signs, pulse oximetry, and intake and
output as well as FHR. • Hematology studies may reveal decreased levels of Hb and
• Administer maternal oxygen by cannula or mask at 8 to HCT.
10 L/minute. Key treatments
• Maintain I.V. fluid replacement. • Laceration repair
• Place the patient in left lateral recumbent position. • Analgesics: ibuprofen (Motrin), acetaminophen and oxycodone
• Obtain blood samples to determine hematocrit (HCT), (Percocet), acetaminophen (Tylenol)
hemoglobin (Hb) level, PT and PTT, fibrinogen level, and platelet Key interventions
count and to type and crossmatch blood. • Monitor vital signs, including temperature.
• Monitor administration of blood products as necessary. • Monitor laceration site for signs of infection.
(continued)
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Intrapartum care refresher (continued)

PRECIPITATE LABOR • Magnesium sulfate to maintain uterine relaxation
Key signs and symptoms • Tocolytic agents, such as terbutaline (Brethine) and ritodrine
• Cervical dilation greater than 5 cm/hour in a nulliparous (Yutopar), to inhibit uterine contractions
woman; more than 10 cm/hour in a multiparous woman Key interventions
Key test results • Monitor maternal vital signs, contractions, and FHR every 15
• There are no key test results specific to this complication. minutes during tocolytic therapy (otherwise, provide continuous
fetal monitoring).
Key treatments
• Monitor for maternal adverse reactions to terbutaline or rito-
• Controlled delivery to prevent maternal and fetal injury
drine.
Key interventions • Monitor for magnesium sulfate toxicity, and make sure calcium
• Monitor FHR and variability. gluconate is available.
PREMATURE RUPTURE OF MEMBRANES PROLAPSED UMBILICAL CORD
• Blood-tinged amniotic fluid gushing or leaking from the vagina • Cord visible at the vaginal opening
• Uterine tenderness • Variable decelerations or bradycardia noted on fetal monitor
Key test results strip
• Nitrazine test is positive, indicating possible ruptured mem- Key test results
branes. • Ultrasonography may reveal the cord as the presenting part.
• Vaginal probe ultrasonography allows detection of amniotic Key treatments
sac tear or rupture.
• Immediate delivery of the fetus
Key treatments
Key interventions
• Hospitalization to monitor for maternal fever and leukocytosis
• Place the patient in Trendelenburg’s position (position the
and fetal tachycardia if pregnancy is between 28 and 34 weeks.
woman’s hips higher than her head in a knee-to-chest position).
If infection is confirmed, labor must be induced.
• Monitor FHR and variability.
• Oxytocic agent: oxytocin (Pitocin) for labor induction if term
pregnancy and labor doesn’t result with 24 hours after mem- UTERINE RUPTURE
brane rupture Key signs and symptoms
Key interventions • Abdominal pain and tenderness, especially at the peak of a
• Monitor for signs of infection or fetal distress. contraction, or the feeling that “something ripped”
• Administer antibiotics as prescribed. • Late decelerations, reduced FHR variability, tachycardia and
• Encourage the patient to express her feelings and concerns. bradycardia, cessation of FHR
PRETERM LABOR Key test results
• Hematology tests reveal decreased levels of Hb and HCT.
• Feeling of pelvic pressure or abdominal tightening Key treatments
• Increased vaginal discharge • Fluid resuscitation: I.V. fluids and blood products via rapid infu-
• Intestinal cramping sion
• Uterine contractions that result in cervical dilation and efface- • Surgery to remove the fetus and repair the tear or hysterecto-
ment my if necessary
• Oxytocic agent: oxytocin (Pitocin) to help contract the uterus
Key test results
• Electronic fetal monitoring confirms uterine contractions. Key interventions
• Vaginal examination confirms cervical effacement and dilation. • Monitor vital signs frequently.
• Prepare patient for immediate surgery.
Key treatments
• Betamethasone (Celestone) administered I.M. at regular inter-
vals over 48 hours to increase fetal lung maturity in a fetus ex-
pected to be delivered preterm
920123.qxd 8/7/08 3:56 PM Page 499
• bloody show as the mucus plug is expelled

from the cervix True or false?
• increase in clear vaginal secretions
• rupture of membranes, occurring before Use the chart below to help distinguish between true and false labor.
the onset of labor in about 12% of patients and
within 24 hours for about 80% of patients True labor False labor
• a sudden burst of energy before the onset
of labor, commonly demonstrated by house- Regular contractions Irregular, brief contractions
cleaning activities and called the nesting in-
stinct. (See True or False?) Back discomfort that spreads to the Discomfort that’s localized in the
abdomen abdomen
Evaluating the mother during Progressive cervical effacement No cervical change

labor and dilation
Gradually shortened intervals be- No change or irregular change in

Here’s a review of methods and techniques tween contractions intervals between contractions
used to monitor the progress of labor and the
mother’s condition. Increased intensity of contractions Contractions that may be relieved
with ambulation with ambulation
Starting to open
Evaluate dilation. The external os opening Contractions that increase in dura- Usually no change in duration and
should increase from 0 to 10 cm. tion and intensity intensity of contractions
The thick and thin of it Usually bloody show Usually no bloody show
Evaluate effacement, cervical thinning and
shortening, which is measured from 0%
(thick) to 100% (paper thin).
What’s the situation? Determine head flexion by moving fin-

Using abdominal palpation (Leopold’s maneu- gers down both sides of the uterus to assess
vers), determine fetal position and presen- the descent of the presenting part into the
tation. The process consists of four maneu- pelvis; greater resistance is met as the fingers
vers. move downward on the cephalic prominence
(brow) side.
Palpate the fundus to identify the occupy-
ing fetal part: the fetus’s head is firm and What’s the relationship?
rounded and moves freely; the breech is soft- Check the station, the relationship of the pre-
er and less regular and moves with the trunk. senting part to the pelvic ischial spines:
• The presenting part is even with the ischial
Palpate the abdomen to locate the fetus’s spines at 0 station.
back: the back should feel firm, smooth, and • The presenting part is above the ischial
convex, whereas the front is soft, irregular, spines at ⫺3, ⫺2, or ⫺1.
and concave. • The presenting part is below the ischial
spines at ⫹1, ⫹2, or ⫹3.
Determine the level of descent of the
head by grasping the lower portion of the ab- Thirsty?
domen above the symphysis pubis to identify Monitor the patient for signs of dehydration,
the fetal part presenting over the inlet; an un- such as poor skin turgor, decreased urine out-
engaged head can be rocked from side to put, and dry mucous membranes.
side.
920123.qxd 8/7/08 3:56 PM Page 500
I need a little rest All around adaptations

Use an external pressure transducer to moni- Labor also prompts a series of responses
tor the patient for tetanic contractions, sus- throughout the mother’s body, including
tained prolonged contractions with little rest changes in the cardiovascular, respiratory,
in-between that reduce oxygen supply to the and GI systems. (See Maternal responses to
fetus. labor.)
Measuring contractions
Phases of uterine contractions include in- Evaluating the fetus during
crement (buildup and longest phase), acme
(peak of the contraction), and decrement labor
(letting-down phase). Contractions are mea-
sured by duration, frequency, and intensity. Evaluation of uterine contractions and fetal
Here’s how to measure each: heart rate (FHR) during labor involves exter-
• Duration is measured from the beginning nal and internal monitoring.
of the increment of the contraction to the end
of the decrement of the contraction and aver- Heart check
ages 30 seconds early in labor and 60 seconds FHR can be monitored either intermittently
later in labor. with a handheld device or continuously with a
• Frequency is measured from the begin- fetal monitor.
ning of one contraction to the beginning of
the next and averages 5 to 30 minutes apart Pressure check
early in labor and 2 to 3 minutes apart later in Contraction frequency and intensity is moni-
labor. tored externally with a tocotransducer. This
• Intensity is assessed during the acme pressure-sensitive device records uterine mo-
phase and can be measured with an intrauter- tion during contractions.
ine catheter or by palpation; normal resting
pressure when using an intrauterine catheter From the inside out
is 5 to 15 mm Hg; pressure increases to 30 to Internal electronic fetal monitoring can
50 mm Hg during the acme. evaluate fetal status during labor more accu-
Maternal responses to labor

During labor, the mother undergoes • Increased evaporative water volume • Prolonged gastric emptying time
physiologic changes. from increased respiratory rate
RENAL SYSTEM
CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM • Forward and upward displacement of
• Increased intrathoracic pressure dur- • Increased oxygen consumption the bladder base at engagement
ing pushing in the second stage • Increased respiratory rate • Possibly proteinuria from muscle
• Increased peripheral resistance during breakdown
HEMATOPOIETIC SYSTEM
contractions, which elevates blood pres- • Possibly impaired blood and lymph
• Increased plasma fibrinogen level and
sure and decreases pulse rate drainage from the bladder base, resulting
leukocyte count
• Increased cardiac output from edema caused by the presenting fe-
• Decreased blood coagulation time and
tal part
FLUID AND ELECTROLYTE BALANCE blood glucose levels
• Decreased bladder sensation if epidur-
• Increased water loss from diaphoresis
GI SYSTEM al anesthetic has been administered
and hyperventilation
• Decreased gastric motility and absorp-
tion
920123.qxd 8/7/08 3:56 PM Page 501
rately than external methods. A spiral elec- strong intensity. During this phase, the pa-
trode attached to the presenting fetal part pro- tient may lose control, thrash in bed, groan,
vides the baseline FHR and allows evaluation or cry out.
of FHR variability.
SECOND STAGE
Intense info The second stage of labor extends from com-
To determine the true intensity of contrac- plete dilation to delivery. This stage lasts an
tions, a pressure-sensitive catheter is in- average of 40 minutes (20 contractions) for
serted into the uterine cavity alongside the the primiparous patient and 20 minutes (10
fetus. contractions) for the multiparous patient. It
may last longer if the patient has had epidural
anesthesia.
Stages of labor The patient may become exhausted and de-
hydrated as she moves from coping with con-
The labor process is divided into four stages, tractions to actively pushing. During this
ranging from the onset of true labor, through stage, the fetus is moved along the birth canal
delivery of the fetus and placenta, to the first by the mechanisms of labor described here.
hour after delivery.
A brief engagement
FIRST STAGE The fetus’s head is considered to be engaged
The first stage is measured from the onset of when the biparietal diameter passes the pelvic
true labor to complete dilation of the cervix. inlet.
This period lasts from 6 to 18 hours in a primi-
parous patient and from 2 to 10 hours in a Going down
multiparous patient. There are three phases The movement of the presenting part through
of stage one. the pelvis is called descent.
This is getting exciting Flex that chin

During the latent phase, the cervix is dilated During flexion, the head flexes so that the
0 to 3 cm, contractions are irregular, and the chin moves closer to the chest.
patient may experience anticipation, excite-
ment, or apprehension. Cervical effacement is Head rotation I
almost complete. Internal rotation is the rotation of the head
Remember that
in order to pass through the ischial spines. the patient shouldn’t
This is getting serious try to push until the
During the active phase, the cervix is dilated Stretch as you go by cervix is completely
4 to 7 cm. Cervical effacement is complete. Extension is when the head extends as it dilated.
Contractions are about 5 to 8 minutes apart passes under the symphysis pubis.
and last 45 to 60 seconds with moderate to
strong intensity. During this phase, the pa- Head rotation II
tient becomes serious and concerned about External rotation in-
the progress of labor; she may ask for pain volves the external rota-
medication or use breathing techniques. If tion of the head as the
membranes haven’t ruptured spontaneously, shoulders rotate to the
amniotomy may be performed. anteroposterior position
in the pelvis.
Whole lotta shakin’ going on
During the transitional phase, the cervix is
dilated 8 to 10 cm. Contractions are about 1 to
2 minutes apart and last 60 to 90 seconds with
920123.qxd 8/7/08 3:56 PM Page 502
Helping to
promote maternal- Nursing care during labor and delivery
neonatal bonding is a
key nursing Nursing actions include interventions that corre- • Monitor fetal heart rate (FHR) during and be-
responsibility in the spond to all stages of labor as well as those that tween contractions, and report changes.
first hour after apply only to certain stages. • Observe for rupture of membranes, noting the
delivery. time, color, odor, amount, and consistency of
CARE DURING ALL STAGES OF LABOR
amniotic fluid.
• Monitor and record vital signs, I.V. fluid intake,
• Watch for signs of hypotensive supine syn-
and urine output.
drome; if blood pressure falls, position the pa-
• Provide emotional support to the patient and
tient on the left side and report changes immedi-
her coach.
ately.
• Evaluate the need for pain medication and the
• During the second stage, observe the peri-
effectiveness of pain-relief measures.
neum for show and bulging.
• Maintain sterile technique and standard pre-
cautions. CARE DURING FIRST, SECOND, AND THIRD
• Maintain the patient’s comfort by offering STAGES
mouth care, ice chips, and a change of bed • Assist with breathing techniques.
linen. • Encourage rest between contractions.
• Explain the purpose of all nursing actions and
CARE DURING THE FOURTH STAGE
medical equipment.
• Monitor lochia and the location and consisten-
CARE DURING FIRST AND SECOND STAGES cy of the fundus.
• Monitor the frequency, duration, and intensity • Encourage bonding.
of contractions. • Initiate breast-feeding.
THIRD STAGE Pain relief during labor and

The third stage of labor extends from deliv-
ery of the neonate to expulsion of the placen-
delivery
ta and lasts from 5 to 30 minutes.
Pain relief is an important element of patient
Pain, then placenta care during labor and delivery. Pain relief dur-
During this period, the patient typically focusing labor includes nonpharmacologic meth-
es on the neonate’s condition. The patient ods, analgesics, and general and regional
may experience discomfort from uterine con- anesthetics.
tractions before expelling the placenta.
Just relax
FOURTH STAGE Relaxation techniques may be effective.
The fourth stage of labor is the 1 to 4 hours
after delivery, when the primary activity is the Just rub it
promotion of maternal-neonatal bonding. Effleurage, a light abdominal stroking with
For a review of nursing actions during the the fingertips in a circular motion, is effective
delivery process, see Nursing care during la- for mild to moderate discomfort.
bor and delivery.
Hey, look over here
Distraction can divert attention from mild dis-
comfort early in labor. Focal point imaging
and music are sometimes effective diversions.
920123.qxd 8/7/08 3:56 PM Page 503
Breathing, breathing, breathing anesthesia is useful for urgent cesarean deliv-

Hypotension after
Three patterns of controlled chest breathing, eries. an epidural is
called Lamaze breathing, are used primarily uncommon but can
during the active and transitional phases of la- Delivery relief occur if the patient
bor. Local infiltration involves an injection of doesn’t receive enough
anesthetic into the perineal nerves. It offers fluids beforehand.
Ancient pain relief no relief from discomfort during labor but re-
The stimulation of key trigger points with lieves pain during delivery.
needles (acupuncture) or finger pressure
(acupressure) can reduce pain and enhance Pain blocker I
energy flow. A pudendal block involves blockage of the
pudendal nerve. This procedure is used only
Pain relief but not without risk for delivery.
Opioids such as nalbuphine (Nubain) can be
used to relieve pain. If an opioid is given with- Pain blocker II
in 2 hours of delivery, it can cause neonatal A paracer vical block involves the blockage
respiratory depression, hypotonia, and lethar- of nerves in the peridural space at the sacral
gy. hiatus, which provides analgesia for the first
and second stages of labor and anesthesia for
Knockout drops delivery. This procedure increases the risk of
General anesthetics can be administered forceps delivery.
I.V. or through inhalation, resulting in uncon-
sciousness. General anesthetics should be
used only if regional anesthetics are con-
traindicated or in a rapidly developing emer-
gency.
Keep abreast of
I.V. anesthetics, which are usually reserved
for patients with massive blood loss, include:
diagnostic tests
• thiopental (Pentothal) The key diagnostic test in the intrapartum pe-
• ketamine (Ketalar). riod is fetal blood sampling.
Inhalation anesthetics include:
• nitrous oxide Scratch the scalp
• isoflurane (Forane) Fetal blood sampling is a method of moni-
• halothane (Fluothane). toring fetal blood pH when indefinite or suspi-
cious FHR patterns occur. The blood sample
Less pain but still awake is usually taken from the scalp but may also
Lumbar epidural anesthesia requires an in- be taken from the presenting part if the fetus
jection of medication into the epidural space is in a breech presentation. Fetal blood sam-
in the lumbar region, leaving the patient pling requires that:
awake and cooperative. An epidural provides • membranes be ruptured
analgesia for the first and second stages of • the cervix be dilated 2 to 3 cm
labor and anesthesia for delivery without • the presenting part be no higher than ⫺2
adverse fetal effects. Hypotension is uncom- station.
mon, but its incidence increases if the patient A pH of 7.25 or higher is normal, 7.20 to
doesn’t receive a proper fluid load before the 7.24 is preacidotic, and lower than 7.20 consti-
procedure. Epidural anesthesia may decrease tutes severe acidosis.
the woman’s urge to push.
Nursing actions
Urgent cases • After the procedure, observe the FHR and
Spinal anesthesia involves an injection of observe the patient for vaginal bleeding,
medication into the cerebrospinal fluid in the which may indicate fetal scalp bleeding.
spinal canal. Because of its rapid onset, spinal
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• Uteroplacental insufficiency
Catch up on DIAGNOSTIC FINDINGS
complications • Ultrasonography locates the placenta and
may reveal a clot or hematoma.
Some potential intrapartum complications are • Coagulation studies may show evidence of
abruptio placentae, amniotic fluid embolism, DIC—increased partial thromboplastin time
disseminated intravascular coagulation (DIC), (PTT) and prothrombin time (PT), elevated
dystocia, fetal distress, inverted uterus, lacer- level of fibrinogen degradation products, and
ation, precipitate labor, premature rupture of decreased fibrinogen level.
membranes, prolapsed umbilical cord, and • Hematology may reveal decreased platelet
uterine rupture. count if DIC is present.
NURSING DIAGNOSES
Abruptio placentae • Anxiety
Abruptio placentae refers to premature sepa- • Ineffective tissue perfusion: Cardiopulmo-
ration of the placenta from the uterine wall af- nary
ter 20 to 24 weeks of gestation. It may occur
as late as the first or second stage of labor. TREATMENT
Placental separation is measured by degree • Transfusion: packed red blood cells
(from grades 0 to 3) to determine the fetal (RBCs), platelets, and fresh frozen plasma
and maternal outcome. if necessary
Perinatal mortality depends on the degree • Cesarean delivery
of placental separation and fetal level of matu-
rity. Most serious complications stem from INTERVENTIONS AND RATIONALES
hypoxia, prematurity, and anemia. The mater- • Monitor maternal vital signs, FHR, uterine
nal mortality rate is about 6% and depends on contractions, and vaginal bleeding to evaluate
the severity of bleeding, the presence of coag- maternal and fetal well-being.
ulation defects, hypofibrinogenemia, and the • Monitor fluid and electrolyte balance to
time lapse between placental separation and evaluate renal function.
delivery. • Avoid pelvic or vaginal examinations and
enemas to prevent further placental disruption.
CAUSES • Monitor administration of packed RBCs,
• Abdominal trauma platelets, or fresh frozen plasma to detect ad-
• Cocaine use verse reactions.
• Decreased blood flow to the placenta • Provide oxygen by mask to minimize fetal
• Hydramnios hypoxia.
• Multifetal pregnancy • Position the patient in a left lateral recum-
• Other risk factors (low serum folic acid lev- bent position to help relieve pressure on the
els, vascular or renal disease, hypertension in vena cava from an enlarged uterus, which
pregnancy) could further compromise fetal circulation.
• Provide emotional support to allay patient
DATA COLLECTION FINDINGS anxiety.
• Acute abdominal pain
• Frequent, low-amplitude contractions (not- Teaching topics
ed with external fetal monitor) • Understanding the treatment plan
• Hemorrhage, either concealed or apparent,
with dark red vaginal bleeding
• Rigid abdomen
• Shock
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Amniotic fluid embolism Drug therapy

In amniotic fluid
• Anticoagulant: heparin embolism, amniotic
With amniotic fluid embolism, amniotic fluid fluid escapes into the
escapes into the maternal circulation because INTERVENTIONS AND RATIONALES maternal circulation.
of a defect in the membranes after rupture or • Monitor and record vital signs to watch for It’s an emergency
partial abruptio placentae. During labor (or in tachycardia and tachypnea, which may indi- situation that can
the postpartum period), solid particles such cate hypoxemia. require
as skin cells enter the maternal circulation • Monitor respiratory and cardiovascular sta- cardiopulmonary
and reach the lungs as small emboli, forcing a tus to detect early signs of compromise. resuscitation.
massive pulmonary embolism. • Monitor FHR to detect fetal distress.
• Administer oxygen as prescribed to improve
CAUSES oxygenation.
• Oxytocin (Pitocin) administration • Perform CPR, if necessary, to restore breath-
• Abruptio placentae ing and circulation.
• Polyhydramnios • Monitor and record intake and output to de-
tect deficient fluid volume.
DATA COLLECTION FINDINGS • Assist with immediate delivery of neonate to
• Chest pain prevent fetal compromise.
• Coughing with pink, frothy sputum • Assist with ET intubation and mechanical
• Cyanosis ventilation, if necessary, to maintain pul-
• Hemorrhage monary function.
• Increasing restlessness and anxiety
• Shock disproportionate to blood loss Teaching topics
• Sudden dyspnea • Explaining the disorder and treatment op-
• Tachypnea tions to the patient and her family
DIAGNOSTIC FINDINGS
• Electronic fetal monitor reveals fetal dis- Disseminated intravascular
tress (during the intrapartum period).
• Arterial blood gas (ABG) results reveal hy- coagulation
poxemia.
• Coagulation studies may reveal DIC. DIC refers to increased production of pro-
thrombin, platelets, and other coagulation
NURSING DIAGNOSES factors, leading to widespread thrombus for-
• Decreased cardiac output mation, depletion of clotting factors, and
• Impaired gas exchange hemorrhage.
CAUSES
TREATMENT • Abruptio placentae
• Oxygen therapy: face mask, cannula, or en- • Amniotic fluid embolism
dotracheal (ET) intubation and mechanical • Retained dead fetus
ventilation if respiratory arrest occurs
• Cardiopulmonary resuscitation (CPR) if pa- DATA COLLECTION FINDINGS
tient is apneic and pulseless • Abnormal bleeding (petechiae, hematomas,
• Emergency delivery using forceps or by ecchymosis, cutaneous oozing)
cesarean birth • Nausea
• Blood transfusion if signs of DIC are pres- • Oliguria
ent • Severe muscle, back, and abdominal pain
• Fluid replacement • Shock
• Vomiting
920123.qxd 8/7/08 3:56 PM Page 506
DIAGNOSTIC FINDINGS Teaching topics

• Coagulation studies reveal decreased fib- • Explaining the disorder and treatment op-
rinogen level, positive D-dimer test specific for tions to the patient and her family
DIC, and prolonged PT and PTT. • Bleeding prevention
• Hematology studies reveal decreased
platelet count.
Dystocia
NURSING DIAGNOSES
• Risk for deficient fluid volume Dystocia is long, difficult, or abnormal labor.
• Ineffective tissue perfusion: Peripheral It’s estimated that approximately 10% of
• Decreased cardiac output women experience dystocia during the first
stage of labor when the fetus assumes the ver-
TREATMENT tex position.
• Transfusion therapy: packed RBCs, fresh
frozen plasma, platelets, and cryoprecipitate CAUSES
• Supplemental oxygen • Contracted pelvis
• Treatment of underlying condition • Obstructive tumors in the mother
• Immediate delivery of the fetus • Malposition or malformation of the fetus
• Hypertonic uterine patterns
Drug therapy • Hypotonic uterine patterns
• Anticoagulant: heparin
INTERVENTIONS AND RATIONALES • Arrested descent
• Monitor cardiovascular, respiratory, neuro- • Hypertonic contractions
logic, GI, and renal status to detect early signs • Hypotonic contractions
of complications. • Prolonged active phase
• Monitor vital signs frequently to detect signs • Prolonged deceleration phase
of shock (increased tachycardia and hypoten- • Protracted latent phase
sion). • Uncoordinated contractions
• Closely monitor intake and output to detect
signs of hypovolemia. DIAGNOSTIC FINDINGS
• Enforce complete bed rest to protect the pa- • Ultrasonography shows fetal position or
tient from injury. malformation.
• Monitor the patient closely for signs and
symptoms of a transfusion reaction. Notify the NURSING DIAGNOSES
doctor immediately if signs or symptoms oc- • Acute pain
cur. Follow your facility’s policy for transfu- • Deficient fluid volume
sion reactions should any occur. Immediate • Fear
intervention prevents life-threatening complica-
tions. TREATMENT
• Administer oxygen to meet the body’s in- • I.V. fluid administration
creased oxygen demands. • Delivery of the fetus by cesarean birth if la-
• Monitor the results of serial blood studies to bor fails to progress and mother or fetus
help guide the treatment plan. show signs of compromise
• Check all I.V. and venipuncture sites fre-
quently for bleeding. Apply pressure to injec- Drug therapy
tion sites for at least 10 minutes. Alert other • Oxytocic agent: oxytocin (Pitocin) if con-
personnel to the patient’s tendency to hemor- tractions are ineffective
rhage. These measures help to prevent hemor-
rhage.
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INTERVENTIONS AND RATIONALES • I.V. fluid administration

The left side-lying
• Monitor vital signs to detect early signs of • Emergent fetal delivery by cesarean birth position increases the
compromise. patient’s comfort and
• Provide emotional support and encourage- Drug therapy relieves pressure on
ment to help alleviate fear and anxiety. • Discontinuing oxytocin infusion the vena cava from
• Assist the patient to a left side-lying position the enlarged uterus.
to increase comfort and to relieve pressure on INTERVENTIONS AND RATIONALES
the vena cava from an enlarged uterus, which • Monitor FHR, fetal activity, and fetal
could compromise fetal circulation. heart variability to detect early signs of fe-
• Encourage the patient to void every 2 hours tal compromise.
to keep the bladder empty. • Monitor maternal vital signs and
• Monitor the effectiveness of oxytocin thera- pulse oximetry to detect early signs of
py and watch for complications to ensure compromise.
prompt intervention if complications occur. • Notify the doctor immediately of
signs of compromise to ensure
Teaching topics prompt treatment.
• Explaining the treatment plan • Monitor intake and output to de-
tect early signs of deficient fluid vol-
ume.
Fetal distress • Assist the patient to a left side-lying position
to relieve pressure on the vena cava from an en-
Fetal distress refers to fetal compromise that larged uterus, which could compromise fetal
results in a stressful and potentially lethal circulation. Understanding
condition.
Teaching topics
amnioinfusion
CAUSES • Explaining the treatment plan Amnioinfusion is the
• Fetal hypoxia replacement of amni-
• Prolapsed umbilical cord otic fluid volume
• Unfavorable uterine environment Inverted uterus through intrauterine in-
• Moderate to severe Rh factor isoimmuni- fusion of a saline solu-
zation An inverted uterus can occur during delivery tion, using a pressure
of the placenta. The inversion can be partial catheter. This proce-
DATA COLLECTION FINDINGS or total. dure is indicated for
• Change in FHR the treatment of repeti-
CAUSES tive variable decelera-
DIAGNOSTIC FINDINGS • Excessive cord traction tions not alleviated by
• Fetal scalp blood sampling reveals acidosis. • Excessive fundal pressure maternal position
change and oxygen
NURSING DIAGNOSES DATA COLLECTION FINDINGS administration.
• Anxiety • Large, sudden gush of blood from the vagi- Amnioinfusion re-
• Fear na lieves umbilical cord
• Ineffective tissue perfusion: Cardiopulmo- • Signs of blood loss, such as hypotension, compression in such
nary dizziness, paleness, and diaphoresis, which conditions as:
can progress to shock if blood loss continues • oligohydramnios as-
TREATMENT unchecked for more than a few minutes sociated with postma-
• Supplemental oxygen by face mask, typical- • Inability to palpate the fundus turity
ly at 6 to 8 L/minute • Severe uterine pain • intrauterine growth
• Amnioinfusion if the fetus exhibits variable • Uterine mass within the vaginal canal retardation
deceleration not relieved by oxygen, position- • premature rupture of
ing, or discontinuation of oxytocin (Pitocin) membranes.
infusion (see Understanding amnioinfusion)
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Here’s a number to
DIAGNOSTIC FINDINGS sues during delivery. Lacerations are classi-
know: 500 ml or more • Hematology tests reveal decreased hemo- fied as first, second, third, or fourth degree.
of blood loss within 1 globin (Hb) levels and hematocrit (HCT).
hour of delivery First-degree laceration involves the vagi-
indicates postpartum NURSING DIAGNOSES nal mucosa and the skin of the perineum and
hemorrhage. • Acute pain fourchette.
• Ineffective tissue perfusion: Cardiopulmo- Second-degree laceration involves the
nary vagina, perineal skin, fascia, levator ani mus-
cle, and perineal body.
TREATMENT
• Fluid resuscitation with I.V. fluids and blood Third-degree laceration involves the en-
products tire perineum and the external anal sphincter.
• Supplemental oxygen administration
• Immediate manual replacement of the Fourth-degree laceration involves the en-
uterus tire perineum and rectal sphincter and por-
• Possible emergency hysterectomy tions of the rectal mucosa.
Drug therapy CAUSES

• Vasodilator: nitroglycerin to relax the • Large infant size
uterus • Instruments used to facilitate birth
• Tocolytic agent: terbutaline (Brethine) • Position of the fetus
• Oxytocic agent: oxytocin (Pitocin) after re-
placing the uterus to aid contraction DATA COLLECTION FINDINGS
• Antibiotics to prevent infection because the • Increased vaginal bleeding after delivery of
uterus was exposed placenta
INTERVENTIONS AND RATIONALES DIAGNOSTIC FINDINGS

• Administer supplemental oxygen to meet in- • Hematology studies may reveal decreased
creased oxygen demand. levels of Hb and HCT.
• Monitor vital signs frequently to detect early
signs of shock. NURSING DIAGNOSES
• Closely monitor intake and output to detect • Acute pain
signs of deficient fluid volume. • Deficient fluid volume
• Be prepared to administer CPR if the pa- • Fear
tient’s heart fails from sudden blood loss to
restore circulation and breathing. TREATMENT
• During the recovery phase, evaluate the • Laceration repair
uterus for firmness, height, and position to • Cold application followed by heat applica-
detect complications. tion
• Provide emotional support to the patient • Sitz bath
and her family to help allay fears and anxiety.
Drug therapy
Teaching topics • Antibiotics may be necessary in some cases
• Explaining the treatment plan • Analgesics: ibuprofen (Motrin), aceta-
minophen and oxycodone (Percocet), aceta-
minophen (Tylenol)
Laceration • Stool softener: docusate sodium (Colace)
Laceration refers to tears in the perineum,

vagina, or cervix from the stretching of tis-
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INTERVENTIONS AND RATIONALES TREATMENT

• Monitor vital signs, including temperature, • Nonpharmacologic measures for pain con-
to detect early signs of infection. trol
• Monitor laceration site for signs of infection • Controlled delivery to prevent maternal and
to ensure prompt treatment interventions. fetal injury
• Provide maternal support and explain pro-
cedures to allay anxiety. Drug therapy
• Refrain from taking rectal temperature or • Tocolytic agent: terbutaline (Brethine) to
administering suppositories or enemas to a reduce the force and frequency of contrac-
patient with a third- or fourth-degree lacerations
tion to prevent trauma to repaired laceration
site. INTERVENTIONS AND RATIONALES
• Apply cold packs for 24 hours, followed by • Monitor FHR and variability to detect early
heat packs and sitz baths for the next 12 signs of fetal distress.
hours, to promote comfort and healing. • Monitor infusion of tocolytic drug to detect
early signs of adverse reactions.
Teaching topics • Institute nonpharmacologic measures to
• Explaining the treatment plan control pain, such as breathing exercises and
• Perineal care distraction.
• Provide emotional support to allay anxiety
and fear.
Precipitate labor
Teaching topics
Precipitate labor occurs when uterine contrac- • Explaining the treatment plan
tions are so strong that the woman delivers
with only a few rapidly occurring contrac-
tions. It’s commonly defined as labor complet- Premature rupture of
ed within less than 3 hours. Such rapid labor
may occur with multiparity. It may also follow membranes
induction of labor by oxytocin (Pitocin) or an
amniotomy. With premature rupture of membranes, rup-
ture occurs 1 or more hours before the onset
CAUSES of labor. Chorioamnionitis may occur if the
• Lack of maternal tissue resistance to the time between rupture of membranes and on-
passage of the fetus set of labor is longer than 24 hours.
• Oxytocin administration
• Amniotomy CAUSES AND CONTRIBUTING FACTORS
• Cause is unknown; however, malpresen-
DATA COLLECTION FINDINGS tation and a contracted pelvis commonly
• Cervical dilation greater than 5 cm/hour in accompany the rupture
a nulliparous woman; more than 10 cm/hour • Lack of proper prenatal care
in a multiparous woman • Poor nutrition and hygiene
• Maternal smoking
DIAGNOSTIC FINDINGS • Incompetent cervix
• There are no diagnostic test findings specif- • Increased uterine tension from hydramnios
ic to this complication. or multiple gestation
• Reduced amniotic membrane tensile
NURSING DIAGNOSES strength
• Anxiety • Uterine infection
• Fear
• Risk for injury
920123.qxd 8/7/08 3:56 PM Page 510

• Fetal tachycardia • Explaining the complication and treatment
Umbilical cord • Blood-tinged amniotic fluid gushing or leak- plan
prolapse is an ing from the vagina
emergency that
• Foul-smelling amniotic fluid if infection is
requires prompt
action to save present Prolapsed umbilical cord
the fetus. • Maternal fever
• Uterine tenderness A prolapsed umbilical cord occurs when the
umbilical cord descends into the vagina be-
DIAGNOSTIC FINDINGS fore the presenting fetal part.
• Nitrazine test is positive, indicating possible
ruptured membranes. CAUSES
• Hematology studies may reveal an elevated • Premature rupture of membranes
white blood cell count if infection is present. • Fetal presentation other than cephalic
• Vaginal probe ultrasonography allows detec- • Placenta previa
tion of amniotic sac tear or rupture. • Intrauterine tumors that prevent the pre-
• Amniotic fluid culture and sensitivity identi- senting part from engaging
fies the causative organism of infection. • Small fetus
• Cephalopelvic disproportion that prevents
NURSING DIAGNOSES firm engagement
• Anxiety • Hydramnios
• Risk for infection • Multiple gestation
• Risk for injury
TREATMENT • Cord palpable during vaginal examination
• Hospitalization to monitor for maternal • Cord visible at the vaginal opening
fever and leukocytosis and fetal tachycardia if • Variable decelerations or bradycardia noted
pregnancy is between 28 and 34 weeks. If in- on fetal monitor strip
fection is confirmed, labor must be induced.
• Cesarean delivery if labor induction fails DIAGNOSTIC FINDINGS
• Ultrasonography may reveal the cord as the
Drug therapy presenting part.
• Oxytocic agent: oxytocin (Pitocin) for labor
induction if term pregnancy and labor doesn’t NURSING DIAGNOSES
result with 24 hours after membrane rupture • Anxiety
• Antibiotics according to culture and sensi- • Risk for injury
tivity results if infection is present • Risk for suffocation
INTERVENTIONS AND RATIONALES TREATMENT

• Monitor for signs of infection or fetal dis- • Supplemental oxygen therapy at
tress to avoid treatment delay. 10 L/minute by face mask
• Administer antibiotics as prescribed to treat • Immediate delivery of the fetus
infection and prevent complications.
• Encourage the patient to express her feel- Drug therapy
ings and concerns to allay her anxiety. • Tocolytic agent: terbutaline (Brethine) may
• Monitor intake and output closely to quickly be used to reduce the force and frequency of
identify signs of deficient fluid volume. contractions
• Evaluate patient for adverse reactions to
oxytocin to prevent complications.
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INTERVENTIONS AND RATIONALES DIAGNOSTIC FINDINGS

• Place the patient in Trendelenburg’s posi- Diagnostic testing may not be possible in
tion (position the woman’s hips higher than light of the life-threatening situation.
her head in a knee-to-chest position) to relieve • Hematology tests reveal decreased levels of
pressure on the umbilical cord and restore Hb and HCT.
blood flow to the fetus.
• Administer supplemental oxygen to help NURSING DIAGNOSES
meet increased oxygen demands of the mother • Acute pain
and fetus. • Deficient fluid volume
• Apply warm saline-moistened towels to the • Ineffective tissue perfusion: Cardiopul-
protruding cord to prevent drying and retard monary
cooling of the cord.
• Monitor FHR and variability to detect early TREATMENT
signs of fetal distress. • Fluid resuscitation: I.V. fluids and blood
• Assist with immediate delivery of the fetus products via rapid infusion
to prevent fetal death. • Supplemental oxygen therapy, which may
include ET intubation and mechanical ventila-
tion
Uterine rupture • Surgery to remove the fetus and repair the
tear or hysterectomy if necessary
Uterine rupture occurs when the uterus un-
dergoes more strain than it can bear. Without Drug therapy
emergency intervention, maternal and fetal • Oxytocic agent: oxytocin (Pitocin) to help
death may occur. contract the uterus

• Prolonged labor • Monitor vital signs frequently to detect signs
• Previous cesarean delivery of shock.
• Faulty presentation • Prepare the patient for immediate surgery
• Induction of labor with oxytocin to avoid life-threatening treatment delay.
• Previous uterine surgery • Administer supplemental oxygen to meet in-
•Multiple gestation creased oxygen demands.
• Obstructed labor • Monitor I.V. fluid administration to detect
• Trauma early signs of infiltration.
• Closely monitor intake and output to detect
DATA COLLECTION FINDINGS early signs of deficient fluid volume.
• Abdominal pain and tenderness, especially • Monitor cardiovascular, neurologic, and re-
at the peak of a contraction, or the feeling that nal status to detect early signs of compromise.
“something ripped” • Expect the parents to go through a grieving
• Cessation of uterine contractions process for the loss of this child (if applicable)
• Chest pain or pain on inspiration and the inability to have other children. Griev-
• Excessive external bleeding ing is necessary to promote the healing process.
• Hypovolemic shock caused by hemorrhage
• Late decelerations, reduced FHR variability, Teaching topics
tachycardia and bradycardia, cessation of • Explaining the treatment plan
FHR • Postoperative care
• Palpation of the fetus outside the uterus • Availability of grief counseling
• Pathological retraction ring (indentation ap-
parent across abdomen and over the uterus)
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Uterine rupture
Emergency birth and • Abdominal pain and tenderness, especially
at the peak of a contraction, or the feeling that
preterm labor “something ripped”
• Cessation of uterine contractions
Emergency birth and preterm labor are two • Chest pain or pain on inspiration
examples of conditions requiring nursing care • Excessive external bleeding
that may occur during the intrapartum period. • Hypovolemic shock caused by hemorrhage
• Late decelerations, reduced FHR variability,
tachycardia and bradycardia, cessation of
Emergency birth FHR
• Palpation of the fetus outside the uterus
Emergency delivery of the fetus may become
necessary when the well-being of the mother Amniotic fluid embolism
or fetus is in jeopardy. Causes may include a • Chest pain
prolapsed umbilical cord, uterine rupture, or • Coughing with pink, frothy sputum
amniotic fluid embolism. • Cyanosis
• Hemorrhage
Note the most
common
CAUSES • Increasing restlessness and anxiety
complications Contributing factors vary for each emergency • Shock disproportionate to blood loss
requiring emergency birth situation. • Sudden dyspnea
birth: prolapsed • Tachypnea
umbilical cord, uterine Prolapsed umbilical cord
rupture, and amniotic • Fetus at high fetal station DIAGNOSTIC FINDINGS
fluid embolism. • Hydramnios (excess of amniotic fluid) Prolapsed umbilical cord
• Multifetal pregnancy • Ultrasonography confirms that the cord is
• Small fetus or breech presentation prolapsed.
• Transverse lie
Uterine rupture
Uterine rupture • Urinalysis can detect gross hematuria.
• Blunt abdominal trauma • Ultrasonography may reveal the absence of
• High parity with thin uterine wall the amniotic cavity within the uterus.
• Intense uterine contractions (natural or
oxytocin-induced), especially with fetopelvic Amniotic fluid embolism
disproportion • ABG analysis reveals hypoxemia.
• Previous uterine surgery • Hematology reveals thrombocytopenia, de-
creased fibrinogen level and platelet count,
Amniotic fluid embolism prolonged PT, and a PTT consistent with DIC.
• Fetal particulate matter (skin, hair, vernix,
cells, meconium) in the fluid that obstructs NURSING DIAGNOSES
the maternal pulmonary vessels • Ineffective coping
• Acute pain
DATA COLLECTION FINDINGS • Risk for infection
Data collection findings vary for each emer-
gency birth situation. TREATMENT
• Administration of I.V. fluid
Prolapsed umbilical cord • Administration of oxygen by nasal cannula
• Cord palpable during vaginal examination or mask (ET intubation and mechanical venti-
• Cord visible at the vaginal opening lation may be necessary in the case of amniot-
• Variable decelerations or bradycardia noted ic fluid embolism)
on fetal monitor strip
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Emergency birth and preterm labor 513
Cesarean delivery
Cesarean delivery is the planned or emergency • Monitor uterine contractions and labor
removal of the neonate from the uterus through progress, when appropriate.
an abdominal incision. A midline and vertical • Obtain blood samples for hematocrit, hemoglo-
(classic) incision, allowing easy access to the bin level, prothrombin and partial thromboplastin
fetus, is usually used in emergency situations. times, fibrinogen level, platelet count, and typing
A low-segment, transverse, or Pfannenstiel’s and crossmatching.
(bikini) incision is usually chosen in a planned • Maintain I.V. fluid replacement as necessary.
cesarean birth. • Prepare the patient for surgery, including shav-
ing of the abdomen and perineal area as neces-
NURSING ACTIONS
sary.
• Provide emotional support and reassurance to
• Insert an indwelling urinary catheter as or-
the patient and her family, including reassurance
dered.
about the well-being of the fetus.
• Provide preoperative teaching as necessary.
• Monitor fetal heart rate and maternal vital
• Administer preoperative sedation as ordered.
signs and intake and output.
• Provide immediate postoperative care.
• For uterine rupture, placing the patient in • Prepare the patient and her family for the
left lateral recumbent position possibility of cesarean delivery to reduce anxi-
• For uterine rupture, emergency hysterec- ety.
tomy
• Emergency cesarean delivery (see Cesare- Teaching topics
an delivery) • Learning about procedures
• Possible transfusion of packed RBCs, fresh • Understanding preoperative instruction
frozen plasma, or platelets • Using breathing techniques

• Monitor maternal vital signs, pulse oxime- Preterm labor
try and intake and output and FHR to detect Therapeutic
complications. Preterm labor, also known as premature labor, communication is key
• Administer maternal oxygen by cannula or occurs before the end of the 37th week of ges- during emergency
mask at 8 to 10 L/minute to maintain utero- tation. Preterm labor can place both the moth- birth situations. The
placental oxygenation. er and the fetus at high risk. patient and her family
• Maintain I.V. fluid replacement to replace rely on you for
volume loss. CAUSES AND RISK FACTORS support, reassurance,
and information.
• Place the patient in a left lateral recumbent Causes and risk factors of preterm labor can
position to relieve pressure on the vena cava be maternal or fetal.
due to an enlarged uterus, which would com-
promise fetal circulation. Maternal causes
• Provide emotional support and reassurance • Abdominal surgery or trauma
to the patient to allay fears and reduce anxiety. • Cardiovascular and renal disease
• Obtain blood samples to determine HCT, • Dehydration
Hb level, PT and PTT, fibrinogen level, and • Diabetes mellitus
platelet count and to type and crossmatch • Incompetent cervix
blood to establish baseline values. • Infection
• Monitor blood product administration as • Placental abnormalities
necessary to replace volume loss. • Hypertension in pregnancy
• Premature rupture of membranes
920123.qxd 8/7/08 3:56 PM Page 514
Fetal causes pounds associated with the initiation of labor;

• Hydramnios adverse maternal effects include nausea, vom-
What can I • Infection iting, and dyspepsia; premature closure of the
say…some times • Multifetal pregnancy fetus’s ductus arteriosus can occur if indo-
I show up late,
methacin is given before 32 weeks’ gestation
some times I
show up early! DATA COLLECTION FINDINGS • Magnesium sulfate to prevent a reflux of
• Feeling of pelvic pressure or abdominal calcium into the myometrial cells, thereby
tightening maintaining a relaxed uterus
• Increased vaginal discharge • Tocolytic agents, such as terbutaline
• Intestinal cramping (Brethine) and ritodrine (Yutopar), to inhibit
• Menstrual-like cramps uterine contractions; maternal adverse effects
• Pain or discomfort in vulva or thighs include tachycardia, hypoglycemia, hypokal-
• Persistent, low, dull backache emia, hypotension, and nervousness
• Uterine contractions that result in cervical
dilation and effacement INTERVENTIONS AND RATIONALES
• Vaginal spotting • Monitor maternal vital signs, contractions,
and FHR every 15 minutes during tocolytic
DIAGNOSTIC FINDINGS therapy (otherwise, provide continuous fetal
• Electronic fetal monitoring confirms uterine monitoring) to monitor maternal and fetal
contractions. well-being.
• Vaginal examination confirms cervical ef- • Monitor the mother’s respiratory status to
facement and dilation. detect pulmonary edema, an adverse effect asso-
ciated with tocolytic therapy.
NURSING DIAGNOSES • Monitor for maternal adverse reactions to
• Anxiety terbutaline or ritodrine to detect possible tachy-
• Deficient knowledge (treatment plan) cardia, diarrhea, nervousness, tremors, nau-
• Risk for injury sea, vomiting, headache, hyperglycemia, hypo-
glycemia, hypokalemia, or pulmonary edema.
TREATMENT • Notify the doctor if the maternal pulse rate
• Suppression of preterm labor (if fetal mem- exceeds 120 beats/minute or the FHR ex-
branes are intact, there’s no evidence of ceeds 180 beats/minute to expedite medical
bleeding, the well-being of the fetus and evaluation of maternal and fetal status.
mother isn’t in jeopardy, cervical effacement • Provide emotional support to the mother to
is no more than 50%, and cervical dilation is ease anxiety and establish a therapeutic rela-
less than 4 cm) tionship.
• Place the patient in the lateral position to in-
Drug therapy crease placental perfusion.
• Antibiotics according to organism sensitivi- • Monitor for magnesium sulfate toxicity,
ty if urinary tract infection is present which causes central nervous system (CNS)
• Betamethasone (Celestone) administered depression in the mother and fetus, and make
I.M. at regular intervals over 48 hours to in- sure calcium gluconate is available to reverse
crease fetal lung maturity in a fetus expected these effects.
to be delivered preterm
• Nifedipine (Procardia), a calcium channel Teaching topics
blocker, to decrease the production of calci- • Following instructions for ongoing tocolytic
um, a substance associated with the initiation therapy if appropriate
of labor; adverse maternal effects include
dizziness, nausea, bradycardia, and flushing
• Indomethacin (Indocin) to decrease the
production of prostaglandins and lipid com-
920123.qxd 8/7/08 3:56 PM Page 515
1. Put the client in a knee-to-chest posi-

tion.
2. Call the physician or midwife.
3. Push down on the uterine fundus.
4. Arrange for fetal blood sampling to as-
sess for fetal acidosis.
Answer: 1. The knee-to-chest position gets the
weight off the baby and umbilical cord, which
would prevent blood flow. Calling the physi-
cian or midwife and arranging for blood sam-
pling are important, but they have a lower pri-
ority than getting the baby off the cord. Push-
ing down on the fundus would increase the
Pump up on practice danger by further compromising blood flow.
questions integrity
risk potential
1. A client in the 28th week of gestation Cognitive level: Analysis
comes to the emergency department because
she thinks that she’s in labor. To confirm a di-
agnosis of preterm labor, the nurse would ex-
pect the physical examination to reveal:
1. irregular uterine contractions with no
cervical dilation.
2. painful contractions with no cervical di-
lation.
3. regular uterine contractions with cervi-
cal dilation.
4. regular uterine contractions with no
cervical dilation.
Answer: 3. Regular uterine contractions
(every 10 minutes or more) along with cervi- 3. A client is attempting to deliver vaginally
cal dilation before 36 weeks’ gestation or rup- despite the fact that her previous delivery was
ture of fluids indicates preterm labor. Uterine by cesarean delivery. Her contractions are 2
contractions without cervical dilation don’t to 3 minutes apart, lasting from 75 to 100 sec-
indicate preterm labor. onds. Suddenly, the client complains of in-
Client needs category: Physiological tense abdominal pain, and the fetal monitor
integrity stops picking up contractions. The nurse rec-
Client needs subcategory: Physio- ognizes that which event may have occurred?
logical adaptation 1. Abruptio placentae
Cognitive level: Knowledge 2. Prolapsed cord
3. Partial placenta previa
2. A client in the active phase of labor has a 4. Complete uterine rupture
reactive fetal monitor strip and has been en- Answer: 4. With complete uterine rupture, the
couraged to walk. When she returns to bed client would feel a sharp pain in the lower ab-
for a monitor check, she complains of an urge domen and contractions would cease. FHR
to push. The nurse notes that the amniotic would also cease within a few minutes. Uter-
membranes have ruptured and she can visual- ine irritability would continue to be indicated
ize the umbilical cord. What should the nurse by the fetal heart monitor tracing with abrup-
do next? tio placentae. With a prolapsed cord, contrac-
920123.qxd 8/7/08 3:56 PM Page 516
tions would continue and there would be no Client needs category: Physiological
pain from the prolapse itself. There would be integrity
vaginal bleeding with a partial placenta pre- Client needs subcategory: Reduction of
via, but no pain outside of the expected pain risk potential
of contractions. Cognitive level: Knowledge
integrity 5. The nurse can consider the fetus’s head to
Client needs subcategory: Physio- be engaged when:
logical adaptation 1. the presenting part moves through the
Cognitive level: Application pelvis.
2. the fetal head rotates to pass through
the ischial spines.
3. the fetal head extends as it passes un-
der the symphysis pubis.
4. the biparietal diameter passes the
pelvic inlet.
Answer: 4. The fetus’s head is considered en-
gaged when the biparietal diameter passes
the pelvic inlet. The presenting part moving
through the pelvis is called descent. Rotation
of the head to pass through the ischial spines
is called internal rotation. Extension of the
head as it passes under the symphysis pubis
4. A client with gravida 3 para 2 (three preg- is called extension.
nancies and two children) at 40 weeks’ gesta- Client needs category: Health promo-
tion is admitted with spontaneous contraction and maintenance
tions. The physician performs an amniotomy Client needs subcategory: None
to augment her labor. The priority nursing ac- Cognitive level: Comprehension
tion is to:
1. explain the rationale for the amniotomy
to the client.
2. monitor fetal heart tones after the am-
niotomy.
3. ambulate the client to strengthen the
contraction pattern.
4. position the client in a lithotomy posi-
tion to administer perineal care.
Answer: 2. The nurse should first monitor fe-
tal heart tones. After an amniotomy is per- 6. A client is experiencing true labor when
formed, the umbilical cord may be washed her contraction pattern shows:
down below the presenting part and cause 1. occasional irregular contractions.
umbilical cord compression, which would be 2. irregular contractions that increase in
indicated by variable deceleration on the fetal intensity.
heart tracing. An explanation of the rationale 3. regular contractions that remain the
for amniotomy would be given before the pro- same.
cedure. The nurse would ambulate the client 4. regular contractions that increase in
only if the presenting part were engaged. The frequency and duration as well as intensity.
nurse would provide perineal care after as- Answer: 4. Regular contractions that increase
sessing the fetal response to the amniotomy. in frequency and duration as well as intensity
920123.qxd 8/7/08 3:56 PM Page 517
indicate true labor. The other choices don’t 8. A client in the second stage of labor expe-
describe the contraction pattern of true labor. riences rupture of the membranes. The most
Client needs category: Physiological appropriate intervention by the nurse is to:
integrity 1. obtain the client’s vital signs immedi-
Client needs subcategory: Physio- ately.
logical adaptation 2. evaluate for prolapsed cord and monitor
Cognitive level: Knowledge FHR.
3. administer oxygen through a face mask
at 6 to 10 L/minute.
4. position the client on her left side.
Answer: 2. The nurse should immediately
check for prolapsed cord and monitor FHR.
When the membranes rupture, the cord may
become compressed between the fetus and
maternal cervix or pelvis, thus compromising
fetoplacental perfusion. It isn’t necessary to
monitor maternal vital signs, administer oxy-
7. A client is admitted to the hospital with gen, or position the client on her left side
contractions that are about 1 to 2 minutes when the client’s membranes rupture.
apart and last for 60 seconds. Vaginal exami- Client needs category: Physiological
nation reveals that her cervix is dilated 8 cm. integrity
The client is in which stage of labor? Client needs subcategory: Reduction of
1. The latent phase risk potential
2. The active phase Cognitive level: Application
3. The third stage
4. The transitional phase
Answer: 4. The client is in the transitional
phase of labor. This phase of labor is charac-
terized by cervical dilation of 8 to 10 cm and
contractions that are about 1 to 2 minutes
apart and last for 60 to 90 seconds with strong
intensity. In the latent phase, the cervix is di-
lated 0 to 3 cm and contractions are irregular.
During the active phase, the cervix is dilated
4 to 7 cm, and contractions are about 5 to 8
minutes apart and last 45 to 60 seconds with
moderate to strong intensity. The third stage
of labor extends from delivery of the neonate
to expulsion of the placenta and lasts from 5
to 30 minutes. 9. During labor, a primigravida client re-
Client needs category: Health promo- ceives epidural anesthesia. The nurse assists
tion and maintenance in monitoring maternal and fetal status.
Client needs subcategory: None Which finding suggests an adverse reaction
Cognitive level: Knowledge to the anesthesia?
1. Increased variability
2. Maternal hypotension
3. Fetal tachycardia
4. Anuria
Answer: 2. As the epidural anesthetic spreads
through the spinal canal, it may produce hy-
potensive crisis, which is characterized by
920123.qxd 8/7/08 3:56 PM Page 518
maternal hypotension, decreased beat-to-beat Answer: 2. Magnesium toxicity causes signs

variability, and fetal bradycardia. Although the of CNS depression, such as loss of deep ten-
client may experience some postpartum urine don reflexes, paralysis, respiratory depres-
retention, anuria isn’t associated with epidural sion, drowsiness, lethargy, blurred vision,
anesthesia. slurred speech, and confusion. Headache may
Client needs category: Health promo- be an adverse effect of calcium channel block-
tion and maintenance ers, which are sometimes used to treat
Client needs subcategory: None preterm labor. Palpitations are an adverse ef-
Cognitive level: Comprehension fect of terbutaline (Brethine) and ritodrine
(Yutopar), which are also used to treat
10. A client is receiving magnesium sulfate preterm labor. Dyspepsia may occur as an ad-
to help suppress preterm labor. The nurse verse effect of indomethacin (Indocin), a
should watch for which sign of magnesium prostaglandin synthetase inhibitor used to
toxicity? suppress preterm labor.
1. Headache Client needs category: Physiological
2. Loss of deep tendon reflexes integrity
3. Palpitations Client needs subcategory: Pharmaco-
4. Dyspepsia logical therapies
Congratulations!
You’ve labored through
a difficult chapter.
920124.qxd 8/7/08 3:11 PM Page 519
24 Postpartum
care
• increased thirst from fluids lost during la-
In this chapter,
you’ll review:
Brush up on key bor and delivery.
✐ physiologic and psy- concepts Increasing capacity

Genitourinar y system changes include:
chological changes
that occur immediate- A mother undergoes both physiologic and • increased urine output during the first 24
psychological changes after delivery. Under- hours after delivery due to increased glome-
ly after pregnancy
standing these changes is essential to provid- rular filtration rate and a drop in progesterone
✐ postpartum assess-
ing safe, effective patient care. levels
ment At any time, you can review the major points • increased bladder capacity
✐ how to care for post- of this chapter by consulting the Cheat sheet • proteinuria caused by the catalytic process
partum complications. on page 520. of involution (in 50% of women)
• decreased bladder-filling sensation caused
by swollen and bruised tissues
Physiologic changes after • return of dilated ureters and renal pelvis to
prepregnancy size after 6 weeks.
delivery
Hormone readjustment
Here’s a brief review of body system changes In the endocrine system, thyroid function
that occur immediately after delivery. and the production of anterior pituitary go-
nadotropic hormones is increased. Simultane-
Circulation gyration ously, the production of other hormones, in-
In the vascular system, blood volume de- cluding estrogen, aldosterone, progesterone,
creases and hematocrit (HCT) increases after human chorionic gonadotropin, corticoids,
vaginal delivery. Excessive activation of and ketosteroids, decreases.
blood-clotting factors also occurs. Blood vol-
ume returns to prenatal levels within 3 weeks.
Psychological changes after
Reproductive regeneration
In the reproductive system, uterine involu- pregnancy
tion occurs rapidly immediately after delivery.
Progesterone production ceases until the pa- More than 50% of women experience tran-
tient’s first ovulation. Endometrial regenera- sient mood alterations immediately after preg-
tion begins after 6 weeks. The cervical open- nancy. This mood change is called postpar-
ing is permanently altered from a circle to a tum depression, or the “baby blues,” and
jagged slit. signs and symptoms include sadness, crying,
fatigue, and low self-esteem. Possible causes
Hungry for hard work include hormonal changes, genetic predispo-
GI system changes include: sition, and adjustment to an altered role and
• increased hunger after labor and delivery self-concept.
• delayed bowel movement from decreased Teach the patient that mood swings and
intestinal muscle tone and perineal discom- bouts of depression are normal postpartum
fort responses; they typically occur during the
920124.qxd 8/7/08 3:11 PM Page 520
520 Postpartum care
et
heat she
C
Postpartum care refresher
MASTITIS • Monitor the fundus for location.
Key signs and symptoms • Monitor I.V. infusion of dilute oxytocin.
• Chills PSYCHOLOGICAL MALADAPTATION
• Localized area of redness and inflammation
• Temperature of 101.1° F (38.4° C) or higher
• Inability to stop crying
Key test results • Increased anxiety about self and infant’s health
• Culture of purulent discharge may test positive • Overall feeling of sadness
for Staphylococcus aureus. • Unwillingness to be left alone
• Incision and drainage if abscess occurs • Counseling for the patient and family at risk
• Moist heat application • Psychotherapy for the patient
• Pumping breasts every 2 to 4 hours to preserve • Antidepressants: imipramine (Tofranil), nor-
breast-feeding ability if abscess occurs triptyline (Pamelor)
• Analgesics: acetaminophen (Tylenol), ibuprofen
Key interventions
(Advil)
• Obtain a health history during the antepartum
• Antibiotics: cephalexin (Keftab), cefaclor (Ce-
period to determine risk of postpartum depres-
clor), clindamycin (Cleocin)
sion.
Key interventions • Evaluate the patient’s support systems.
• Administer antibiotic therapy. • Evaluate maternal-infant bonding.
• Apply moist heat. • Provide emotional support and encouragement.
Expecting mothers
spend 9 months POSTPARTUM HEMORRHAGE PUERPERAL INFECTION
imagining what I Key signs and symptoms Key signs and symptoms
MIGHT be like…it
• Blood loss greater than 500 ml within a 24-hour • Abdominal pain and tenderness
takes them a little
period; may occur up to 6 weeks after delivery • Purulent, foul-smelling lochia
while to get used to
the real me! • Signs of shock (tachycardia, hypotension, oli- • Tachycardia
guria)
Key test results
• Uterine atony
• A complete blood count may show an elevated
Key test results white blood cell count in the upper ranges of
• Hematology studies show decreased hemoglo- normal (more than 30,000/µl) for the postpartum
bin and hematocrit levels, low fibrinogen level, period.
and decreased partial thromboplastin time. • Cultures of the blood or the endocervical and
Key treatments uterine cavities may reveal the causative organ-
• Bimanual compression of the uterus and dilata- ism.
tion and curettage to remove clots Key treatments
• I.V. replacement of fluids and blood • Broad-spectrum I.V. antibiotic therapy unless a
• Parenteral administration of methylergonovine causative organism is identified
(Methergine)
Key interventions
• Rapid I.V. infusion of dilute oxytocin (Pitocin)
• Monitor vital signs every 4 hours.
Key interventions • Place the patient in Fowler’s position.
• Massage the fundus and express clots from the • Maintain I.V. fluid administration as ordered.
uterus. • Administer antibiotics as prescribed.
• Perform a pad count.
920124.qxd 8/7/08 3:11 PM Page 521
Keep abreast of postpartum data collection 521
first 3 weeks after delivery and subside within Monitor, monitor, monitor Studying for a big
1 to 10 days. The patient’s respiratory rate should return to test can also cause
Maternal behavior after delivery is divided normal after delivery. Other findings are list- mood swings—
into three phases: ed below. sometimes you may
• taking-in phase • The patient’s temperature may be elevated feel confident, other
• taking-hold phase to 100.4° F (38° C) from dehydration and the times anxious. Remind
• letting-go phase. exertion of labor. yourself that it’s a
• Blood pressure is usually normal within 24 normal reaction.
What have I gotten myself into? hours of delivery.
During the taking-in phase (1 to 2 days after • Bradycardia of 50 to 70 beats/minute is
delivery), the mother is passive and depen- common during the first 6 to 10 days after de-
dent, directing energy toward herself instead livery because of reductions in cardiac strain,
of toward her infant. She may relive her labor stroke volume, and the vascular bed.
and delivery experience to integrate the
process into her life and may have difficulty Nursing actions
making decisions. • Monitor vital signs every 15 minutes for the
first 1 to 2 hours, then every 4 hours for the
Getting to know you first 24 hours, and then during every shift.
During the taking-hold phase (about 2 to 7
days after delivery), the mother has more en- Fundal features
ergy and begins to act independently and initi- Check the tone and location of the fundus
ate self-care activities. Although she may ex- (the uppermost portion of the uterus) every
press a lack of confidence in her abilities, she 15 minutes for the first 1 to 2 hours after de-
accepts responsibility for her neonate and be- livery and then during every shift. The invo-
comes receptive to infant care and patient luting uterus should be at the midline. The
teaching about self-care activities. fundus is usually:
• midway between the umbilicus and sym-
Assuming the role physis 1 to 2 hours after delivery
During the letting-go phase (about 7 days af- • 1 cm above or at the level of the umbilicus
ter delivery), the mother begins to readjust to 12 hours after delivery
family members, assuming the mother role • 3 cm below the umbilicus by the third day
and the responsibility that comes with it. She after delivery
relinquishes the infant she has imagined dur- • firm to the touch. Patients often
ing her pregnancy and accepts her real infant The fundus will continue to descend about exhibit a slightly
as an entity separate from herself. 1 cm/day until it isn’t palpable above the sym- elevated
physis (about 9 days after delivery). The temperature—up
to 100.4° F—just
uterus shrinks to its prepregnancy size 5 to 6
after delivery.
weeks after delivery.
Keep abreast of A firm uterus helps control postpartum
bleeding by clamping down on uterine blood
postpartum data vessels. The doctor may prescribe oxytocin
(Pitocin), ergonovine (Ergotrate), or methyl-
collection ergonovine (Methergine) to maintain uterine
firmness. (See Fundal evaluation and mas-
The period immediately after labor and deliv- sage, page 522.)
ery is crucial to good postpartum nursing
care. An understanding of normal and abnor- Nursing actions
mal data collection findings is essential. • Massage a boggy (soft) fundus gently; if the
fundus doesn’t respond, use a firmer touch.
• Be aware that the uterus may relax if over-
stimulated by massage or medications.
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522 Postpartum care
Stepping up
Memory
jogger Fundal evaluation and massage
To remem-
WHY YOU DO IT HOW YOU DO IT
ber what
to assess in the Fundal evaluation is done to check the progress • Explain the procedure to the patient and an-
postpartum pa- of the uterus after birth, including uterine size, swer any questions. Provide privacy.
tient, remember firmness, and descent. Fundal massage helps to • Place the patient in the supine position or with
BUBBLE: maintain or stimulate uterine contractions, her head slightly elevated.
which are essential in preventing postpartum • Expose the abdomen and perineum.
Breasts
hemorrhage. • Gently compress the uterus between your
Uterus Evaluation and massage should be performed hands to evaluate firmness and position in rela-
Bowels every 15 minutes for the 1st hour after delivery, tion to the umbilicus (in fingerbreadths or cen-
every 30 minutes for the next 2 hours, every hour timeters).
Bonding • If the fundus seems soft and boggy, massage it
for the next 4 hours, and then every 4 hours for
Lochia the first postpartum day. gently in a circular motion until it’s firm.
Episiotomy. • Observe lochia flow during massage.
• Document the patient’s position, firmness of
the fundus, and the response to massage (if per-
formed).
• Suspect a distended bladder if the uterus • Foul-smelling lochia may indicate an infec-
isn’t firm at the midline. A distended bladder tion.
can impede the downward descent of the • Continuous seepage of bright red blood
uterus by pushing it upward and, possibly, to may indicate a cervical or vaginal laceration.
the side. • Lochia that saturates a sanitary pad within
• Evaluate maternal-infant bonding by ob- 45 minutes usually indicates an abnormally
serving how the mother responds to her heavy flow.
neonate. • Lochia may diminish after a cesarean deliv-
• Evaluate for excessive vaginal bleeding. ery.
Don’t forget to • Numerous large clots should be evaluated
communicate with Discharge diagnosis further; they may interfere with involution.
my mother…she Lochia is the discharge from the sloughing of • Lochia may be scant but should never be
might have the uterine decidua. absent; absence may indicate postpartum in-
questions or might • Lochia rubra is the vaginal discharge that fection.
just need a little occurs for the first 2 to 3 days after delivery; it
reassurance.
has a fleshy odor and is bloody with small Nursing actions
clots. Collect data on the lochia during every shift,
• Lochia serosa refers to the vaginal dis- and note its color, amount, odor, and consis-
charge that occurs during days 3 through 9; it tency.
is pinkish or brown with a serosanguineous
consistency and fleshy odor. Breast check
• Lochia alba is a yellow to white discharge Collect data on the size and shape of the pa-
that usually begins about 10 days after deliv- tient’s breasts every shift, noting reddened
ery; it may last from 2 to 6 weeks. areas, tenderness, and engorgement. Check
Some lochia characteristics may indicate the nipples for cracking, fissures, and sore-
the need for further intervention: ness.
920124.qxd 8/7/08 3:11 PM Page 523
Nursing actions livery, the edges of an episiotomy are usually

Explain to the new
• Advise the patient to wear a support bra to sealed. mother that she’ll
maintain shape and enhance comfort. need to increase her
• Tell the patient that she can relieve discom- Nursing actions protein and caloric
fort from engorged breasts by wearing a sup- • Administer medications to relieve discom- intake to restore body
port bra, applying ice packs, and taking pre- fort from the episiotomy, uterine contractions, tissue.
scribed medications. incisional pain, or engorged breasts as pre-
• If the patient is breast-feeding, advise her scribed. Medications may include analgesics,
that she can relieve breast engorgement by stool softeners and laxatives, or oxytocic
applying warm compresses, and expressing agents.
milk manually.
• Explain that nipples should be washed with Teaching topics
plain water and allowed to air dry. Soap and •Changing perineal pads frequently, remov-
towel drying dries out nipples, causing cracking from front to back
ing. • Reporting lochia with a foul odor, heavy
flow, or clots
Elimination examination • Showering daily to relieve discomfort of
Evaluate the patient’s elimination patterns. normal postpartum diaphoresis
The patient should void within the first 6 to 8 • Following instructions on sexual activity
hours after delivery. Check for a distended and contraception
bladder, which can interfere with elimination • Performing Kegel exercises to help
and increase the risk of hemorrhage within strengthen the pubococcygeal muscles
the first few hours after delivery. • Requesting assistance getting out of bed the
first several times after delivery to minimize
Nursing actions dizziness and fainting from medications,
• Pour warm water over the perineum to help blood loss, and decreased fluid intake
stimulate voiding. • Sitting with legs elevated for 30 minutes if
• Insert a urinary catheter if the patient can’t lochia increases or lochia rubra returns, ei-
void. ther of which may indicate excessive activity;
• Encourage the patient to have a bowel notify the doctor if excessive vaginal dis-
movement within 1 to 2 days after delivery to charge persists
avoid constipation. • Increasing protein and caloric intake to re-
• Apply required ice packs or analgesic prepa- store body tissues (if breast-feeding, increas-
rations to the patient with hemorrhoids. ing daily caloric intake by 200 kcal over the
• Encourage the patient to increase her fluid pregnancy requirement of 2,400 kcal)
and fiber intake. • Relieving perineal discomfort from an epi-
• Alleviate maternal anxieties regarding pain siotomy by using ice packs (for the first 8 to
from or damage to the episiotomy site. 12 hours to minimize edema); spray peri bot-
• Administer laxatives, stool softeners, sup- tles; sitz baths; anesthetic sprays, creams, and
positories, or enemas as needed. pads; and prescribed pain medications
• Avoid rectal temperatures and enemas in
patients who have a fourth-degree laceration.
• Encourage ambulation.
Evaluating episiotomy
Catch up on
The site of episiotomy (surgical incision into
the perineum and vagina) should be assessed
complications
every shift to evaluate healing, noting erythe- Potential postpartum complications include
ma, intactness of stitches, edema, and any mastitis, postpartum hemorrhage, psycholog-
odor or drainage. Twenty-four hours after de- ical maladaptation, and puerperal infection.
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524 Postpartum care
Mastitis • Antibiotics: cephalexin (Keftab), cefaclor

(Ceclor), clindamycin (Cleocin)
Mastitis is an infection of the lactating breast.
It most commonly occurs during the second INTERVENTIONS AND RATIONALES
and third weeks after birth but can occur at • Monitor vital signs to detect complications.
any time. • Administer antibiotic therapy to treat infec-
tion.
CAUSES • Apply moist heat to increase circulation and
• Staphylococcus aureus (the most common reduce inflammation and edema.
causative pathogen) • Encourage patient to breast-feed on the un-
affected side before the affected side; breast-
RISK FACTORS feeding should be stopped and pumping initi-
• Altered immune response ated if an abscess occurs to ensure emptying of
• Constriction from a bra that’s too tight (may the unaffected breast.
interfere with complete emptying of the
breast) Teaching topics
• Engorgement and stasis of milk (usually • Positioning the infant during breast-feeding
precede mastitis) to avoid trauma to the nipples and milk stasis
• Injury to nipple, such as a crack or blister, • Avoiding bras that are too tight and may re-
which may allow causative organism to enter strict the flow of milk
• Breast-feeding every 2 to 3 hours and com-
DATA COLLECTION FINDINGS pletely emptying the breasts
• Aching muscles • Changing nipple shields as soon as they be-
• Chills come wet to prevent infection
• Edema and breast heaviness • Using a breast pump and discarding milk if
• Fatigue breast abscess has developed
• Headache
• Localized area of redness and inflammation
• Malaise Postpartum hemorrhage
• Purulent drainage
• Temperature of 101.1° F (38.4° C) or high- Postpartum hemorrhage is maternal blood
er loss from the uterus greater than 500 ml with-
in a 24-hour period. It can occur immediately
DIAGNOSTIC FINDINGS after delivery (within the first 24 hours) or lat-
• Culture of the purulent discharge may test er (during the remaining days of the 6-week
Uterine blood loss
greater than 500 ml positive for the S. aureus bacteria. puerperium).
in a 24-hour period
indicates postpartum NURSING DIAGNOSES CAUSES
hemorrhage. • Ineffective coping • Administration of magnesium sulfate
• Acute pain • Cesarean birth
• Situational low self-esteem • Clotting disorders
• Disseminated intravascular coagulation
TREATMENT • Forceps delivery
• Incision and drainage if abscess occurs • General anesthesia
• Moist heat application • Low implantation of placenta or placenta
• Pumping breasts every 2 to 4 hours to pre- previa
serve breast-feeding ability if abscess occurs • Multiparity
• Overdistention of uterus (multifetal preg-
Drug therapy nancy, hydramnios, large infant)
• Analgesics: acetaminophen (Tylenol), • Perineal laceration
ibuprofen (Advil) • Precipitate labor or delivery
920124.qxd 8/7/08 3:11 PM Page 525
• Previous postpartum hemorrhage • Perform a pad count to estimate the amount

• Previous uterine surgery of vaginal bleeding.
• Prolonged labor • Monitor lochia, including amount, color,
• Retained placental fragments and odor, to detect infection.
• Soft, boggy uterus, indicating relaxed uter- • Monitor the fundus for location to check for
ine tone uterine displacement.
• Subinvolution of the uterus • Monitor I.V. infusion of dilute oxytocin as
• Urinary bladder distention ordered to increase uterine contraction and
• Use of tocolytic drugs tone.
• Administer methylergonovine as ordered to
DATA COLLECTION FINDINGS increase uterine contraction and tone.
• Blood loss greater than 500 ml within a 24- • Monitor blood products and I.V. fluids as
hour period; may occur up to 6 weeks after prescribed to replace volume loss.
delivery • Provide emotional support to help alleviate
• Perineal lacerations fears and anxiety.
• Retained placental fragments • Advise the patient to get assistance with am-
• Signs of shock (tachycardia, hypotension, bulation to prevent injury.
oliguria)
• Uterine atony Teaching topics
• Learning about surgical procedures if ap-
DIAGNOSTIC FINDINGS propriate
• Hematology studies show decreased hemo- • Reporting changes in vaginal bleeding
globin and HCT levels, a low fibrinogen level,
and decreased partial thromboplastin time.
Psychological maladaptation
NURSING DIAGNOSES
• Ineffective tissue perfusion: Peripheral Known as postpartum depression, psychologi-
• Deficient fluid volume cal maladaptation is depression of a signifi-
• Risk for infection cant depth and duration after childbirth. Although many
Many postpartum patients experience some patients experience
TREATMENT level of mood swings; psychological maladap- some depression after
• Bimanual compression of the uterus and di- tation refers to depression that lasts longer childbirth, depression
that lasts longer than
latation and curettage to remove clots than 2 weeks, indicating a serious problem.
2 weeks may signal a
• I.V. replacement of fluids and blood more serious problem.
• Abdominal hysterectomy if other interven- CAUSES AND RISK FACTORS
tions fail to control blood loss • Difficult pregnancy, labor, or delivery
• Urinary catheterization to empty the blad- • Neonatal complications
der • History of depression
• Hormonal shifts as estrogen and prog-
Drug therapy esterone levels decline
• Parenteral administration of methyler- • Lack of support from family and friends
gonovine (Methergine) • Lack of self-esteem
• Rapid I.V. infusion of dilute oxytocin • Stress in the home or work
(Pitocin) • Troubled childhood

• Monitor vital signs to detect complications. • Extreme fatigue
• Massage the fundus, and express clots from • Inability to make decisions
the uterus to increase uterine contraction and • Inability to stop crying
tone. • Increased anxiety about self and in-
fant’s health
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526 Postpartum care
• Overall feeling of sadness sarean deliveries. Puerperal infection affects

• Postpartum psychosis (hallucinations, delu- the uterus and structures above it and is one
sions, potential for suicide or homicide) of the leading causes of maternal death.
• Psychosomatic symptoms (nausea, vomit-
ing, diarrhea) CAUSES AND RISK FACTORS
• Unwillingness to be left alone • Catheterization
• Cesarean delivery
DIAGNOSTIC FINDINGS • Colonization of lower genital tract with path-
• No specific test findings (rather, diagnosis ogenic organisms, such as group B strepto-
based on signs and symptoms) cocci, Chlamydia trachomatis, Staphylococcus
aureus, Escherichia coli, and Gardnerella vagi-
NURSING DIAGNOSES nalis
• Fatigue • Episiotomy
• Ineffective coping • Forceps delivery
• Social isolation • Excessive number of vaginal examinations
• Intrauterine fetal monitoring
TREATMENT • Laceration
• Counseling for the patient and family at risk • History of previous infection
• Group therapy • Low socioeconomic status
• Psychotherapy • Medical conditions such as diabetes
mellitus
Drug therapy • Poor general health
• Antidepressants: imipramine (Tofranil), nor- • Poor nutrition
triptyline (Pamelor) • Prolonged labor
• Premature rupture of membranes
INTERVENTIONS AND RATIONALES • Retained placental fragments
• Obtain a health history during the antepar- • Trauma
tum period to determine whether the patient is
at risk for postpartum depression. DATA COLLECTION FINDINGS
• Collect data on the patient’s support sys- • Abdominal pain and tenderness
tems to evaluate the need for additional help. • Anorexia
• Collect data on maternal-infant bonding to • Chills
evaluate for signs of depression. • Fever
Women who • Provide emotional support and encourage- • Lethargy
have undergone ment to reduce anxiety. • Malaise
cesarean delivery
• Notify a skilled professional if you observe • Purulent, foul-smelling lochia
are at higher risk
for puerperal psychotic symptoms in the patient to obtain • Subinvolution of the uterus
infection. necessary treatment. • Tachycardia
• Uterine cramping
Teaching topics
• Understanding that continued depression DIAGNOSTIC FINDINGS
may require psychiatric counseling • A catheterized urine specimen may reveal
• Understanding how to meet her own physi- the causative organism.
cal and emotional needs • A complete blood count may show an ele-
vated white blood cell count in the upper
ranges of normal (more than 30,000/µl) for
Puerperal infection the postpartum period.
• Cultures of the blood or of the endocervical
Puerperal infection occurs after childbirth in and uterine cavities may reveal the causative
2% to 5% of all women who have vaginal deliv- organism.
eries and in 15% to 20% of those who have ce-
920124.qxd 8/7/08 3:11 PM Page 527
NURSING DIAGNOSES
• Acute pain
TREATMENT
• Administration of I.V. fluids (if hydration is
needed)
Drug therapy
• Broad-spectrum I.V. antibiotic therapy, un-
less a causative organism is identified

• Monitor vital signs every 4 hours to detect
Pump up on practice
complications.
• Place the patient in Fowler’s position to fa-
questions
cilitate drainage of lochia.
• Administer pain medication as ordered to 1. When checking a postpartum client for
relieve pain and discomfort. uterine bleeding, the nurse finds the fundus
• Provide emotional support and reassurance to be boggy. After fundal massage by the
to ease anxiety. nurse, the physician prescribes 0.2 mg of
• Maintain I.V. fluid administration as or- methylergonovine (Methergine) by mouth.
dered to replace volume loss. What should the nurse tell the client?
• Administer antibiotics as prescribed to fight 1. “Methergine is commonly used to help
infection. the uterus contract so that the bleeding
will decrease. You may experience more
Teaching topics cramping as your uterus becomes firmer.”
• Recognizing signs and symptoms of a wors- 2. “You’ll probably take this medication
ening condition, such as nausea, vomiting, ab- until you’re discharged from the hospital.
sent bowel sounds, abdominal distention, and Every patient usually needs to take this
severe abdominal pain medication.”
3. “If your blood pressure is low, you
won’t be able to take this medication; I’ll
Placing the establish a new I.V. line so I can start
patient in Fowler’s Pitocin again.”
position helps with the 4. “Most people don’t experience addition-
drainage of lochia. al pain or cramping from taking this med-
ication.”
Answer: 1. Methylergonovine, an ergot alka-
loid, is commonly given to stimulate sustained
uterine contraction. It allows the uterus to re-
main contracted and firm, thus decreasing
postpartum bleeding. Abdominal cramping,
which may become painful, is a common ad-
verse effect. Methylergonovine is discontin-
ued when the lochia flow has decreased or
the client complains of severe cramping.
Clients may need only a few doses of methyl-
ergonovine to keep the uterus contracted.
920124.qxd 8/7/08 3:11 PM Page 528
528 Postpartum care
Methylergonovine is contraindicated in Answer: 1. Women who experience a twin de-

clients with high—not low—blood pressure. livery have a higher risk of postpartum hem-
Client needs category: Physiological orrhage due to overdistention of the uterus,
integrity which causes uterine atony. Checking fundal
Client needs subcategory: Pharmaco- tone and lochia flow helps to determine the
logical therapies risk of hemorrhage. Applying cold packs to
Cognitive level: Application the perineum, administering analgesics as or-
dered, and offering the bedpan are all signifi-
2. The nurse is providing care for a postpar- cant nursing interventions; however, detect-
tum client. Which conditions would place this ing and preventing postpartum hemorrhage
client at greater risk for a postpartum hemor- is most important.
rhage? Client needs category: Physiological
1. Hypertension integrity
2. Severe pain Client needs subcategory: Physio-
3. Placenta previa logical adaptation
4. Uterine infection Cognitive level: Comprehension
Answer: 3. The client with placenta previa is at
greatest risk for postpartum hemorrhage. In
placenta previa, the lower uterine segment
doesn’t contract as well as the fundal part of
the uterus; therefore, more bleeding occurs.
Hypertension, severe pain, and uterine infec-
tion don’t place the client at increased risk for
postpartum hemorrhage.
4. Which is a normal physiologic response in

the early postpartum period?
1. Urinary urgency and dysuria
2. Rapid diuresis
3. Decrease in blood pressure
4. Increased motility of the GI system
Answer: 2. In the early postpartum period
there’s an increase in the glomerular filtration
rate and a drop in progesterone levels, which
result in rapid diuresis. There should be no
urinary urgency, although a woman may be
anxious about voiding. There’s minimal
change in blood pressure following childbirth
3. A client has delivered twins. What’s the and a residual decrease in GI motility.
most important intervention for the nurse to Client needs category: Physiological
perform? integrity
1. Check fundal tone and lochia flow. Client needs subcategory: Physio-
2. Apply a cold pack to the perineal area. logical adaptation
3. Administer analgesics as ordered. Cognitive level: Knowledge
4. Encourage voiding by offering the
bedpan.
920124.qxd 8/7/08 3:11 PM Page 529
5. During the third postpartum day, which rhage, but in the postpartum period a full
finding would the nurse be most likely to find bladder is the most common cause of uterine
in the client? bleeding. Endometritis, an infection of the in-
1. She’s interested in learning more about ner lining of the endometrium, and maternal
neonate care. hypertension don’t cause postpartum hemor-
2. She talks a lot about her birth experi- rhage.
ence. Client needs category: Health promo-
3. She sleeps whenever the baby isn’t pre- tion and maintenance
sent. Client needs subcategory: None
4. She requests help in choosing a name Cognitive level: Knowledge
for the baby.
Answer: 1. The second to seventh days of
postpartum care are the “taking-hold” phase,
in which the new mother strives for indepen-
dence and is eager for her baby. Options 2, 3,
and 4 describe the “taking-in phase” in which
the mother relives her birth experience.
7. When checking a client’s episiotomy, the

nurse should be especially careful to observe:
1. location.
2. discharge and odor.
3. edema and approximation.
4. subinvolution.
Answer: 3. An episiotomy should be checked
for edema and approximation of incision. An
edematous perineum causes more tension of
the suture line and increases pain. Although
the sutures may be difficult to visualize, the
suture line should be intact. Episiotomy loca-
6. Which circumstance is most likely to tion is important, but it isn’t as important as
cause uterine atony, leading to postpartum he- the presence of edema. Discharge and odor
morrhage? refer to an evaluation of lochia. Subinvolution
1. Cervical and vaginal tears refers to the complete return of the uterus to
2. Endometritis its prepregnancy size and shape.
3. Urine retention Client needs category: Physiological
4. Hypertension integrity
Answer: 3. Urine retention is most likely to Client needs subcategory: Reduction of
cause uterine atony and subsequent postpar- risk potential
tum hemorrhage. Urine retention causes a Cognitive level: Comprehension
distended bladder to displace the uterus
above the umbilicus and to the side, which
prevents the uterus from contracting. The
uterus needs to remain contracted if bleeding
is to stay within normal limits. Cervical and
vaginal tears can cause postpartum hemor-
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530 Postpartum care
8. While performing a routine fundal evalua- 10. A client treated with magnesium sulfate
tion, the nurse finds that the client’s fundus is during labor is now on the postpartum unit.
boggy. What should the nurse do first? The nurse should be aware that the client is
1. Call the physician. at risk for which of the following complication
2. Massage the fundus. of magnesium sulfate therapy?
3. Assess lochia flow. 1. Hypotension
4. Obtain an order for methylergonovine 2. Uterine infection
(Methergine). 3. Postpartum hemorrhage
Answer: 2. The nurse should begin to mas- 4. Postpartum depression
sage the uterus so that it will be stimulated to Answer: 3. Because magnesium sulfate pro-
contract. Lochia flow can be checked while duces a smooth-muscle depressive effect, the
the uterus is being massaged. The nurse uterus should be checked for uterine atony.
shouldn’t leave the client to call the physician. The uterus may be unable to maintain a firm
If the fundus remains boggy and the uterus tone, thus increasing the risk of postpartum
continues to bleed, the nurse should use the hemorrhage. Magnesium sulfate does de-
call button to ask another nurse to call the crease blood pressure, but it’s considered
physician. Methylergonovine may be pre- more of an anticonvulsant than an antihyper-
scribed if needed. tensive. Uterine infection and postpartum de-
Client needs category: Physiological pression aren’t associated with magnesium
integrity sulfate therapy.
Cognitive level: Application Client needs subcategory: Pharmaco-
logical therapies
9. Which type of lochia should the nurse ex- Cognitive level: Comprehension
pect to find in a client who’s 2 days postpar-
tum?
1. Foul-smelling
2. Serosa
3. Alba
4. Rubra
Just one more
Answer: 4. Lochia rubra lasts about 4 days maternal-neonatal
and is followed by lochia serosa, which ex- chapter to go.
tends through the seventh day, and then Let’s do it!
lochia alba, which occurs during the second
and third postpartum weeks. Foul-smelling
lochia is a sign of infection.
integrity
logical adaptation
920125.qxd 8/7/08 3:12 PM Page 531
25 Neonatal
care
neonate has a minimal range of chemical bal-
In this chapter,
you’ll review:
Brush up on key ance and safety. The neonate’s limited ability
to excrete drugs, coupled with excessive
✐ neonatal adaptations concepts neonatal fluid loss, can rapidly lead to acidosis
and fluid imbalances.
to extrauterine life
✐ initial and ongoing A neonate experiences many changes as he
neonatal assessment
adapts to life outside the uterus. Knowledge Digestive difficulties
of these changes and of the normal physiolog- The GI system also isn’t fully developed be-
✐ common neonatal dis-
ic characteristics of the neonate provides the cause normal bacteria aren’t present in the
orders. basis for normal neonatal care. neonate’s GI tract. The lower intestine con-
At any time, you can review the major points tains meconium at birth; the first meconium
of this chapter by consulting the Cheat sheet (sterile, greenish black, and viscous) usually
on pages 532 and 533. passes within 24 hours. Some aspects of GI
development include:
• audible bowel sounds 1 hour after birth
Adaptations to • uncoordinated peristaltic activity in the
esophagus for the first few days of life
extrauterine life • a limited ability to digest fats because amy-
lase and lipase are absent at birth
Here’s a review of how the neonate’s body • frequent regurgitation because of an imma-
systems change. ture cardiac sphincter.
Heart seals Bun from the oven

Because the renal The cardiovascular system changes from Changes in neonatal thermogenesis depend
system hasn’t fully the very first breath, which expands the on environment. In an optimal environment,
matured yet, the neonate’s lungs and decreases pulmonary the neonate can produce sufficient heat, but
neonate can easily vascular resistance. Clamping the umbilical rapid heat loss may occur in a suboptimal
develop acidosis and cord increases systemic vascular resistance thermal environment.
fluid imbalances. and left atrial pressure, which functionally
closes the foramen ovale (fibrosis may take Disease control
from several weeks to a year). The neonatal immune system depends
largely on three immunoglobulins: immu-
Every breath you take noglobulin (Ig) G, IgM, and IgA. IgG (detect-
The respirator y system also begins to ed in the fetus at the 3rd month of gestation)
change with the first breath. The neonate’s is a placentally transferred immunoglobulin,
breathing is a reflex triggered in response to providing antibodies to bacterial and viral
noise, light, and temperature and pressure agents. The infant synthesizes its own IgG
changes. Air immediately replaces the fluid during the first 3 months of life, thus compen-
that filled the lungs before birth. sating for concurrent catabolism of maternal
antibodies. By the 20th week of gestation, the
A delicate balance fetus synthesizes IgM, which is undetectable
Renal system function doesn’t fully mature at birth because it doesn’t cross the placenta.
until after the 1st year of life; as a result, the (Text continues on page 534.)
920125.qxd 8/7/08 3:12 PM Page 532
532 Neonatal care
et
heat she
C
Neonatal care refresher
FETAL ALCOHOL SYNDROME HYPOTHERMIA
• Difficulty establishing respirations • Kicking and crying (a mechanism used to in-
• Lethargy crease the metabolic rate to produce body heat)
• Opisthotonos • Core body temperature lower than 97.7 F
• Seizures (36.5 C)
Key test result Key test results
• Chest X-ray may reveal congenital heart defect. • Arterial blood gas (ABG) analysis shows hypox-
Key treatments emia.
• Swaddling • Blood glucose level reveals hypoglycemia.
• I.V. phenobarbital Key treatment
Key interventions • Radiant warmer
• Provide a stimulus-free environment for the Key interventions
neonate; darken the room, if necessary. • Dry the neonate immediately after delivery.
• Provide gavage feedings, if necessary. • Allow the mother to hold the neonate skin to
HUMAN IMMUNODEFICIENCY VIRUS (HIV) skin.
• Monitor vital signs every 15 to 30 minutes.
• Provide a knitted cap for the neonate.
• Produces no symptoms at birth
• Place the neonate in a radiant warmer.
Key test results
• Test interpretation is problematic because most NEONATAL DRUG DEPENDENCY
neonates with an HIV-positive mother test posi- Key signs and symptoms
tive at birth. Uninfected neonates lose this mater- • High-pitched cry
nal antibody between 8 and 15 months, and in- • Irritability
fected neonates remain seropositive. Therefore, • Jitteriness
testing should be repeated at age 15 months. • Poor sleeping pattern
Time for a Key treatments • Tremors
change. I • Antimicrobial therapy to treat opportunistic in- Key treatments
experience many fections • Gavage feedings, if necessary
bodily changes as • Zidovudine (Retrovir) administration based on • Paregoric and phenobarbital (Barbita) to treat
I adapt to life
the neonate’s lymphocyte count withdrawal symptoms; methadone shouldn’t be
outside the
Key interventions given to neonates because of its addictive nature
uterus.
• Monitor cardiovascular and respiratory status. Key interventions
• Keep the umbilical stump meticulously clean. • Monitor cardiovascular status.
• Maintain standard precautions. • Use tight swaddling for comfort.
• Place the neonate in a dark, quiet environment.
• Encourage use of a pacifier (in cases of heroin
withdrawal).
920125.qxd 8/7/08 3:12 PM Page 533
Neonatal care refresher (continued)

• Be prepared to administer gavage feedings (in cases of RESPIRATORY DISTRESS SYNDROME
methadone withdrawal). Key signs and symptoms
• Maintain fluid and electrolyte balance. • Cyanosis and pallor
NEONATAL INFECTIONS • Expiratory grunting
• Fine crackles and diminished breath sounds
• Seesaw respirations
• Feeding pattern changes, such as poor sucking or decreased
• Sternal, substernal, and intracostal retractions
intake
• Tachypnea (more than 60 breaths/minute)
• Sternal retractions
• Subtle, nonspecific behavioral changes, such as lethargy or Key test results
hypotonia • ABG analysis reveals respiratory acidosis.
• Temperature instability • Chest X-rays reveal bilateral diffuse reticulogranular density.
• Blood and urine cultures are positive for the causative organ- • Endotracheal (ET) intubation and mechanical ventilation
ism, most commonly gram-positive beta-hemolytic streptococci • Nutrition supplements (total parenteral nutrition [TPN] or enter-
and the gram-negative Escherichia coli, Aerobacter, Proteus, al feedings if possible)
and Klebsiella. • Surfactant replacement by way of ET tube
• Complete blood count shows an increased white blood cell • Temperature regulation with a radiant warmer
count. Key interventions
Key treatments • Monitor cardiovascular, respiratory, and neurologic status.
• I.V. therapy to provide adequate hydration • Monitor vital signs.
• Antibiotic therapy: broad-spectrum until causative organism is • Maintain ventilatory support status.
identified and then specific antibiotic • Administer medications, including ET surfactant as prescribed.
• Provide adequate nutrition through enteral feedings, if possi-
Key interventions
ble, or TPN.
• Monitor cardiovascular and respiratory status.
• Administer broad-spectrum antibiotics before culture results TRACHEOESOPHAGEAL FISTULA
are received and specific antibiotic therapy after results are re- Key signs and symptoms
ceived. • Difficulty feeding, such as choking or aspiration; cyanosis dur-
NEONATAL JAUNDICE ing feeding
• Signs of respiratory distress
• Jaundice Key test result
• Lethargy • Abdominal X-ray shows the fistula and a gas-free abdomen.
Key test result Key treatments
• Bilirubin levels exceed 12 mg/dl in premature or term neonates. • Emergency surgical intervention to prevent pneumonia, dehy-
dration, and fluid and electrolyte imbalances
Key treatments
• Maintenance of patent airway
• Increased fluid intake
• Phototherapy Key interventions
• Monitor cardiovascular, respiratory, and GI status.
Key interventions
• Place the neonate in high Fowler’s position.
• Monitor neurologic status.
• Keep a laryngoscope and ET tube at bedside.
• Monitor serum bilirubin levels.
• Provide the neonate with a pacifier.
• Initiate and maintain phototherapy (provide eye protection
• Provide gastrostomy tube feedings postoperatively.
while under phototherapy lights and remove eye shields prompt-
ly when removed from the phototherapy lights).
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534 Neonatal care
High levels of IgM in the neonate indicate a First things first

nonspecific infection. Secretory IgA (which Initial neonatal data collection involves detect-
limits bacterial growth in the GI tract) is ing abnormalities and keeping accurate
found in colostrum and breast milk. records.
Poietic license Nursing actions

In the neonatal hematopoietic system, • Ensure a proper airway by suctioning, and
blood volume accounts for 80 to 85 ml/kg of administer oxygen as needed.
body weight. The neonate experiences pro- • Dry the neonate under the warmer while
longed coagulation time after birth because keeping the head lower than the trunk (to
maternal stores of vitamin K become depleted promote drainage of secretions).
and the neonate’s immature liver can’t pro- • Apply a cord clamp, and monitor the neo-
duce enough to maintain adequate levels. nate for abnormal bleeding from the cord;
check the number of cord vessels.
Nervous energy • Observe the neonate for voiding and meco-
The full-term neonate’s neurologic system nium; document the first void and stools.
should produce equal strength and symmetry • Check the neonate for gross abnormalities
in responses and reflexes. Diminished or ab- and clinical manifestations of suspected ab-
sent reflexes may indicate a serious neurolog- normalities.
ic problem, and asymmetrical responses may • Continue to collect data on the neonate by
indicate trauma during birth, including nerve using the Apgar score criteria even after the
damage, paralysis, or fracture. Some neonatal 5-minute score is received. (See Apgar
Physiologic reflexes gradually weaken and disappear dur- scoring.)
jaundice is a mild ing the early months. • Obtain clear footprints and fingerprints (the
jaundice that lasts neonate’s footprints are kept on a record that
for the first few days Liver concerns includes the mother’s fingerprints).
after birth.
Increased serum levels of unconjugated • Apply identification bands with matching
bilirubin from increased red blood cell (RBC) numbers to the mother (one band) and neo-
lysis, altered bilirubin conjugation, or in- nate (two bands) before they leave the deliv-
creased bilirubin reabsorption from the GI ery room.
tract may cause jaundice—a major complica- • Promote bonding between the mother and
tion for the neonatal hepatic system. Physio- neonate.
logic jaundice appears after the first 24 hours
of extrauterine life; pathologic jaundice is evi- Keep on keepin’ on
dent at birth or within the first 24 hours of ex- Ongoing neonatal physical data collection in-
trauterine life; and breast milk jaundice ap- clude observing and recording vital signs and
pears after the 1st week of extrauterine life administering prescribed medications.
when physiologic jaundice is declining.
Nursing actions
• Monitor the neonate’s vital signs.
• Take the first temperature by the rectal
Keep abreast of route to determine whether the rectum is
patent. Temperatures obtained by this route
neonatal data must be done gently to prevent injury to the
rectal mucosa.
collection • Take the apical pulse for 60 seconds (nor-
mal rate is 120 to 160 beats/minute).
Neonatal data collection includes initial and • Count respirations with a stethoscope for
ongoing data collection as well as a thorough 60 seconds (normal rate is 30 to 60 breaths/
physical examination. minute).
920125.qxd 8/7/08 3:12 PM Page 535
Keep abreast of neonatal data collection 535
Apgar scoring
The Apgar scoring system provides a way to evaluate the neonate’s cardiopulmonary and neurolog-
ic status. An Apgar score is obtained at 1 and 5 minutes after birth and repeated every 5 minutes un-
til the infant stabilizes. A score of 8 to 10 indicates that the neonate is in no apparent distress; a
score below 8 indicates that resuscitative measures may be needed.
Sign 0 1 2
Heart rate Absent Less than 100 beats/minute Greater than 100 beats/minute
Respiratory effort Absent Slow, irregular Good crying
Muscle tone Flaccid Some flexion of extremities Active motion
Reflex irritability None Grimace Vigorous cry
Color Pale, blue Body pink, blue extremities Completely pink
• Measure and record blood pressure (nor- Neonatal physical

mal reading ranges from 60/40 mm Hg to
90/45 mm Hg). examination
• Measure and record the neonate’s vital sta-
tistics (weight, length, and head and chest cir- The neonate should receive a thorough visual
cumference). and physical examination of each body part.
• Complete a gestational age evaluation. The following is a brief review of normal and
• Administer prescribed medications such as abnormal neonatal physiology.
vitamin K (AquaMEPHYTON), which is a
prophylactic against transient deficiency of Heads up
coagulation factors II, VII, IX, and X. The neonate’s head is about one-fourth of
• Administer erythromycin ointment (Ilo- body size. The term molding refers to the
tycin), the drug of choice for neonatal eye shaping of the fetal head as it adapts to the
prophylaxis, to prevent damage and blindness shape of the birth canal. This is a normal oc-
from conjunctivitis caused by Neisseria gonor- currence with most births. The heads of most
rhoeae and Chlamydia; treatment is required neonates return to their normal shape within
by law. 3 days after delivery.
• Administer first hepatitis B vaccine within Cranial complications that can occur in-
12 hours after birth. clude:
• Perform laboratory tests. • cephalohematoma—blood collects between
• Monitor glucose levels and hematocrit. the skull and the periosteum; may occur on
one or both sides of the head but doesn’t
cross the suture lines.
• caput succedaneum—swelling in the soft
tissues of the scalp, which can extend across
the suture lines
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536 Neonatal care
Closing time to an imaginary line from the inner to the out-

The neonatal skull has two fontanels: a er canthus of the eye. Low-set ears are associ-
diamond-shaped anterior fontanel and a ated with several syndromes, including chro-
triangular-shaped posterior fontanel. The mosomal abnormalities.
anterior fontanel is located at the juncture of The neonate should respond to sudden
the frontal and parietal bones, measures 11⁄8⬙ sounds by increasing his heart and respirato-
to 15⁄8⬙ (3 to 4 cm) long and 3⁄4⬙ to 11⁄8⬙ (2 to ry rates.
3 cm) wide, and closes in about 18 months.
The posterior fontanel is located at the junc- Flexi-neck
ture of the occipital and parietal bones, mea- The neonate’s neck is typically short and
sures about 3⁄4⬙ across, and closes in 8 to 12 weak with deep folds of skin.
weeks. The fontanels:
• should feel soft to the touch Flexi-chest
• shouldn’t be depressed—a depressed The neonatal chest is characterized by a cylin-
fontanel indicates dehydration drical thorax and flexible ribs. Breast en-
• shouldn’t bulge—bulging fontanels require gorgement from maternal hormones may be
immediate attention, as they may indicate in- apparent, and supernumerary nipples may be
creased intracranial pressure. located below and medially to the true nip-
ples.
Jeepers peepers
• The neonate’s eyes are usually blue or gray Nice abs
because of scleral thinness. Permanent eye The neonatal abdomen is usually cylindrical
color is established within 3 to 12 months. with some protrusion. A scaphoid appearance
• Lacrimal glands are immature at birth, re- indicates diaphragmatic hernia. The umbilical
sulting in tearless crying for up to 2 months. cord is white and gelatinous with two arteries
• The neonate may demonstrate transient and one vein and begins to dry within 1 to 2
strabismus. hours after delivery.
• Doll’s eye reflex (when the head is rotated
laterally, the eyes deviate in the opposite di- I’ll show you mine…
rection) may persist for about 10 days. Characteristics of a male neonate’s genitalia
• Subconjunctival hemorrhages may appear include rugae on the scrotum and testes de-
from vascular tension changes during birth. scended into the scrotum. The urinary mea-
tus is located in one of three places:
Nose only • at the penile tip (normal)
Because infants are obligatory nose breathers • on the dorsal surface (epispadias)
for the first few months of life, nasal passages • on the ventral surface (hypospadias).
must be kept clear to ensure adequate respi- In the female neonate, the labia majora cov-
ration. Neonates instinctively sneeze to re- er the labia minora and clitoris, vaginal dis-
move obstruction. charge from maternal hormones appears, and
the hymenal tag is present.
Dry mouth
The neonate’s mouth usually has scant saliva Extreme measures
and pink lips. Epstein’s pearls (pearly, white, All neonates are bowlegged and have flat feet.
pinpoint papules) may be found on the gums Some neonates may have abnormal extremi-
or hard palate, and precocious teeth may also ties. They may be polydactyl (more than five
be apparent. digits on an extremity) or syndactyl (two or
more digits fused together).
Sound check
The neonate’s ears are characterized by in- Soldier straight
curving of the pinna and cartilage deposition. The neonatal spine should be straight and
The top of the ear should be above or parallel flat, and the anus should be patent without
920125.qxd 8/7/08 3:12 PM Page 537
any fissure. Dimpling at the base of the spine lying supine, the extremities on the same side
I have a
is commonly associated with spina bifida. straighten while those on the opposite side repertoire of
flex reflexes.
Baby-smooth skin • Babinski’s: when the sole on the side of the
The skin of a neonate can indicate many con- small toe is stroked, the neonate’s toes fan up-
ditions—some quite normal and others reward
quiring more serious attention. Data collec- • palmar grasp: when a finger is placed in
tion findings include: each of the neonate’s hands, the neonate’s fin-
• acrocyanosis (cyanosis of the hands and gers grasp tightly enough to be pulled to a sit-
feet), which results from high levels of hemo- ting position
globin and vasomotor instability during the • dancing: when held upright with the feet
first week of life touching a flat surface, the neonate exhibits
• milia (clogged sebaceous glands) on the dancing or stepping movements
nose or chin • startle: a loud noise such as a hand clap elic-
• lanugo (fine, downy hair) appearing after 20 its neonatal arm abduction and elbow flexion;
weeks of gestation on the entire body except the neonate’s hands stay clenched
the palms and soles • trunk incurvature: when a finger is run lat-
• vernix caseosa (a white, cheesy protective erally down the neonate’s spine, the trunk
coating composed of desquamated epithelial flexes and the pelvis swings toward the stimu-
cells and sebum) lated side.
• erythema toxicum neonatorum (a transient,
maculopapular rash)
• telangiectasia (flat, reddened vascular ar-
eas) appearing on the neck, upper eyelid, or
upper lip
Catch up on
• port-wine stain (nevus flammeus), a capil-
lary angioma located below the dermis and
complications
commonly found on the face Potential neonatal complications and disor-
• strawberry hemangioma (nevus vasculo- ders include fetal alcohol syndrome, human Warn
sus), a capillary angioma located in the der- immunodeficiency virus, hypothermia, drug mothers-to-be
mal and subdermal skin layers indicated by a dependency, infections, jaundice, respiratory that binge
rough, raised, sharply demarcated birthmark distress syndrome, and tracheoesophageal drinking is even
• Mongolian spot, an area of bluish skin dis- fistula. more
coloration sometimes found in Blacks, Native detrimental
than moderate
Americans, and neonates of Mediterranean
daily alcohol
descent. Fetal alcohol syndrome consumption.
Reflections on reflexes Fetal alcohol syndrome (FAS) results from a

Normal neonates display a number of reflex- mother’s chronic or periodic intake of alcohol
es, which include: during pregnancy. The degree of alcohol con-
• sucking: sucking motion begins when a nip- sumption necessary to cause the syndrome
ple is placed in the neonate’s mouth varies. Because alcohol crosses the placenta
• Moro’s: when lifted above the crib and sud- in the same concentration as is present in the
denly lowered, the arms and legs symmetri- maternal bloodstream, alcohol consumption
cally extend and then abduct while the fingers (particularly binge drinking) is especially dan-
spread to form a “C” gerous during critical periods of organogene-
• rooting: when the cheek is stroked, the sis. The fetal liver isn’t mature enough to
neonate turns his head in the direction of the detoxify alcohol.
stroke
• tonic neck (fencing position): when the
neonate’s head is turned while the neonate is
920125.qxd 8/7/08 3:12 PM Page 538
538 Neonatal care
Prevention point:
CAUSES Human immunodeficiency
• Risk of teratogenic effects increases propor-
Administering
zidovudine to an HIV- tionally with daily alcohol intake; FAS has virus
positive pregnant been detected in neonates of even moderate
woman significantly drinkers (1 to 2 oz of alcohol daily) A mother can transmit the human immuno-
reduces the risk of deficiency virus (HIV) to her fetus trans-
transmission to the DATA COLLECTION FINDINGS placentally at various gestational ages—peri-
neonate. • Abdominal distention natally through maternal blood and bodily
• Difficulty establishing respirations fluids—and postnatally through breast milk.
• Facial anomalies (microcephaly, microoph- Administration of zidovudine to HIV-positive
thalmia, maxillary hypoplasia, short palpebral pregnant women significantly reduces the
fissures) risk of transmission to the fetus.
• Irritability
• Lethargy CAUSES
• Opisthotonos • Transmission of the virus to the fetus or
• Seizures neonate from an HIV-positive mother
• Sleep disturbances (either always awake or
always asleep, depending on the mother’s al- DATA COLLECTION FINDINGS
cohol level close to birth) • Produces no symptoms (at birth)
• Tremulousness • Opportunistic infections (may appear be-
• Weak sucking reflex tween ages 3 and 6 months)
DIAGNOSTIC FINDINGS DIAGNOSTIC FINDINGS

• Chest X-ray may reveal congenital heart • Test interpretation is problematic because
defect. most neonates with an HIV-positive mother
test positive at birth. Uninfected neonates
NURSING DIAGNOSES lose this maternal antibody between 8 and
• Imbalanced nutrition: Less than body re- 15 months, and infected neonates remain
quirements seropositive. Therefore, testing should be re-
• Delayed growth and development peated at age 15 months.
• Risk for impaired parenting • HIV-DNA polymerase chain reaction or vi-
ral cultures for HIV should be performed at
TREATMENT birth and again between ages 1 and 2 months.
• Swaddling
NURSING DIAGNOSES
Drug therapy •Imbalanced nutrition: Less than body re-
• I.V. phenobarbital (to control hyperactivity quirements
and irritability) • Ineffective protection
• Refer mother to alcohol treatment center for TREATMENT
ongoing support and rehabilitation. • I.V. fluid administration
• Provide a stimulus-free environment for the • Nutritional supplements to prevent weight
neonate; darken the room if necessary to min- loss
imize stimuli.
• Provide gavage feedings as necessary to en- Drug therapies
sure adequate nutrition for the infant. • Antimicrobial therapy to treat opportunistic
infections
Teaching topics • Routine immunizations with killed viruses,
• Avoiding alcohol during pregnancy except the varicella vaccines
920125.qxd 8/7/08 3:12 PM Page 539
• Zidovudine (Retrovir): recommended dur- DATA COLLECTION FINDINGS Brrr… In the

ing the first 6 weeks of life to prevent perina- • Kicking and crying (a mechanism to in- womb, the
tal transmission crease the metabolic rate to produce body temperature was
• Combination therapy: recommended when heat) constant. At birth,
HIV infection is confirmed; therapy should in- • Core body temperature lower than 97.7 F my temperature
clude zidovudine combined with lamivudine (36.5 C) may fall rapidly.
(Epivir) or didanosine (Videx); or lamivudine
combined with didanosine DIAGNOSTIC FINDINGS
• Arterial blood gas (ABG) analysis shows
INTERVENTIONS AND RATIONALES hypoxemia.
•Monitor the neonate’s cardiovascular and • Blood glucose level reveals hypoglycemia.
respiratory status to detect complications.
• Monitor vital signs and fluid intake and out- NURSING DIAGNOSES
put to evaluate for dehydration. • Hypothermia
• Monitor fluid and electrolyte status to guide • Ineffective thermoregulation
fluid and electrolyte replacement therapy. • Risk for impaired parent-infant attachment
• Keep the umbilical stump meticulously
clean to prevent opportunistic infection. TREATMENT
• Maintain standard precautions to prevent the • Radiant warmer
• Assist with blood sample and urine speci- INTERVENTIONS AND RATIONALES
men collection to prevent the spread of infec- • Dry the neonate immediately to prevent heat
tion. loss.
• Administer medications as indicated to treat • Wrap the neonate in a warm blanket to help
infection and improve immune function. stabilize body temperature.
• Provide emotional support to the family to • Allow the mother to hold the neonate skin
allay anxiety to skin to provide warmth.
• Monitor the neonate for signs of oppor- • Monitor vital signs every 15 to 30 minutes
tunistic infection to prevent treatment delay. to detect temperature fluctuations and compli-
cations.
Teaching topics • Provide a knitted cap for the neonate to pre-
• Providing the child with all necessary im- vent heat loss through the head.
munizations • Place the neonate in a radiant warmer to
maintain thermoregulation.
Hypothermia Teaching topics

• Stressing infant-parent bonding (see Teach-
A neonate’s temperature is about 99° F ing neonatal care to parents, page 540)
(37.2° C) at birth. Inside the womb, the fetus
was confined in an environment where the
temperature was constant. At birth, this tem- Neonatal drug dependency
perature can fall rapidly.
Neonates born to drug-addicted mothers are
CAUSES at risk for preterm birth, aspiration pneumo-
• Cold temperature in delivery environment nia, meconium-stained fluid, and meconium
• Heat loss due to evaporation, conduction, aspiration. Drug-dependent neonates also
radiation, or convection may experience withdrawal from such sub-
• Immature temperature-regulating system stances as heroin and cocaine.
• Inability to conserve heat due to little sub-
cutaneous fat CAUSES
• History of drug addiction in the mother
920125.qxd 8/7/08 3:12 PM Page 540
540 Neonatal care
Teaching neonatal care to parents

Here are some topics to include when • The neonate’s first stools are called • Experiment with various breast-feeding
teaching parents about caring for their meconium; they are odorless, dark positions.
neonate. green, and thick. • Perform thorough breast care to pro-
• Transitional stools occur about 2 to 3 mote cleanliness and comfort.
CORD CARE
days after the ingestion of milk; they are • Follow a diet that ensures adequate nu-
With every diaper change, wipe the um-
greenish brown and thinner than meco- trition for the mother and neonate (drink
bilical cord with alcohol, especially
nium. at least four 8-oz glasses of fluid daily, in-
around the base. Report any odor, dis-
• The stools change to pasty yellow and crease caloric intake by 200 kcal over
charge, or signs of skin irritation around
pungent (bottle-fed neonate) or loose the pregnancy requirement of 2,400 kcal,
the cord. Fold the diaper below the cord
yellow and sweet-smelling (breast-fed avoid foods that cause irritability, gas, or
until the cord falls off after 7 to 10 days.
neonate) by the fourth day. diarrhea).
CUT CARE • Change diapers before and after every • Consult the doctor before taking any
Gently clean the circumcised penis with feeding; expose the neonate’s buttocks medication.
water, and apply fresh petroleum gauze to the air and light several times a day for • Know that ingested substances (caf-
with each diaper change. Loosen the pe- about 20 minutes to treat diaper rash; ap- feine, alcohol, and medications) can
troleum gauze stuck to the penis by pour- ply ointment to minimize contact with pass into breast milk.
ing warm water over the area. Don’t re- urine and feces.
MEALTIME WITH THE BOTTLE
move yellow discharge that covers the
BATH TIME Follow the pediatrician’s instructions for
glans after circumcision; this is part of
Give the neonate sponge baths until the preparing and feeding with formula. Fol-
normal healing. Report any foul-smelling,
cord falls off; then wash the neonate in a low these guidelines:
purulent discharge promptly. Apply dia-
tub containing 3⬙ to 4⬙ (7.5 to 10 cm) of • Feed the neonate in an upright position,
pers loosely until the circumcision heals
warm water. and keep the nipple full of formula to min-
after about 5 days.
imize air swallowing.
If the plastibell method of circumcision MEALTIME AT THE BREAST
• Burp the neonate after each ounce of
was used, leave the plastic ring in place Initiate breast-feeding as soon as possi-
formula or more frequently if the neonate
until it falls off on its own, typically in 5 to ble after delivery, and then feed the
spits up.
8 days. No special dressing is applied neonate on demand. Follow these guide-
and bathing and diapering are performed lines: SAFETY SEATS
normally. • Position the neonate’s mouth slightly Make sure parents understand the im-
differently at each feeding to reduce irri- portance of using child safety seats. In-
UNCUT CARE
tation at one site. struct them to place the neonate in the
Don’t retract the foreskin when washing
• Burp the neonate before switching to back seat facing to the rear until the
the uncircumcised penis because the
the other breast. neonate is over 20 lb (9 kg) and older
foreskin is adhered to the glans.
• Insert the little finger into a corner of than 1 year.
POTTY PATTERNS the neonate’s mouth to separate the
Become familiar with the neonate’s void- neonate from the nipple.
ing and elimination patterns:
DATA COLLECTION FINDINGS • Increased tendon reflexes

• Diarrhea • Irritability
• Frequent sneezing and yawning • Jitteriness
• High-pitched cry • Poor feeding habits
• Hyperactive reflexes • Poor sleeping pattern
920125.qxd 8/7/08 3:12 PM Page 541
• Tremors Teaching topics

• Inconsolable • Avoiding breast-feeding
• Vigorous sucking on hands
• Withdrawal symptoms (depend on the
length of maternal addiction, the drug ingest- Neonatal infections
ed, and the time of last ingestion before deliv-
ery; usually appear within 24 hours of deliv- A neonate may contract an infection before,
ery) during, or after delivery. Maternal IgM
doesn’t cross the placenta, and IgA requires
DIAGNOSTIC FINDINGS time to reach optimum levels after birth, limit-
• Drug screen reveals agent abused by ing the neonate’s immune response. Dysma-
mother turity caused by intrauterine growth retarda-
tion, preterm birth, or postterm birth can fur-
NURSING DIAGNOSES ther compromise the neonate’s immune
• Imbalanced nutrition: Less than body re- system and predispose him to infection.
quirements Sepsis is one of the most significant causes
• Risk for deficient fluid volume of neonatal morbidity and mortality. Toxoplas-
• Risk for injury mosis, syphilis, rubella, cytomegalovirus, and
herpes are common perinatal infections
TREATMENT known to affect neonates. Beta-hemolytic
• Gavage feedings, if necessary streptococci infection may occur as a result of
• I.V. therapy to maintain hydration contact with the maternal genital tract during
labor and delivery.
Drug therapy
• Clonidine (Catapres), Diazepam (Valium), CAUSES
paregoric, and phenobarbital (Barbita) to • Chorioamnionitis
treat withdrawal symptoms; methadone • Low birth weight or premature birth
shouldn’t be given to neonates because of its • Maternal substance abuse
addictive nature • Maternal urinary tract infections
• Meconium aspiration There’s a lot to
INTERVENTIONS AND RATIONALES • Nosocomial infection know about neonatal
care…how did we get
• Monitor cardiovascular status to detect car- • Premature labor
ourselves into this,
diovascular compromise. • Prolonged maternal rupture of membranes anyway?
• Monitor vital signs and fluid intake and out-
put to detect complications. DATA COLLECTION FINDINGS
• Encourage the mother to hold the neonate • Abdominal distention What do
to promote maternal-infant bonding. • Apnea you mean we?
• Use tight swaddling for comfort. • Feeding pattern changes, such as poor I’m not taking
• Place the neonate in a dark, quiet room to sucking or decreased intake the NCLEX!
provide a stimulus-free environment. • Hyperbilirubinemia
• Encourage the use of a pacifier to meet suck- • Pallor
ing needs (in cases of heroin withdrawal). • Petechiae
• Be prepared to administer gavage feeding • Poor weight gain
because of the neonate’s poor sucking reflex (in • Sternal retractions
cases of methadone withdrawal). • Subtle, nonspecific behavioral
• Maintain fluid and electrolyte balance to re- changes, such as lethargy or hy-
place fluid loss. potonia
• Monitor bilirubin levels and evaluate for • Tachycardia
jaundice (in cases of methadone withdrawal) • Temperature instability
to detect liver damage. • Vomiting
• Diarrhea
920125.qxd 8/7/08 3:12 PM Page 542
542 Neonatal care

• Blood and urine cultures are positive for the • Knowing the importance of continuing drug
Phototherapy
causative organism, most commonly gram- therapy for the duration prescribed
is the
treatment of
positive beta-hemolytic streptococci and the • Preventing infection
choice for gram-negative Escherichia coli, Aerobacter,
neonatal Proteus, and Klebsiella.
jaundice. • Blood chemistry shows increased direct Neonatal jaundice
bilirubin levels.
• Complete blood count (CBC) shows an in- Also called hyperbilirubinemia, neonatal jaun-
creased white blood cell (WBC) count. dice is characterized by a bilirubin level that:
• Lumbar puncture is positive for causative • exceeds 6 mg/dl within the first 24 hours
organisms. after delivery
• remains elevated beyond 7 days (in a
NURSING DIAGNOSES full-term neonate)
• Imbalanced nutrition: Less than body re- • remains elevated for 10 days (in a prema-
quirements ture neonate).
• Hypothermia The neonate’s bilirubin levels rise as biliru-
• Risk for deficient fluid volume bin production exceeds the liver’s capacity to
metabolize it. Unbound, unconjugated biliru-
TREATMENT bin can easily cross the blood-brain barrier,
• Gastric aspiration leading to kernicterus (an encephalopathy).
• I.V. therapy to provide adequate hydration
CAUSES
Drug therapy • Absence of intestinal flora needed for biliru-
• Antibiotic therapy: broad-spectrum until the bin passage in the bowel
causative organism is identified and then spe- • Enclosed hemorrhage
cific antibiotic • Erythroblastosis fetalis (hemolytic disease
of the neonate)
INTERVENTIONS AND RATIONALES • Hypoglycemia
• Monitor cardiovascular and respiratory sta- • Hypothermia
tus to detect complications. • Impaired hepatic functioning
• Monitor vital signs to detect complications. • Neonatal asphyxia (respiratory failure in
• Monitor fluid and electrolyte status to deter- the neonate)
mine the need for fluid replacement. • Polycythemia
• Initiate and maintain respiratory support as • Prematurity
needed to maintain respiratory filtration. • Reduced bowel motility and delayed meco-
• Administer broad-spectrum antibiotics be- nium passage
fore culture results are received and specific • Sepsis
antibiotic therapy after results are received to
treat infection. DATA COLLECTION FINDINGS
• Provide the family with reassurance and • Decreased reflexes
support to reduce anxiety. • High-pitched crying
• Provide the neonate with physiologic sup- • Jaundice
portive care to maintain a neutral thermal en- • Lethargy
vironment. • Opisthotonos
• Maintain I.V. therapy as ordered to replace • Seizures
fluid loss.
• Obtain blood samples and urine specimens DIAGNOSTIC FINDINGS
to evaluate antibiotic therapy efficacy. • Bilirubin levels exceed 12 mg/dl in prema-
ture or term neonates.
920125.qxd 8/7/08 3:12 PM Page 543
• Conjugated (direct) bilirubin levels exceed Respiratory distress

2 mg/dl.
• Bilirubin levels rise by more than 5 mg/day. syndrome
NURSING DIAGNOSES Respiratory distress syndrome occurs most
• Impaired parenting often in preterm neonates of diabetic mothers,
• Deficient fluid volume and neonates delivered by cesarean births. In
• Risk for injury respiratory distress syndrome, a hyaline-like
membrane lines the terminal bronchioles,
TREATMENT alveolar ducts, and alveoli, preventing ex-
• Exchange transfusion to remove maternal change of oxygen and carbon dioxide.
antibodies and sensitized RBCs if photothera-
py fails. CAUSES
• Increased fluid intake • Inability to maintain alveolar stability
• Phototherapy (preferred treatment) • Low level or absence of surfactant
• Treatment for anemia if jaundice is caused
by hemolytic disease DATA COLLECTION FINDINGS
• Cyanosis and pallor
INTERVENTIONS AND RATIONALES • Expiratory grunting
• Monitor neurologic status to detect signs of • Fine crackles and diminished breath
encephalopathy, which indicates the potential sounds
for permanent damage. • Hypothermia
• Maintain a neutral thermal environment to • Nasal flaring
prevent hypothermia. • Respiratory acidosis
• Monitor serum bilirubin levels to determine • Seesaw respirations
increased or decreased levels of bilirubin. • Sternal, substernal, and intracostal retrac-
• Initiate and maintain phototherapy (provide tions
eye protection while the neonate is under • Tachypnea (more than 60 breaths/minute)
phototherapy lights, and remove eye shields
promptly when he’s removed from the pho- DIAGNOSTIC FINDINGS
totherapy lights) to prevent complications. • ABG analysis reveals respiratory acidosis.
• Allow time for maternal-neonate bonding • Chest X-rays reveal bilateral diffuse reticu-
and interaction during phototherapy to pro- logranular density.
mote bonding.
• Keep the neonate’s anal area clean and dry. NURSING DIAGNOSES
Frequent, greenish stools result from bilirubin • Imbalanced nutrition: Less than body re-
excretion and can lead to skin irritations. quirements
• Provide the parents with support, reassur- • Ineffective tissue perfusion: Cardiopul-
ance, and encouragement to reduce anxiety. monary
Teaching topics
• Encouraging frequent feedings to maintain TREATMENT
adequate caloric intake and hydration and to • Acid-base balance maintenance
facilitate excretion of wastes • Endotracheal (ET) intubation and mechani-
cal ventilation
• Nutrition supplements (total parenteral nu-
trition [TPN] or enteral feedings if possible)
• Surfactant replacement by way of ET tube
• Temperature regulation with a radiant
warmer
920125.qxd 8/7/08 3:12 PM Page 544
544 Neonatal care
Drug therapy • Signs of respiratory distress (tachypnea,

• Indomethacin (Indocin) to promote closure cyanosis, sternal and substernal retractions)
of ductus arteriosus (a fetal blood vessel con-
necting the left pulmonary artery to the de- DIAGNOSTIC FINDINGS
scending aorta) • Abdominal X-ray shows the fistula and a
gas-free abdomen.
INTERVENTIONS AND RATIONALES • Bronchoscopy shows a blind pouch.
• Monitor cardiovascular, respiratory, and
neurologic status to detect respiratory distress. NURSING DIAGNOSES
• Monitor vital signs to observe for changes. • Imbalanced nutrition: Less than body re-
• Maintain ventilatory support status to main- quirements
tain air supply. • Impaired gas exchange
• Administer medications, including ET sur- • Risk for aspiration
factant, as prescribed to improve respiratory
function. TREATMENT
• Evaluate hydration status to determine fluid • Emergency surgical intervention to prevent
loss. pneumonia, dehydration, and fluid and elec-
• Maintain I.V. therapy to maintain fluid trolyte imbalances
levels. • Gastrostomy tube placement
• Provide adequate nutrition through enteral • Maintenance of patent airway
feedings, if possible, or TPN to provide ade-
quate nutrition. Drug therapy
• Maintain thermoregulation to reduce cold • Antibiotics (as prophylaxis for aspiration
stress. pneumonia)
• Obtain blood samples as necessary to detect
complications. INTERVENTIONS AND RATIONALES
• Monitor cardiovascular, respiratory, and GI
Teaching topics status to detect complications.
• Promoting maternal-neonatal bonding • Monitor vital signs, fluid intake and output,
and transcutaneous blood oxygen tension to
determine fluid replacement needs.
Tracheoesophageal fistula • Place the neonate in high Fowler’s position
to prevent aspiration of gastric contents.
Tracheoesophageal fistula is a congenital • Keep a laryngoscope and ET tube at bed-
anomaly in which the esophagus and trachea side in case extreme edema causes obstruction.
don’t separate normally. Most commonly, the • Provide frequent shallow suctioning for
A neonate exhibits esophagus ends in a blind pouch, with the tra- very short periods to maintain airway
difficulty feeding and chea communicating by a fistula with the low- patency.
respiratory distress? er esophagus and stomach. • Provide the neonate with a pacifier to meet
That might mean sucking needs.
tracheoesophageal CAUSES • Provide gastrostomy tube feedings postop-
fistula. • Abnormal development of the trachea and eratively to maintain nutrition.
esophagus during the embryonic period • Maintain I.V. fluid therapy to replace fluid
volume.
• Difficulty feeding, such as choking or aspi- Teaching topics
ration; cyanosis during feeding • Promoting maternal-neonatal bonding
• Difficulty passing a nasogastric tube
• Excessive mucus secretions
• History of maternal polyhydramnios (be-
cause fetus can’t swallow amniotic fluid)
920125.qxd 8/7/08 3:12 PM Page 545
hydration. Neonates with high bilirubin levels

shouldn’t just be observed; intervention is
necessary. Stool softeners aren’t a part of
medical management for neonatal jaundice.
integrity
logical adaptation
Pump up on practice
questions
1. A neonate weighing 1,503 g is born at 32
weeks’ gestation. During data collection 12
hours after birth, the nurse notices these
signs and symptoms: hyperactivity, persistent 3. The nurse is collecting data on a 4-hour-
shrill cry, frequent yawning and sneezing, and old neonate. Which finding would be a cause
jitteriness. These symptoms indicate: of concern?
1. sepsis. 1. Anterior fontanel is 3⁄4 (1.9 cm) wide,
2. hepatitis. head is molded, and sutures are overrid-
3. drug dependence. ing.
4. hypoglycemia. 2. Hands and feet are cyanotic, abdomen
Answer: 3. These classic symptoms of drug is rounded, and the neonate hasn’t voided
dependency usually appear within the first 24 or passed meconium.
hours after birth. Sepsis is indicated by tem- 3. Color is dusky, axillary temperature is
perature instability and tachycardia. Hepatitis 97° F (36.1° C), and the neonate is spitting
will manifest itself as jaundice. Hypothermia, up excessive mucus.
muscle twitching, diaphoresis, and respirato- 4. Irregular abdominal respirations and in-
ry distress may be signs of hypoglycemia. termittent tremors in the extremities.
Client needs category: Physiological Answer: 3. Skin color is expected to be pink-
integrity tinged or ruddy, saliva should be scant, and
Client needs subcategory: Physio- the normal axillary temperature ranges from
logical adaptation 97.7° to 98.6° F (36.5° to 37° C). Overriding
Cognitive level: Analysis sutures and molding, when present, may per-
sist for a few days. Acrocyanosis may be pre-
2. Which is a preferred treatment for neona- sent for 2 to 6 hours. The neonate would be
tal jaundice? expected to pass meconium and void within
1. Exchange transfusion 24 hours. Neonatal tremors are common in a
2. Phototherapy full-term neonate; however, they must be eval-
3. Observing and monitoring bilirubin lev- uated to differentiate them from seizures.
els Client needs category: Health promo-
4. Stool softener tion and maintenance
Answer: 2. The preferred treatment for neona- Client needs subcategory: None
tal jaundice is phototherapy. Exchange trans- Cognitive level: Application
fusion is performed when the bilirubin levels
rapidly rise despite the use of phototherapy or
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546 Neonatal care
4. Which neonate is at greatest risk for devel- Client needs category: Health promo-
oping respiratory distress syndrome? tion and maintenance
1. A neonate with a history of intrauterine Client needs subcategory: None
growth retardation Cognitive level: Knowledge
2. A neonate born at less than 35 weeks’
gestation 6. The nurse collects data on a neonate’s res-
3. A neonate whose mother experienced piratory rate at 46 breaths/minute 6 hours af-
prolonged rupture of membranes ter birth. Respirations are shallow, with peri-
4. A neonate born at 38 weeks’ gestation ods of apnea lasting up to 5 seconds. Which
Answer: 2. Respiratory distress syndrome is action should the nurse take next?
predominantly seen in premature neonates; 1. Attach an apnea monitor.
the more premature the neonate, the more se- 2. Continue routine monitoring.
vere the disease. Intrauterine growth retarda- 3. Follow respiratory arrest protocol.
tion and prolonged rupture of membranes are 4. Call the pediatrician immediately to re-
unlikely to be associated with development of port findings.
respiratory distress syndrome. A 38-week Answer: 2. The normal respiratory rate is 30
gestation neonate usually has mature lungs to 60 breaths/minute. Attaching the apnea
and isn’t at risk for respiratory distress syn- monitor, following respiratory arrest protocol,
drome. and notifying the pediatrician of findings
Client needs category: Physiological aren’t necessary because the listed findings
integrity are normal respiratory patterns in neonates.
Client needs subcategory: Reduction of Client needs category: Health promo-
risk potential tion and maintenance
Cognitive level: Knowledge Client needs subcategory: None
5. Which infection can be acquired by the 7. Which statement is true?

neonate during labor and delivery? 1. Binge drinking is less detrimental to
1. Group B streptococci the fetus than low-level chronic drinking.
2. Rubella 2. The mother’s blood alcohol level is
3. Hepatitis greater than that of the fetus.
4. Syphilis 3. The fetus can stay inebriated for many
Answer: 1. Group B streptococci may contami- days.
nate the maternal genital tract during labor 4. Fetal blood alcohol levels drop off
and delivery. Rubella is acquired in utero. He- quickly.
patitis is a postnatal infection. Syphilis is also Answer: 3. The fetal liver isn’t mature enough
acquired in utero. to detoxify the alcohol. Binge drinking is
more detrimental to the fetus than chronic
low-level drinking for this reason as well. Al-
cohol goes directly from mother to fetus at
920125.qxd 8/7/08 3:12 PM Page 547
the same level of concentration. High fetal 1. Immediately after birth, dry the
blood alcohol levels stay that way for a long neonate and place her under a radiant
time. heater for 2 hours.
Client needs category: Physiological 2. Administer oxygen for the first 30 min-
integrity utes after birth.
Client needs subcategory: Reduction of 3. Decrease integumentary stimulation af-
risk potential ter birth.
Cognitive level: Analysis 4. Maintain the environmental tempera-
ture at a constant level.
Answer: 1. Drying the neonate and placing
her in a radiant warmer helps prevent loss of
body heat. Administering oxygen and de-
creasing integumentary circulation would
have no effect in preventing cold stress. Main-
taining environmental temperature wouldn’t
prevent loss of heat via conduction, evapora-
tion, or convection.
integrity
logical adaptation
8. The best way to prevent FAS is for a preg-
nant woman to: 10. The nurse is caring for a drug-dependent
1. only drink on social occasions. neonate. Which intervention should the nurse
2. stop drinking once she becomes preg- perform?
nant. 1. Limit sensory stimulation of the
3. decrease alcohol intake while attempt- neonate.
ing to become pregnant. 2. Cluster activities.
4. abstain from drinking before becoming 3. Wrap the neonate loosely in blankets.
pregnant and during the entire pregnancy. 4. Increase environmental stimuli.
Answer: 4. The best prevention is to abstain Answer: 1. Limiting sensory stimulation al-
from alcohol before and during pregnancy. lows for extensive rest periods. The nurse
Decreasing alcohol intake may not prevent in- may want to modulate sensory input as toler-
trauterine growth retardation. Social drinking ated by the neonate. The neonate needs to be
can have adverse effects on an unborn child. swaddled tightly in a flexed position. Increas-
Because the fetus can be damaged before the ing environmental stimuli may exacerbate ir-
mother realizes that she’s pregnant, stopping ritability and restlessness. Beautiful.
drinking once the pregnancy becomes known Client needs category: Physiological You finished
may not prevent FAS. integrity another chapter.
Way to goo goo!
Client needs category: Health promo- Client needs subcategory: Physio-
tion and maintenance logical adaptation
9. A baby girl delivered at 38-weeks’ gesta-

tion weighs 2,325 grams (5 lb, 2 oz) and is
having difficulty maintaining body tempera-
ture. Which nursing intervention would best
prevent cold stress?
920125.qxd 8/7/08 3:12 PM Page 548

1. The nurse is collecting data on a neonate Client needs category: Physiological
with tracheoesophageal fistula. Which finding integrity
should the nurse expect to encounter? Client needs subcategory: Reduction of
1. Increase in saliva risk potential
2. Gastric tube easily passed Cognitive level: Knowledge
3. Feeding without difficulty
4. Normal chest X-ray 3. Six hours after birth, a neonate is trans-
Answer: 1. The neonate’s inability to swallow ferred to the nursery. The nurse is planning
saliva leads to an increase in saliva. The other interventions to prevent hypothermia. What’s
options aren’t likely findings in tracheoesoph- a common source of radiant heat loss?
ageal fistula. The neonate is unable to pass a 1. Low room humidity
gastric tube. During feedings, the neonate is 2. Cold weight scale
at risk for choking and cyanosis. Pulmonary 3. Cool incubator walls
infiltrates, lobar collapse, and atelectasis fre- 4. Cool room temperature
quently appear on the chest X-ray. Answer: 3. Common sources of radiant heat
Client needs category: Physiological loss include cool incubator walls and win-
integrity dows. Low room humidity promotes evapora-
Client needs subcategory: Physio- tive heat loss. When the skin directly contacts
logical adaptation a cooler object, such as a cold weight scale,
Cognitive level: Knowledge conductive heat loss may occur. A cool room
temperature may lead to convective heat loss.
2. A client is scheduled for amniocentesis. Client needs category: Health promo-
When preparing her for the procedure, the tion and maintenance
Get ready to
nurse should: Client needs subcategory: None
rock these 30
maternal-neonatal 1. ask her to void. Cognitive level: Knowledge
practice questions. 2. instruct her to drink 1 qt (1 L) of fluid.
Pump it up! 3. prepare her for I.V. anesthesia. 4. A client is in her 25th week of pregnancy.
4. place her on her left side. Which procedure is used to detect fetal anom-
Answer: 1. To prepare a client for amniocente- alies?
sis, the nurse should ask the client to empty 1. Amniocentesis
her bladder to reduce the risk of bladder per- 2. Chorionic villi sampling
foration. The nurse may instruct the client to 3. Fetoscopy
drink 1 qt of fluid to fill the bladder before 4. Ultrasound
transabdominal ultrasound (unless ultrasound Answer: 4. Ultrasound is performed between
is done before amniocentesis to locate the pla- 18 and 40 weeks’ gestation to identify normal
centa). I.V. anesthesia isn’t given for amnio- fetal growth and detect fetal anomalies and
centesis. The client should be supine during other problems. Amniocentesis is done dur-
the procedure; afterward, she should be ing the third trimester to determine fetal lung
placed on her left side to avoid supine hypo- maturity. Chorionic villi sampling is per-
tension, promote venous return, and ensure formed at 8 to 12 weeks’ gestation to detect
adequate cardiac output. genetic disease. Fetoscopy is done at about 18
weeks’ gestation to observe the fetus directly
and obtain a skin specimen or blood sample.
920125.qxd 8/7/08 3:12 PM Page 549
Client needs category: Health promo- Turning the client onto her left side relieves
tion and maintenance pressure on the vena cava, restoring normal
Client needs subcategory: None venous return and blood pressure. Deep
Cognitive level: Knowledge breathing wouldn’t relieve this client’s symp-
toms. Listening to fetal heart tones and mea-
suring the client’s blood pressure don’t pro-
vide relevant information.
care environment
Client needs subcategory: Safety and
infection control
5. Which nursing intervention has priority

when feeding a neonate with a cleft lip or
palate?
1. Directing the flow of milk in the center
of the mouth
2. Providing frequent, small feedings
3. Avoiding breast-feeding
4. Infrequent burping 7. A client has meconium-stained amniotic
Answer: 2. Frequent, small feedings help to fluid. The fetal monitoring strip shows fetal
prevent fatigue and frustration in the neonate. bradycardia. Fetal blood sampling indicates a
The flow of milk should be directed to the pH of 7.12. Based on these findings, which
side of the mouth. Breast-feeding may be pos- nursing intervention is called for?
sible. These neonates need frequent burping 1. Administer oxygen as prescribed.
because of the large amount of air swallowed 2. Prepare for cesarean delivery.
while feeding. 3. Reposition the client.
Client needs category: Physiological 4. Start I.V. oxytocin infusion as pre-
integrity scribed.
Client needs subcategory: Physio- Answer: 2. Fetal blood pH of 7.19 or lower sig-
logical adaptation nals severe fetal acidosis; meconium-stained
Cognitive level: Analysis amniotic fluid and bradycardia are additional
signs of fetal distress that warrant cesarean
6. During a physical examination, a client in delivery. Oxygen administration and client
her 32nd week of pregnancy becomes pale, repositioning may improve uteroplacental per-
dizzy, and light-headed while supine. Which fusion but are only temporary measures. Oxy-
intervention takes priority? tocin administration increases contractions,
1. Turning the client onto her left side exacerbating fetal stress.
2. Asking the client to breathe deeply Client needs category: Physiological
3. Listening to fetal heart tones integrity
4. Measuring the client’s blood pressure Client needs subcategory: Reduction of
Answer: 1. As the uterus enlarges, pressure risk potential
on the inferior vena cava increases, compro- Cognitive level: Comprehension
mising venous return and causing blood pres-
sure to drop. This may lead to syncope and
other symptoms when the client is supine.
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550 Maternal-neonatal care
8. Which phase of uterine contractions is de- Client needs category: Safe, effective care
scribed as the letting-down phase? environment
1. Increment Client needs subcategory: Safety and infec-
2. Decrement tion control
3. Acme Cognitive level: Analysis
4. Variability
Answer: 2. Decrement is the letting-down 10. A client is admitted to the hospital in
phase of uterine contractions. Increment preterm labor. To halt her uterine contrac-
refers to the building-up phase, and acme is tions, the nurse expects to administer:
the peak of the contraction. Variability refers 1. magnesium sulfate.
to the normal variation in the heart rate, 2. dinoprostone (Cervidil).
caused by continuous interplay of the 3. ergonovine (Ergotrate).
parasympathetic and sympathetic nervous 4. terbutaline (Brethine).
systems. Answer: 4. Terbutaline, a beta2-receptor ago-
Client needs category: Health promo- nist, is used to inhibit preterm uterine con-
tion and maintenance tractions. Magnesium sulfate is used to treat
Client needs subcategory: None hypertension in pregnancy. Dinoprostone is
Cognitive level: Knowledge used to induce fetal expulsion and promote
cervical dilation and softening. Ergonovine is
used to stop uterine blood flow, for example,
in hemorrhage.
integrity
logical therapies
11. The nurse reviews the history of a post-

partum client. Which factor most strongly in-
9. Which diagnostic procedure will best de- dicates that this client is at risk for experienc-
termine whether a client in labor has sponta- ing afterpains?
neous rupture of amniotic membranes? 1. The client delivered at 39 weeks’ gesta-
1. CBC tion.
2. Fern test 2. The client smokes cigarettes.
3. Urinalysis 3. The client has decided to bottle-feed
4. Vaginal examination her neonate.
Answer: 2. A fern test indicates spontaneous 4. The client is a gravida 6, para 5.
rupture of amniotic membranes. The name of Answer: 4. In a multiparous client, decreased
this test refers to the microscopic fernlike pat- uterine muscle tone leads to alternating relax-
tern produced by sodium chloride crystalliza- ation and contraction during uterine involu-
tion in dried amniotic fluid, which indicates tion; this, in turn, causes afterpains. A gesta-
the presence of ruptured amniotic mem- tion of 39 weeks and a history of cigarette
branes. A CBC might indicate infection (if smoking don’t contribute directly to after-
WBCs are increased), but it won’t indicate pains. A bottle-feeding client may experience
whether the amniotic sac has ruptured. Uri- afterpains from lack of oxytocin release,
nalysis doesn’t test for the presence of amni- which stimulates the uterus to contract and
otic fluid. A vaginal examination may deter- thus enhances involution. The mere decision
mine whether the membranes have ruptured to bottle-feed doesn’t cause afterpains.
but isn’t conclusive.
920125.qxd 8/7/08 3:12 PM Page 551
Client needs category: Health promo- Answer: 1. The nurse should monitor fluid in-
tion and maintenance take and output because prolonged oxytocin
Client needs subcategory: None infusion may cause severe water intoxication,
Cognitive level: Analysis leading to seizure, coma, and death. Exces-
sive thirst results from the work of labor and
12. The nurse is collecting data on a client limited oral fluid intake, not oxytocin. Oxy-
who gave birth yesterday. Where should the tocin has no nephrotoxic or diuretic effects; in
nurse expect to find the top of the client’s fun- fact, it produces an antidiuretic effect.
dus? Client needs category: Physiological
1. One fingerbreadth above the umbilicus integrity
2. One fingerbreadth below the umbilicus Client needs subcategory: Pharmaco-
3. At the level of the umbilicus logical therapies
4. Below the symphysis pubis Cognitive level: Knowledge
Answer: 2. After a client gives birth, the
height of her fundus should decrease about 14. The nurse is reviewing laboratory results
one fingerbreadth (about 1 cm) each day. So for a postpartum client. What happens to the
by the end of the first postpartum day, the level of human chorionic gonadotropin
fundus should be one fingerbreadth below (HCG) during the postpartum period?
the umbilicus. Immediately after birth, it 1. The circulating HCG level remains high
should be at the level of the umbilicus; 10 for 2 to 4 weeks.
days after birth, it should be below the sym- 2. The serum HCG level diminishes over
physis pubis. 6 weeks.
Client needs category: Physiological 3. Circulating HCG disappears within 24
integrity hours.
Client needs subcategory: Physio- 4. The serum HCG level remains high un-
logical adaptation til the client’s next pregnancy.
Cognitive level: Knowledge Answer: 3. Circulating HCG disappears within
8 to 24 hours after delivery in both lactating
and nonlactating clients.
15. A client has been in labor for 6 hours,

and her contractions are occurring every 2
minutes and lasting 80 seconds. She’s di-
aphoretic, restless, and irritable and tells the
nurse that she “can’t take it anymore.” In
which stage or phase of labor is the client?
1. Transitional phase
13. Cervical effacement and dilation aren’t 2. Latent phase
progressing in a client in labor. The physician 3. Second stage
orders I.V. administration of oxytocin (Pito- 4. Third stage
cin). Why should the nurse monitor the Answer: 1. During the transitional phase, cer-
client’s fluid intake and output closely during vical dilation is between 8 and 10 cm and con-
oxytocin administration? tractions occur every 1 to 2 minutes, last 60 to
1. Oxytocin causes water intoxication. 90 seconds, and are strongly intense. Also
2. Oxytocin causes excessive thirst. during this phase, the client may feel over-
3. Oxytocin is toxic to the kidneys. whelmed and unable to continue with labor,
4. Oxytocin has a diuretic effect. become irritable and restless, groan or cry
920125.qxd 8/7/08 3:12 PM Page 552
out, and experience diaphoresis and, possibly, pressure of the enlarged uterus on the vena
nausea and vomiting. In the latent phase of cava. The supine position reduces sodium and
the first stage, contractions are mild to mod- water excretion because the enlarged uterus
erate and irregular. The second stage of labor compresses the vena cava and aorta; this de-
begins with full cervical dilation and ends creases cardiac output, leading to decreased
with the delivery of the neonate. The third renal blood flow, which in turn impairs kidney
stage begins immediately after delivery. function.
Client needs category: Health promo- Client needs category: Physiological
tion and maintenance integrity
Client needs subcategory: None Client needs subcategory: Reduction of
Cognitive level: Knowledge risk potential
16. The nurse is collecting data on a client
who’s resting comfortably 4 hours after deliv-
ery. Which finding is considered normal?
1. A thready pulse
2. An irregular pulse
3. Tachycardia
4. Bradycardia
Answer: 4. During the client’s first postpartum
rest or sleep, which usually occurs 2 to 4
hours after delivery, the heart rate typically
decreases, possibly slowing to 50 beats/
minute (bradycardia). This probably results 18. The nurse is preparing a postpartum
from supine positioning and such normal client for discharge. The nurse should in-
physiologic phenomena as the postpartum struct her to report:
rise in stroke volume and a reduction in vas- 1. scant lochia alba 2 to 3 weeks after de-
cular bed size. An irregular or thready pulse livery.
is never normal. Tachycardia may indicate ex- 2. a temperature of 99.7° F (37.6° C) for
cessive blood loss, especially if accompanied 24 hours or more.
by a thready pulse and other signs, such as 3. breast tenderness that’s relieved by
pallor, an increased respiratory rate, and di- analgesics.
aphoresis. 4. a red, warm, painful area in the breast.
Client needs category: Health promo- Answer: 4. Signs of postpartum complications
tion and maintenance include a red, warm, painful area in either
Client needs subcategory: None breast; heavy vaginal bleeding or passage of
Cognitive level: Knowledge clots or tissue fragments; and a temperature
of 100.2° F (37.9° C) or higher for 24 hours or
17. The nurse should advise the pregnant longer. Scant lochia alba 2 to 3 weeks after de-
client to use which body position to enhance livery, a temperature of 99.7° F for 24 hours
cardiac output and renal function? or longer, and breast tenderness that’s re-
1. Right lateral lieved by analgesics are normal postpartum
2. Left lateral findings.
3. Supine Client needs category: Physiological
4. Semi-Fowler’s integrity
Answer: 2. The left lateral position shifts the Client needs subcategory: Reduction of
enlarged uterus away from the vena cava and risk potential
aorta, enhancing cardiac output, kidney per- Cognitive level: Knowledge
fusion, and kidney function. The right lateral
and semi-Fowler’s positions don’t alleviate
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19. Just after delivery, rectal measurement Answer: 1. Rubin identified three phases dur-
reveals the neonate’s temperature to be 96.1° ing which a woman adapts to the maternal
F (35.6° C). What should the nurse do? role. During the letting-go (independent)
1. Rewarm the neonate gradually. phase, the client begins to accept the neonate
2. Rewarm the neonate rapidly. as an individual who’s separate from herself.
3. Observe the neonate at least hourly. During the taking-in (dependent) phase,
4. Notify the physician when the neonate’s which usually lasts 1 to 2 days after delivery,
temperature is normal. the client usually is exhausted and dependent
Answer: 1. A neonate with a rectal tempera- on others, focusing on her own needs. During
ture of 96.1° F is experiencing cold stress. To the taking-hold (dependent-independent)
correct cold stress while avoiding hyperther- phase, which may last from 3 days to 8 weeks,
mia and its complications, the nurse should the client vacillates between seeking nurtur-
rewarm the neonate gradually, observing ing and acceptance for herself and seeking to
closely and checking vital signs every 15 to 30 resume an independent role.
minutes. Rapid rewarming may cause hyper- Client needs category: Psychosocial
thermia. Hourly observation isn’t frequent integrity
enough because cold stress increases oxy- Client needs subcategory: None
gen, calorie, and fat expenditure, putting the Cognitive level: Knowledge
neonate at risk for anabolic metabolism and,
possibly, metabolic acidosis. A neonate with 21. A neonate is born at 32 weeks’ gestation
cold stress requires intervention; the nurse to a mother who has admitted to using hero-
should notify the physician of the problem as in. Which neonatal evaluation takes priority?
soon as it’s identified. 1. Auscultation of breath sounds for signs
Client needs category: Safe, effective of pulmonary problems
care environment 2. Careful observation of respiratory ef-
Client needs subcategory: Safety and fort because of the neonate’s prematurity
infection control 3. Evaluation for signs of drug withdrawal
Cognitive level: Comprehension 4. Observation for jaundice
Answer: 3. After delivery, a neonate born to a
substance abuser may exhibit signs of drug
withdrawal, such as irritability, poor feeding,
and continual crying. Auscultating breath
sounds, observing respiratory effort, and ob-
serving for jaundice are appropriate assess-
ments for any neonate, not just the neonate of
a substance abuser.
care environment
Client needs subcategory: Safety and
20. When does the postpartum client begin infection control
to accept the neonate as a separate individual? Cognitive level: Comprehension
1. Letting-go phase
2. Taking-hold phase
3. Dependent phase
4. Taking-in phase
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22. The nurse is assisting with developing a finding suggests normal progression into the
teaching plan for a client who’s about to be sleep cycle. During this period, the neonate
discharged after delivering a hydatidiform shows minimal response to external stimuli.
molar pregnancy. Which expected outcome Hypoglycemia is characterized by irregular
takes highest priority? respirations, apnea, and tremors. Periods of
1. Client states that she may attempt neonatal reactivity are characterized by alert-
another pregnancy after 3 months of ness and attentiveness.
follow-up care. Client needs category: Health promo-
2. Client schedules her first follow-up Pa- tion and maintenance
panicolaou (Pap) test and gynecologic ex- Client needs subcategory: None
amination for 6 months after discharge. Cognitive level: Knowledge
3. Client states that she won’t attempt an-
other pregnancy until her HCG level rises.
4. Client uses a reliable contraceptive
method until her follow-up care is com-
plete in 1 year and her HCG level is nega-
tive.
Answer: 4. After a hydatidiform molar preg-
nancy, the client should receive follow-up
care, including regular HCG testing, for 1
year because of the risk of developing chori-
onic carcinoma. After removal of a hydatidi-
form mole, the HCG level gradually falls to a
negative reading unless chorionic carcinoma 24. The nurse has just finished teaching a
is developing, in which case the HCG level postpartum client about breast-feeding her
rises. A Pap test isn’t an effective indicator of neonate. Which statement is the best indica-
a hydatidiform molar pregnancy. tor that the client knows how to avoid breast
A follow-up examination would be sched- engorgement?
uled within weeks of the client’s discharge. 1. “I’ll apply warm, moist compresses to
The client must not become pregnant during my breasts.”
follow-up care because pregnancy causes the 2. “I’ll breast-feed every 11⁄2 to 3 hours.”
HCG level to rise, making it indistinguishable 3. “I’ll use an electric breast pump.”
from this early sign of chorionic carcinoma. 4. “I’ll wear a bra 24 hours a day.”
Client needs category: Physiological Answer: 2. Because frequent breast-feeding
integrity keeps the breasts relatively empty and in-
Client needs subcategory: Reduction of creases circulation, it helps remove fluid that
risk potential may lead to engorgement. Applying warm
Cognitive level: Knowledge compresses to the breasts increases circula-
tion and decreases inflammation and edema;
23. A client expresses concern that her 3- it’s used to treat, not prevent, breast engorge-
hour-old neonate is difficult to awaken. The ment. An electric breast pump usually isn’t
nurse explains that this behavior indicates: used if the neonate can breast-feed frequently.
1. a physiologic abnormality. Although a bra supports the breasts, it can’t
2. probable hypoglycemia. prevent engorgement.
3. normal progression into the sleep Client needs category: Health promo-
cycle. tion and maintenance
4. normal progression into a period of Client needs subcategory: None
neonatal reactivity. Cognitive level: Application
Answer: 3. Three hours after birth, the
neonate is typically difficult to awaken. This
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25. A client expresses concern that her 2- Client needs category: Physiological
day-old breast-feeding neonate isn’t getting integrity
enough to eat. The nurse should teach the Client needs subcategory: Physio-
client that breast-feeding is effective if: logical adaptation
1. the neonate voids once or twice every Cognitive level: Comprehension
24 hours.
2. the neonate breast-feeds four times in 27. When collecting data on a neonate 1 hour
24 hours. after delivery, the nurse measures an axillary
3. the neonate loses 10% to 15% of birth temperature of 95.8° F (35.4° C), an apical
weight within the first 2 days after birth. pulse of 110 beats/minute, and a respiratory
4. the neonate latches onto the areola and rate of 64 breaths/minute. Which nursing di-
swallows audibly. agnosis takes highest priority?
Answer: 4. Breast-feeding is effective if the in- 1. Hypothermia related to heat loss
fant latches onto the mother’s areola properly 2. Impaired parenting related to the addi-
and if swallowing is audible. A breast-feeding tion of a new family member
neonate should void at least six to eight times 3. Risk for deficient fluid volume related
per day and should breast-feed every 2 to 3 to insensible fluid losses
hours. Over the first few days after birth, an 4. Risk for infection related to transition to
acceptable weight loss is 5% to 10% of the the extrauterine environment
birth weight. Answer: 1. The neonate’s temperature should
Client needs category: Health promo- range from 96° to 97.7° F (35.6° to 36.5° C),
tion and maintenance and the respiratory rate should be less than
Client needs subcategory: None 60 breaths/minute. (The respiratory rate in-
Cognitive level: Comprehension creases as hypothermia develops.) Because
this neonate’s temperature is below normal
26. A client who used heroin during her and because cold stress can lead to respirato-
pregnancy delivers a neonate. When collect- ry distress and hypoglycemia, hypothermia
ing data on the neonate, the nurse expects to related to heat loss takes highest priority. The
find: other options may be appropriate but don’t
1. lethargy 2 days after birth. take precedence over hypothermia, a poten-
2. irritability and poor sucking. tially life-threatening condition.
3. a flattened nose, small eyes, and thin Client needs category: Physiological
lips. integrity
4. congenital defects such as limb anom- Client needs subcategory: Physio-
alies. logical adaptation
Answer: 2. Neonates of heroin-addicted moth- Cognitive level: Knowledge
ers are physically dependent on the drug and
experience withdrawal when the drug is no
longer supplied. Signs of heroin withdrawal
include irritability, poor sucking, and restless-
ness. Lethargy isn’t associated with neonatal
heroin addiction. A flattened nose, small eyes,
and thin lips are seen in infants with FAS.
Heroin use during pregnancy hasn’t been
linked to specific congenital anomalies.
920125.qxd 8/7/08 3:12 PM Page 556
28. A neonate must receive an eye prepara- 30. The nurse collects data on a 1-day-old
tion to prevent ophthalmia neonatorum. How neonate. Which finding indicates that the
should the nurse administer this preparation? neonate’s oxygen needs aren’t being ade-
1. By avoiding holding the eyelid open quately met?
during medication instillation 1. Respiratory rate of 54 breaths/minute
2. By letting the medication drip onto the 2. Abdominal breathing
surface of the eye 3. Nasal flaring
3. By positioning the neonate so that his 4. Acrocyanosis
head remains still Answer: 3. Signs of respiratory distress in-
4. By holding the neonate in the football clude nasal flaring, a respiratory rate above 60
position breaths/minute, labored respirations, grunt-
Answer: 3. After positioning the neonate se- ing, generalized cyanosis, and retractions. Ab-
curely so that the head remains still, the dominal breathing is a normal finding in
nurse should hold the eyelid open and instill neonates. Acrocyanosis (a bluish tinge to the
the medication into the conjunctival sac. Hold- hands and feet) is normal on the first day af-
ing the neonate in the football position doesn’t ter birth.
secure the head. Client needs category: Health promo-
Client needs category: Safe, effective tion and maintenance
care environment Client needs subcategory: None
Client needs subcategory: Safety and Cognitive level: Knowledge
infection control
29. The nurse places a neonate with hyper-

bilirubinemia under a phototherapy lamp.
The goal of phototherapy is: You covered a
1. to prevent hypothermia. lot of material
2. to promote respiratory stability. already. Ready to
3. to decrease the serum conjugated move on to the
bilirubin level. care of the child?
4. to decrease the serum unconjugated
bilirubin level.
Answer: 4. The goal of phototherapy is to re-
duce the serum unconjugated bilirubin level
because a high level may lead to bilirubin en-
cephalopathy (kernicterus). Phototherapy
doesn’t prevent hypothermia or promote res-
piratory stability. It has no effect on conjugat-
ed bilirubin, a water-soluble substance excret-
ed easily in urine and stools.
integrity
logical adaptation
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Part V Care of the child

26 Growth & development 559

920126.qxd 8/7/08 3:12 PM Page 558
920126.qxd 8/7/08 3:12 PM Page 559
26 Growth &
development
• When prone, the neonate can lift his head
In this chapter,
you’ll review:
Brush up on key slightly off the bed.
✐ key concepts of concepts Beat, blood, breath

• Normal pulse rate ranges from 110 to
growth and develop-
ment Growth and development are fundamental 160 beats/minute.
concepts in pediatric nursing. Each develop- • Normal blood pressure is 65/40 to
✐ major developmental
mental stage presents unique patient care 78/52 mm Hg.
milestones
challenges in such areas as nutrition, lan- • Normal respiratory rate is 32 to
✐ important aspects of guage, safety education, medication adminis- 60 breaths/minute.
care. tration, and pain management. • Respirations are irregular and from the
You can review the major points of this abdomen.
chapter by consulting the Cheat sheet on page • The neonate is an obligate nose breather.
560.
Hot and cold
• Temperature regulation is poor.
An infant’s developmental
1 TO 4 MONTHS
milestones At age 3 months, the most primitive reflexes
begin to disappear, except for the protective
A child is considered an infant from the time and postural reflexes (blink, parachute,
he’s born until age 1. During this time, devel- cough, swallow, and gag reflexes), which re-
opment is marked by five major periods: main for life. The infant reaches out voluntari-
• the neonatal period (up to 28 days) ly but is uncoordinated.
Ha, ha. • 1 to 4 months
That’s a • 5 to 6 months Heads up
good one. • 7 to 9 months During this period, the posterior fontanel
At 4 months, • 10 to 12 months. closes. In addition, the infant:
I laugh in • begins to hold up his head
response to the NEONATAL PERIOD • begins to put his hand to his mouth
environment. The neonatal period covers the time from • develops binocular vision
birth to 28 days old. • cries to express needs
• smiles (the instinctual smile appears at 2
Reflexes reign months and the social smile at 3 months)
During this period, you’ll note these findings: • laughs in response to the environment (at
• Head and chest circumferences are approxi- 4 months).
mately equal.
• Behavior is under reflex control. 5 TO 6 MONTHS
• Extremities are flexed. At 5 to 6 months, birth weight doubles. In ad-
• Vision is poor (the neonate fixates momen- dition, the infant:
tarily on light). • rolls over from his stomach to his back
• Hearing and touch are well developed. • cries when his parent leaves
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560 Growth & development
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Growth & development refresher
INFANT (BIRTH TO AGE 1) TODDLER (AGES 1 TO 3)
Neonatal period • Normal pulse rate is 70 to 110 beats/minute.
• All behavior is under reflex control; extremities • Normal blood pressure is 90/55 to
are flexed. 105/70 mm Hg.
• Normal pulse rate ranges from 110 to • Normal respiratory rate is 20 to 30 breaths/
160 beats/minute. minute.
• Normal blood pressure is 65/40 to 78/52 mm Hg. • Separation anxiety arises.
• Normal respiratory rate is 32 to 60 breaths/ • The child is toilet-trained; day dryness is
minute. Respirations are irregular and from the achieved between ages 18 months and 3 years
abdomen; the neonate is an obligate nose and night dryness between ages 2 and 5.
breather. PRESCHOOL CHILD (AGES 3 TO 5)
• Temperature regulation is poor. • Normal pulse rate ranges from 90 to 100
1 to 4 months beats/minute.
• The posterior fontanel closes. • Normal blood pressure ranges from 85/60 to
• The infant begins to hold up his head. 90/70 mm Hg.
• The infant cries to express needs. • Normal respiratory rate is 20 to 25 breaths/
5 to 6 months minute.
• The infant rolls over from his stomach to his • The child may express fear of animal noises,
back. new experiences, and the dark.
• The infant cries when his parent leaves. SCHOOL-AGE CHILD (AGES 5 TO 12)
7 to 9 months • Normal pulse rate ranges from 75 to
• Fear of strangers appears to peak during the 115 beats/minute.
8th month. • Normal blood pressure ranges from 106/69 to
• The infant sits alone with assistance. 117/76 mm Hg.
• The infant creeps on hands and knees with bel- • Normal respiratory rate ranges from 20 to
ly off floor. 25 breaths/minute.
• The infant verbalizes all vowels and most con- • Accidents are a major cause of death and dis-
sonants but speaks no intelligible words. ability during this period.
10 to 12 months • The child plays with peers, develops a first
• The infant holds onto furniture while walking true friendship, and develops a sense of be-
(cruising) at age 10 months, walks with support at longing, cooperation, and compromise.
age 11 months, and stands alone and takes first • The child learns to read and spell.
steps at age 12 months. ADOLESCENT (AGES 12 TO 18)
• The infant says “mama” and “dada” and re- • The adolescent experiences puberty-related
sponds to own name at age 10 months; can say changes in body structure and psychosocial ad-
about five words, but understands many more. justment.
• Vital signs approach adult values
.• Peers influence behavior and values.
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Infants and nutrition

Here’s a rundown of primary nutrition guidelines • Provide rice cereal as the first solid food, fol-
for a child’s first year of life: lowed by any other cereal except wheat. Goo goo. Ga ga.
• Begin with formula or breast milk; give no • Yellow and green vegetables may be given at 8 (Translation: I
more than 30 oz (887 ml) of formula each day. to 9 months. verbalize all vowels and
• Iron supplements may be necessary after 4 • Provide noncitrus fruits at 61⁄2 to 8 months, fol- most consonants but
months. lowed by citrus fruits late in the 1st year. don’t articulate
• No solid foods should be given for the first 4 to • Give junior foods or soft table foods after 9 intelligible words.)
6 months. months.
• attempts to crawl when prone • can say about five words, but understands
• voluntarily grasps and releases objects. many more
• is ready to be weaned from the bottle and
7 TO 9 MONTHS breast (see Infants and nutrition).
At 7 to 9 months, the infant can self-feed
crackers and a bottle. When physically and
emotionally ready, the infant can be weaned. Toddler developmental
The infant understands the word “no.” Efforts
to enforce discipline are appropriate at this milestones
time. Fear of strangers appears to peak dur-
ing the eighth month. Attempts to evaluate The toddler period includes ages 1 to 3. This
breath and heart sounds should be made is a slow growth period with a weight gain of
while the mother holds the infant. 4 to 9 lb (2 to 4 kg) over 2 years.
I settle down with
Sit, creep, and prespeak Beat, blood, breath age. Between ages 1 and
In addition, the infant: • Normal pulse rate is 70 to 3, my normal rate
• sits alone with assistance 110 beats/minute. ranges anywhere from
• creeps on hands and knees with belly off • Normal blood pressure is 90/55 to 70 to 110 beats/minute.
floor 105/70 mm Hg. Between ages 3 and 5,
• verbalizes all vowels and most consonants • Normal respiratory rate is 20 to it ranges from 90 to
but doesn’t articulate intelligible words. 30 breaths/minute. 100 beats/minute.
10 TO 12 MONTHS Me, myself, and I

At 10 to 12 months, birth weight triples, and The toddler exhibits the following behavioral
birth length increases about 50%. The anterior and psychological characteristics:
fontanel normally closes between ages 9 and • egocentricity
18 months. In addition, the infant: • frequent temper tantrums, especially when
• may walk while holding onto furniture confronted with the conflict of achieving au-
(cruising) at age 10 months tonomy and relinquishing dependence on oth-
• walks with support at age 11 months, and ers
stands alone and takes first steps at age 12 • follows the parent wherever he or she goes
months • experiences separation anxiety
• says “mama” and “dada” and responds to • lacks the concept of sharing
own name at age 10 months
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• prefers solitary play and has little interac- dependent play accompanied by sharing or
tion with others; this progresses to parallel talking
play (toddler plays alongside but not with an- • develops a body image
other child). • may count but not understand what num-
bers mean
Look, Ma • may recognize some letters of the alphabet
The toddler: • dresses without help but may be unable to
• plants his feet wide apart and walks by age tie shoes
15 months • speaks in grammatically correct, complete
• climbs stairs at 21 months, runs and jumps sentences
by age 2, and rides a tricycle by age 3 • gets along without parents for short peri-
• uses at least 400 words as well as two- to ods.
three-word phrases and comprehends many
more (by age 2)
• uses about 11,000 words (by age 3) School-age developmental
• undergoes toilet training; day dryness
should be achieved between ages 18 months milestones
and 3 years and night dryness between ages 2
and 5. The school-age years are defined as ages 5
to 12.
Preschool developmental Beat, blood, breath

• Normal pulse rate ranges from 75 to
milestones 115 beats/minute.
• Normal blood pressure ranges from 106/69
The preschool period encompasses ages 3 to to 117/76 mm Hg.
5. Slow growth continues during this period. • Normal respiratory rate ranges from 20 to
Birth length doubles by age 4. 25 breaths/minute.
Beat, blood, breath Watch out

• Normal pulse rate ranges from 90 to • Accidents are a major cause of death and
100 beats/minute. disability during this period.
• Normal blood pressure ranges from 85/60 • Height increases about 2⬙ (5 cm) a year, and
to 90/70 mm Hg. weight doubles between ages 6 and 12.
• Normal respiratory rate is 20 to 25 breaths/ • The first primary tooth is displaced by a
minute. permanent tooth at age 6, and permanent
You have to be teeth erupt by age 12, except for final molars.
careful because Fear factor • Vision matures by age 6.
accidents are a The child may begin to express fear. Antici-
major cause of pate the child’s fear of mutilation of his body, Best friends forever
school-age animal noises, new experiences, and the dark. The child:
disability. Provide adhesive bandages for cuts because • engages in cooperative play
the child may fear losing blood. Using dolls • plays with peers, develops a first true friend-
for role-playing may reduce the preschool ship, and develops a sense of belonging, coop-
child’s anxiety. eration, and compromise
• develops concepts of time and place, cause
Playtime progress and effect, reversibility, conversation, and
The child: numbers
• exhibits parallel play, associative play, group • learns to read and spell
play in activities with few or no rules, and in- • engages in fantasy play and daydreaming.
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Adolescent developmental
milestones
Ages 12 to 18 encompass the adolescent peri-
od. Adolescence is a period of rapid growth
characterized by puberty-related changes in
body structure and psychosocial adjustment.
What’s happening to me?

During adolescence, these changes are noted:
• Vital signs approach adult levels.
• Peers influence behavior and values.
• Nutritional needs increase significantly. Pump up on practice
Ch..ch..changes
Other milestones in adolescent development
questions
include: 1. A parent brings a 19-month-old toddler to
• increased ability to engage in abstract think- the clinic for a well-child checkup. When pal-
ing and to analyze, synthesize, and use logic pating the toddler’s fontanels, the nurse
• increased attraction to the opposite sex (or would expect to find:
same sex) 1. closed anterior fontanel and open
• breast development in females (the first posterior fontanel.
sign of puberty; begins at about age 9 with 2. open anterior fontanel and closed
the bud stage) posterior fontanel.
• the onset of menses in females (between 3. closed anterior and posterior fontanels.
ages 8 and 16; possibly irregular initially) 4. open anterior and posterior fontanels.
• testicular enlargement in males (the first Answer: 3. By age 18 months, the anterior and
sign of puberty). posterior fontanels should be closed. The
diamond-shaped anterior fontanel normally
closes between ages 9 and 18 months. The tri-
As a child moves
angular posterior fontanel normally closes be-
into adolescence,
nutritional needs tween ages 2 and 3 months.
increase significantly. Client needs category: Health promo-
Remember, most tion and maintenance
eating disorders Client needs subcategory: None
emerge during Cognitive level: Knowledge
adolescence.
2. The nurse is instructing a mother about
the nutritional needs of her full-term, breast-
feeding infant, age 2 months. Which response
shows that the mother understands the in-
fant’s dietary needs?
1. “We won’t start any new foods now.”
2. “We’ll start the baby on skim milk.”
3. “We’ll introduce cereal into the diet
now.”
4. “We should add new fruits to the diet
one at a time.”
Answer: 1. Because breast milk provides all
the nutrients that a full-term infant needs for
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the first 6 months, the parents shouldn’t intro- 4. A preschooler is admitted to the hospital
duce new foods into the infant’s diet at this the day before scheduled surgery. This is the
point. They shouldn’t provide skim milk be- child’s first hospitalization. Which action will
cause it doesn’t have sufficient fat for infant best help reduce the child’s anxiety about the
growth. The parents also shouldn’t provide upcoming surgery?
solid foods, such as cereal and fruit, before 1. Begin preoperative teaching imme-
age 6 months because the infant’s GI tract diately.
doesn’t tolerate them well. 2. Describe preoperative and postopera-
Client needs category: Health promo- tive procedures in detail.
tion and maintenance 3. Give the child dolls and medical equip-
Client needs subcategory: None ment to play out the experience.
Cognitive level: Application 4. Explain that the child will be put to
sleep during surgery and won’t feel any-
thing.
Answer: 3. By playing with medical equipment
and acting out the experience with dolls, the
preschooler can begin to reduce anxiety. The
nurse should schedule teaching shortly be-
fore surgery because preschoolers have little
concept of time and because a delay between
teaching and surgery may increase anxiety by
giving the child time to worry. Detailed expla-
nations are inappropriate for this developmen-
3. What’s the first sign of sexual maturation tal stage and may promote anxiety. The nurse
that the nurse may observe during care of an should avoid such phrases as “put to sleep”
adolescent girl? because they might have a negative meaning
1. Onset of menstruation to the child.
2. Breast development Client needs category: Health promo-
3. Appearance of pubic hair tion and maintenance
4. Appearance of axillary hair Client needs subcategory: None
Answer: 2. The first sign of sexual maturation Cognitive level: Comprehension
in females is the development of breast buds
(elevation of the nipples and areolae). Then
sexual development progresses, causing the
appearance of pubic hair and axillary hair and
the onset of menstruation.
6. The nurse is teaching a mother who plans

to discontinue breast-feeding after 3 months.
The nurse should advise her to include which
food in her infant’s diet?
1. Iron-rich formula and baby food
2. Whole milk and baby food
3. Skim milk and baby food
4. Iron-rich formula only
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Answer: 4. The American Academy of Pedi- 8. Which observation signals the onset of pu-
atrics recommends that infants at age 3 berty in male adolescents?
months should receive iron-rich formula and 1. Appearance of pubic hair
that they shouldn’t receive solid food—even 2. Appearance of axillary hair
baby food—until they’re between age 4 and 6 3. Testicular enlargement
months. The Academy doesn’t recommend 4. Nocturnal emissions
whole milk until age 12 months or skim milk Answer: 3. Testicular enlargement signifies
until after age 2 years. the onset of puberty in the male adolescent.
Client needs category: Health promo- Then sexual development progresses, caus-
tion and maintenance ing the appearance of pubic hair and axillary
Client needs subcategory: None hair and the onset of nocturnal emissions.
Cognitive level: Knowledge Client needs category: Health promo-
7. A mother tells the nurse that her 22-

month-old child says “no” to everything.
When scolded, the toddler becomes angry
and starts crying loudly, but then immediately
wants to be held. What is the best interpreta- 9. Which teaching topic should take priority
tion of this behavior? when talking with the parents of a school-age
1. The toddler isn’t effectively coping with child?
stress. 1. Accident prevention
2. The toddler’s need for affection isn’t be- 2. Keeping a night light on to allay fears
ing met. 3. Normalcy of fears about body integrity
3. This is normal behavior for a 2-year-old 4. Encouraging the child to dress without
child. help
4. This behavior suggests the need for Answer: 1. Accidents are the major cause of
counseling. death and disability during the school-age
Answer: 3. Because toddlers are confronted years. Therefore accident prevention should
with the conflict of achieving autonomy, yet take priority when teaching parents of school-
relinquishing the much-enjoyed dependence age children. Preschool children are afraid of
on the affection of others, their negativism is the dark, have fears concerning body integri-
a necessary assertion of self-control. There- ty, and should be encouraged to dress without
fore, this behavior is a normal part of the help (with the exception of tying shoes), but
child’s growth and development. Nothing none of these should take priority over acci-
about the behavior indicates that the child is dent prevention.
under stress, isn’t receiving sufficient affec- Client needs category: Health promo-
tion, or requires counseling. tion and maintenance
Client needs category: Health promo- Client needs subcategory: None
tion and maintenance Cognitive level: Knowledge
920126.qxd 8/7/08 3:12 PM Page 566
10. A mother brings her infant to the pedia- Answer: 1. Further teaching is indicated if the
trician’s office for his 2-week-old checkup. mother states that she doesn’t understand
The nurse is evaluating whether the mother why her 2-week-old infant doesn’t look at her.
has understood patient teaching points dis- The infant at this period of development has
cussed during a previous visit. Which state- poor vision, is only able to fixate on light mo-
ment indicates that further teaching is need- mentarily, and can’t distinguish objects. The
ed? 2-week-old infant should have his nasal pas-
1. “I don’t understand why my baby sages kept clear because he’s an obligate
doesn’t look at me.” nose breather; he should have limited expo-
2. “I know I should keep my baby’s nasal sure at bath time; and he should have his
passages clear.” head covered when he’s wet or cold.
3. “I should limit my baby’s exposure dur- Client needs category: Health promo-
ing bath time.” tion and maintenance
4. “I should cover my baby’s head when Client needs subcategory: None
he’s wet or cold.” Cognitive level: Analysis
Reviewing this
chapter was good
preparation for the
pediatric chapters
ahead. Good luck, and
remember to focus on
patient care.
920127.qxd 8/7/08 3:13 PM Page 567
27 Cardiovascular
system
In this chapter,
you’ll review:
Brush up on key Keep abreast of
✐ basics of the pediatric concepts diagnostic tests
cardiovascular sys-
tem The cardiovascular system consists of the Some important tests used to diagnose car-
heart and central and peripheral blood ves- diovascular disorders include cardiac cathe-
sels. A child’s cardiovascular system closely terization and echocardiography.
nose pediatric cardio-
resembles that of an adult. The system’s main
vascular disorders functions are to pump and circulate blood Cardiac cath
✐ common pediatric throughout the body. With cardiac catheterization, a catheter is
cardiovascular disor- At any time, you can review the major points inserted into an artery or vein (in the arm or
ders. of this chapter by consulting the Cheat sheet leg) and advanced to the heart. This proce-
on page 568. dure is used to:
• evaluate ventricular function
Shunt stunt • evaluate anatomic abnormalities
A child may have congenital heart defects • measure heart pressures
that impair the movement of blood between • measure the blood’s oxygen saturation
the heart’s chambers. For example, some level.
congenital heart defects cause a left-to-right
shunt, in which increased pressure on the Nursing actions
left side of the heart forces blood back to the Before the procedure
right side. This can lead to tissue hypertrophy • Describe the sensations the child will expe-
A child’s on the right side and increased blood flow to rience.
cardiovascular the lungs. • Determine the child’s height and weight.
system closely • Check the child’s color, pulse rate, blood
resembles that Open late pressure, and temperature of extremities.
of an adult. The blood vessels surrounding the heart also • Locate and mark the child’s peripheral
may suffer congenital defects. Soon after pulses.
birth, the ductus arteriosus (located between • Check the child’s activity level.
the aorta and the pulmonary artery) normally • Prepare the child according to the child’s
closes. If it doesn’t, the infant may experience developmental level; for example, doll play
patent ductus arteriosus, in which blood and hospital play may help ease anxiety in a
shunts from the aorta to the pulmonary preschool-age child.
artery. If a large patent ductus arteriosus re- • Make a security object, such as a teddy bear
mains uncorrected, pressure within the pul- or toy, available.
monary arteries may increase dramatically After the procedure
and cause blood to flow from the right side of • Keep the affected extremity immobile after
the heart to the left, eventually leading to catheterization to prevent hemorrhage.
heart failure. • Keep the catheter site clean and dry and
monitor for hematoma formation.
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Pediatric cardiovascular refresher
INCREASED PULMONARY BLOOD FLOW DE- • Tachypnea
FECTS AND OBSTRUCTIONS TO BLOOD FLOW Key test results
FROM THE VENTRICLES • Arterial blood gas analysis shows diminished
Key signs and symptoms arterial oxygen saturation.
• Congested cough • Complete blood count shows polycythemia.
• Diaphoresis Key treatments
• Fatigue • For transposition of the great vessels or arter-
• Machinelike heart murmur (in patent ductus ar- ies: corrective surgery to redirect blood flow
teriosus) • For tetralogy of Fallot: complete repair or pallia-
• Mild cyanosis (if the condition leads to right- tive treatment
sided heart failure) • For hypoplastic left-heart syndrome: surgery to
• Respiratory distress restructure the heart or heart transplantation
• Tachycardia • For truncus arteriosus: surgery to recreate the
• Tachypnea pulmonary trunk and repair the ventricular septal
Key test result defect
• Chest X-ray results, echocardiography, and Key interventions
cardiac catheterization confirm type of heart de- • Monitor cardiovascular and respiratory status.
fect. • Monitor vital signs, pulse oximetry, and intake
Key treatments and output.
• Surgical repair • Administer prophylactic antibiotics.
• Digoxin (Lanoxin) RHEUMATIC FEVER
• Diuretic such as furosemide (Lasix) Key signs and symptoms
Key interventions • Carditis
• Monitor vital signs, pulse oximetry, and intake • Chorea
and output. • Erythema marginatum (temporary, disk-shaped,
• Monitor cardiovascular and respiratory status. nonpruritic, reddened macules that fade in the
• Take apical pulse for 1 minute before giving center, leaving raised margins)
digoxin. (Bradycardia is considered to be a pulse • Polyarthritis
below 100 beats/minute in infants.) • Subcutaneous nodules
• Monitor fluid status. Key test results
DECREASED PULMONARY BLOOD FLOW AND • Erythrocyte sedimentation rate is increased.
MIXED BLOOD FLOW DEFECTS • Electrocardiogram shows prolonged PR
Key signs and symptoms interval.
• Clubbing Key treatments
• Crouching position assumed frequently • Bed rest until the sedimentation rate normalizes
• Cyanosis • Penicillin to prevent additional damage from fu-
• History of inadequate feeding ture attacks
• Irritability Key intervention
• Tachycardia • Monitor vital signs and intake and output.
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• Compare postcatheterization data collection Increased pulmonary blood

findings to precatheterization baseline data,
comparing all four extremities. flow defects and obstructions
• Ensure adequate intake (I.V. and oral) to
compensate for blood loss during the proce-
to blood flow from the
dure, nothing-by-mouth status, and diuretic ventricles
action of some dyes used.
With increased pulmonary blood flow defects,
Heart mapping blood is usually shunted from the left (oxy-
Echocardiography is a noninvasive test used genated) side to right (unoxygenated) side of
to evaluate the size, shape, and motion of car- the heart. Specific types include:
diac structures by recording the echoes of ul- • atrial septal defect—a defect stemming
trasonic waves beamed through the chest from a patent foramen ovale or the failure of a
onto those structures. septum to develop completely between the
atria
Nursing action • patent ductus arteriosus—a defect result-
• Explain to the child and parents that the ing from the failure of the ductus to close,
child may have to lie on his left side, inhale causing shunting of blood to the pulmonary
and exhale slowly, or hold his breath at inter- artery Mild cyanosis
can occur in a
vals during the test. • ventricular septal defect—a defect occur-
patient with an
ring when the ventricular septum fails to com- increased
plete its formation between the ventricles, re- pulmonary blood
sulting in a left-to-right shunt.
Polish up on patient With obstructions to blood flow from the
ventricles, blood leaving the ventricles runs
flow defect.
care into an area of anatomic narrowing, which ob-

structs blood flow. Types include:
Potential cardiovascular disorders in pediatric • aortic stenosis—a narrowing or fusion of
patients include congential heart defects and the aortic valves, interfering with left ventric-
rheumatic fever. Congenital heart defects are ular outflow
further categorized by how they affect blood • coarctation of the aorta—a narrowing of
flow. Types of congenital heart defects in- the aortic arch, usually distal to the ductus ar-
clude: teriosus beyond the left subclavian artery
• increased pulmonary blood flow • pulmonar y arter y stenosis—a narrowing
• obstructions to blood flow from the ventri- or fusing of valve leaflets at the entrance of
cles the pulmonary artery, interfering with right
• decreased pulmonary blood flow ventricular outflow
• mixed blood flow. (See From high to low.)
From high to low

When cardiac anomalies involve communication—movement DEFECTS THAT DON’T INVOLVE CHAMBERS
of blood through a common opening—between chambers, With defects that don’t involve the cardiac chambers, blood can
blood flows from areas of high pressure to areas of low pres- also flow from high-pressure to low-pressure areas. In patent
sure. For example, a left-to-right shunt may result when in- ductus arteriosus, for instance, the ductus arteriosus (located
creased pressure on the left side of the heart causes increased between the aorta and pulmonary artery) remains open after
blood flow to the right. birth. This causes blood to shunt from the aorta to the pulmo-
nary artery.
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CAUSES ture and enlargement of the left ventricle and

• Defects between structures that inhibit aorta. Cardiac catheterization helps deter-
blood flow to the system or alter pulmonary mine the extent of pulmonary vascular dis-
resistance ease and shows an oxygen content higher in
• Defects in the septa that lead to left-to-right the pulmonary artery than in the right ventri-
shunt cle.
• With pulmonar y arter y stenosis, the
DATA COLLECTION FINDINGS chest X-ray shows right ventricular hypertro-
• Blood pressure lower in legs and higher in phy. Cardiac catheterization provides evi-
arms (with coarctation of the aorta) dence of the degree of shunting.
• Congested cough • With ventricular septal defect, the chest
• Diaphoresis X-ray may be normal for small defects or
• Fatigue show cardiomegaly with a large left atrium
• Frequent respiratory infections and ventricle. With a large defect, the chest
• Full, bounding pulses (with patent ductus X-ray may show prominent pulmonary vascu-
Chest X-ray,
arteriosus) lature. Cardiac catheterization helps deter-
echocardiography,
and cardiac • Machinelike heart murmur (in patent duc- mine the size and exact location of ventricular
catheterization tus arteriosus) septal defect and the degree of shunting.
distinguish the • Mild cyanosis (if the condition leads to
various heart right-sided heart failure) NURSING DIAGNOSES
defects. • Poor growth and development due to in- • Anxiety
creased energy expenditure for breathing • Decreased cardiac output
• Respiratory distress • Impaired gas exchange
• Tachycardia
• Tachypnea TREATMENT
• Aortic stenosis: surgery (valvulotomy or
DIAGNOSTIC FINDINGS commissurotomy)
Chest X-ray results, echocardiography, and • Atrial septal defect: surgery to patch the
cardiac catheterization confirm type of heart hole; mild defects may close spontaneously or
defect. be corrected by cardiac catheterization using
• With aortic stenosis, the chest X-ray a septal occluder
shows left ventricular hypertrophy and promi- • Coarctation of the aorta: balloon angio-
nent pulmonary vasculature. Cardiac plasty, anastomosis, or surgical resection to
catheterization helps determine the degree of relieve the constriction of the aorta
shunting and extent of pulmonary vascular • Patent ductus arteriosus: ligation of the
disease. patent ductus arteriosus in closed-heart oper-
• With atrial septal defect, the chest X-ray ation
shows an enlarged right atrium and ventricle • Pulmonar y arter y stenosis: open-heart
and prominent pulmonary vasculature. Car- surgery to separate the pulmonary valve
diac catheterization shows right atrial blood leaflets or balloon angioplasty to dilate the
that’s more oxygenated than superior vena valve
cava blood. It also helps determine the degree • Ventricular septal defect: pulmonary
of shunting and extent of pulmonary vascular artery banding to prevent heart failure and
disease. permanent correction with a patch later when
• With coarctation of the aorta, the chest heart is larger (spontaneous closure of the
X-ray shows left ventricular hypertrophy, wide ventricular septal defect may occur in some
ascending and descending aorta, and promi- children by age 3)
nent collateral circulation. Cardiac catheteri-
zation shows affected collateral circulation Drug therapy
and pressures in the right and left ventricles. • Cardiac glycoside: digoxin (Lanoxin)
• With patent ductus arteriosus, the chest • Diuretic: furosemide (Lasix)
X-ray shows prominent pulmonary vascula-
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• Indomethacin (Indocin) to achieve pharma- defect, hypertrophy of the right ventricle, and
To prevent
cologic closure (in patent ductus arteriosus) an overriding aorta. toxicity, remember
• Prophylactic antibiotics to prevent endo- Mixed blood flow defects include: to take an apical
carditis • transposition of the great vessels or ar- pulse for 1 minute
teries—a defect in which the aorta arises before giving digoxin.
INTERVENTIONS AND RATIONALES from the right ventricle and the pulmonary You’re checking for
• Monitor vital signs, pulse oximetry, and in- artery arises from the left ventricle bradycardia, which
take and output to evaluate renal function and • hypoplastic left-heart syndrome—a de- in infants is a
detect changes. fect consisting of aortic valve atresia, mitral rate below
• Monitor cardiovascular and respiratory sta- atresia or stenosis, diminutive or absent left 100 beats/minute.
tus to detect early signs of decompensation. ventricle, and severe hypoplasia of the as-
• Take apical pulse for 1 minute before giving cending aorta and aortic arch
digoxin and hold the drug if the heart rate is • truncus arteriosus —a defect in which
below 100 beats/minute (bradycardia in in- there’s incomplete division of the common
fants is a heart rate below 100 beats/minute) great vessel.
to prevent toxicity.
• Monitor fluid status, enforcing fluid restric- CAUSES
tions as appropriate to prevent fluid overload. • Any condition that increases pulmonary
• Weigh the child daily to determine fluid over- vascular resistance
load or deficit. • Structural defects
• Organize physical care and anticipate the
child’s needs to reduce the child’s oxygen de- DATA COLLECTION FINDINGS
mands. • Clubbing
• Give the child high-calorie, easy-to-chew, • Crouching position assumed frequently
and easy-to-digest foods to maintain adequate • Cyanosis
nutrition and decrease oxygen demands. • History of inadequate feeding
• Maintain normal body temperature to pre- • Increasing cyanosis as the foramen ovale or
vent cold stress. ductus arteriosus closes (in transposition of
• Raise the head of the bed or place the infant the great vessels), leading to loss of con-
Memory
in an infant car seat to ease breathing. sciousness, also known as a tet spell (in tetral-
jogger
ogy of Fallot) When a
Teaching topics • Increasing dyspnea, cyanosis, and tachy- child has a
• Preparing the child and parents for the pnea during the first few days after birth; cyanotic heart de-
sights and sounds of the intensive care unit without treatment, heart failure after closure fect, check for the
of the ductus (in hypoplastic left-heart syn-
four Cs:
drome) Cyanosis, especially
Decreased pulmonary blood • Irritability increasing with
• Tachycardia crying
flow and mixed blood flow • Tachypnea Crabbiness or
defects irritability
DIAGNOSTIC FINDINGS Clubbing of digits
Decreased pulmonary blood flow and mixed • Arterial blood gas analysis shows dimin-
blood flow defects result in either unoxy- ished arterial oxygen saturation. Crouching, or
genated blood or a mixture of oxygenated and • Cardiac catheterization results confirm the squatting, which in-
unoxygenated blood being shunted through diagnosis through visualization of defects and
creases systemic
venous return,
the cardiovascular system. This shunting can measurement of oxygen saturation level. shunts blood from
lead to left-sided heart failure, decreased oxy- • Complete blood count (CBC) shows poly- the extremities to
gen supply to the body, and the development cythemia. (Hypoxia stimulates the body to in- the head and trunk,
of collateral circulation. crease red blood cell [RBC] production.) and decreases cya-
An example of a decreased blood flow de- nosis.
fect is tetralogy of Fallot, which consists of NURSING DIAGNOSES
pulmonary artery stenosis, ventricular septal • Impaired gas exchange
920127.qxd 8/7/08 3:13 PM Page 572
• Anxiety • Use a preemie nipple to decrease the energy

Infants with
decreased pulmonary • Decreased cardiac output needed for sucking.
blood flow defects • Provide adequate hydration to prevent se-
have less energy for TREATMENT quelae of polycythemia.
sucking; use a preemie For transposition of the great vessels or arter- • Administer prophylactic antibiotics to pre-
nipple. ies, several therapies are possible, including: vent endocarditis.
• corrective surgery to redirect blood flow by • Administer morphine during tet spells to de-
switching the position of the major blood ves- crease associated infundibular spasm.
sels; performed around age 1 • Provide thorough skin care to prevent skin
• palliative surgery to provide communication breakdown.
between the chambers. • Prepare the child and parents for cardiac
For tetralogy of Fallot, the doctor can use: catheterization to decrease anxiety.
• complete repair or palliative treatment
during the 1st year to increase blood flow to Teaching topics
the lungs by bypassing pulmonic stenosis • Preparing the child and parents for the
(Blalock-Taussig anastomosis of the right pul- sights and sounds of the intensive care unit
monary artery to the right subclavian artery) • Explaining the difference between palliative
• oxygen therapy and corrective procedures
• repair of ventricular septal defect and steno-
sis (may be done in stages).
For hypoplastic left-heart syndrome, the Rheumatic fever
doctor may perform:
• heart transplant Rheumatic fever is an inflammatory disease of
• Norwood procedure, a two-stage procedure childhood. It first occurs 1 to 6 weeks after a
that involves restructuring the heart followed group A beta-hemolytic streptococcal infec-
by a procedure to provide blood flow to the tion and may recur. Rheumatic fever results in
lungs, and the bidirectional Glenn shunt or antigen-antibody complexes that ultimately
modified Fontan procedure. destroy heart tissue.
For truncus arteriosis, several options in- Rheumatic heart disease refers to the car-
clude: diac effects of rheumatic fever and includes
• medical management of heart failure pancarditis (inflammation of the heart mus-
• surgical recreation of the pulmonary trunk cle, heart lining, and sac around the heart)
• corrective surgery to repair ventricular sep- during the early acute phase and chronic
In rheumatic fever, tal defect. heart valve disease later.
antibodies
manufactured to Drug therapy CAUSES
combat streptococci • Morphine during tet spell • Production of antibodies against group A
react and produce • Prophylactic propranolol (Inderal) beta-hemolytic Streptococcus
lesions at specific • Prostaglandin E to keep the ductus arterio- • Untreated group A beta-hemolytic Strepto-
tissue sites, especially sus patent coccus infection (1% to 5% of children infected
in the heart and
with Streptococcus develop rheumatic fever.)
joints.
• Monitor cardiovascular and respiratory sta- DATA COLLECTION FINDINGS
tus to detect early signs of compromise. The Jones criteria for determining major
• Monitor vital signs and pulse oximetry to rheumatic fever include:
detect hypoxia • carditis
• Monitor intake and output to evaluate renal • chorea
status. • erythema marginatum (temporary,
• Provide oxygen when necessary to compen- disk-shaped, nonpruritic, reddened macules
sate for impaired oxygen exchange. that fade in the center, leaving raised mar-
• Anticipate needs and prevent distress to de- gins)
crease oxygen demands on the child. • polyarthritis
920127.qxd 8/7/08 3:13 PM Page 573
• subcutaneous nodules. • Provide appropriate passive stimulation to

The Jones criteria for determining minor maintain growth and development.
rheumatic fever include: • Provide emotional support for long-term
• arthralgia convalescence to help relieve anxiety.
• evidence of a Streptococcus infection • Use sterile technique in dressing changes
• fever and standard precautions to prevent reinfec-
• history of rheumatic fever. tion.

• Antistreptolysin-O titer is elevated. • Understanding the need to inform health
• Erythrocyte sedimentation rate is care providers of existing medical conditions
increased. • Recognizing the signs and symptoms of as-
• Electrocardiogram shows prolonged PR pirin toxicity (tinnitus, bruising, bleeding
interval. gums)
NURSING DIAGNOSES
quirements
TREATMENT
• Bed rest during fever and until the sedimen-
tation rate returns to normal
Drug therapy
• Aspirin for arthritis pain
• Penicillin to prevent additional damage
from future attacks (taken until age 21 or for 5
years after the attack, whichever is longer)
Pump up on practice
• Steroids for severe carditis questions
INTERVENTIONS AND RATIONALES 1. A pediatric client returns to his room after
• Monitor vital signs and intake and output to a cardiac catheterization. Which nursing in-
detect fluid volume overload or deficit. tervention is most appropriate?
• Institute safety measures for chorea; main- 1. Maintain the client on bed rest with no
tain a calm environment, reduce stimulation, further activity restrictions.
avoid the use of forks or glass, and assist in 2. Maintain the client on bed rest with the
walking to prevent injury. affected extremity immobilized.
3. Allow the client to get out of bed to go
Effective to the bathroom, if necessary.
treatment of 4. Allow the client to sit in a chair with the
rheumatic fever affected extremity immobilized.
reduces the Answer: 2. The pediatric client should be
chance that I’ll maintained on bed rest with the affected ex-
suffer tremity immobilized after cardiac catheteriza-
permanent tion to prevent hemorrhage. Allowing the
damage. Thanks! client to move the affected extremity while on
bed rest, allowing the client bathroom privi-
leges, or allowing the client to sit in a chair
with the affected extremity immobilized
places the client at risk for hemorrhage.
920127.qxd 8/7/08 3:13 PM Page 574
Client needs category: Physiological 3. An infant with a ventricular septal defect is

integrity receiving digoxin (Lanoxin). Which interven-
Client needs subcategory: Reduction of tion by the nurse is most appropriate before
risk potential digoxin administration?
Cognitive level: Knowledge 1. Take the infant’s blood pressure.
2. Check the infant’s respiratory rate for 1
minute.
3. Check the infant’s radial pulse for 1
minute.
4. Check the infant’s apical pulse for 1
minute.
Answer: 4. Before administering digoxin, the
nurse should check the infant’s apical pulse
for 1 minute. Checking the blood pressure
and respiratory rate isn’t necessary before
digoxin administration because the medica-
2. A pediatric client is scheduled for echocar- tion doesn’t affect these parameters. Check-
diography. The nurse is providing teaching to ing the radial pulse may be inaccurate.
the client’s mother. Which statement about Client needs category: Physiological
echocardiography indicates the need for fur- integrity
ther teaching? Client needs subcategory: Pharmaco-
1. “I’m glad my child won’t have an I.V. logical therapies
catheter inserted for this procedure.” Cognitive level: Knowledge
2. “I’m glad my child won’t need to have
dye injected into him before the proce- 4. The nurse checks an infant’s apical pulse
dure.” before digoxin administration and finds that
3. “How am I ever going to explain to my the pulse rate is 90 beats/minute. Which ac-
son that he can’t have anything to eat be- tion is most appropriate for the nurse?
fore the test?” 1. Withhold the digoxin, and notify the
4. “I know my child may need to lie on his physician.
left side and breathe in and out slowly dur- 2. Administer the digoxin, and notify the
ing the procedure.” physician.
Answer: 3. Echocardiography is a noninvasive 3. Administer the digoxin, and document
procedure used to evaluate the size, shape, the infant’s pulse rate.
and motion of various cardiac structures. 4. Withhold the digoxin, and document
Therefore, it isn’t necessary for the client to the infant’s pulse rate.
have nothing by mouth, have an I.V. catheter Answer: 1. The nurse should withhold the
inserted, or dye injected, as would be the case digoxin and notify the physician because an
with a cardiac catheterization. The child may apical pulse below 100 beats/minute in an in-
need to lie on his left side and inhale and ex- fant is considered bradycardic. The nurse
hale slowly during the procedure. should also document her findings and inter-
Client needs category: Physiological ventions in the medical record. Administering
integrity the drug to the infant already bradycardic
Client needs subcategory: Reduction of could further decrease his heart rate and
risk potential compromise his status. Withholding the drug
Cognitive level: Analysis and not notifying the physician could compro-
mise the existing treatment plan.
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Client needs category: Physiological Answer: 3. The pediatric client with a de-
integrity creased pulmonary blood flow heart defect
Client needs subcategory: Pharmaco- has cyanosis along with crabbiness (irritabili-
logical therapies ty), clubbing of the digits, and crouching or
Cognitive level: Application squatting. The client with a decreased pul-
monary blood flow defect doesn’t typically
5. A pediatric client has been diagnosed with have hypertension, lethargy, confusion, or
rheumatic fever. Which statement by the clonus.
mother indicates an effective understanding Client needs category: Physiological
of rheumatic fever? integrity
1. “I should avoid giving my child aspirin
for the arthritic pain.”
2. “It’s very upsetting that my child must
take penicillin until he’s 21 years old.”
3. “I need to wear a gown, gloves, and
mask to stay in my child’s room.”
4. “I don’t know how I’ll be able to keep
my child away from his sister when he
gets home.”
Answer: 2. Rheumatic fever is an acquired
autoimmune-complex disorder that occurs 1
to 3 weeks after an infection of group A beta-
hemolytic streptococci, in many cases as a
result of strep throat that hasn’t been treated
with antibiotics. To prevent additional heart
damage from future attacks, the child must Client needs subcategory: Physio-
take penicillin or another antibiotic until the logical adaptation
age of 21 or for 5 years after the attack, which- Cognitive level: Comprehension
ever is longer. Rheumatic fever isn’t conta-
gious, so isolation precautions aren’t neces- 7. The nurse is caring for an infant with
sary. tetralogy of Fallot. Which drug should the
Client needs category: Physiological nurse anticipate administering during a tet
integrity spell?
Client needs subcategory: Reduction of 1. Propranolol (Inderal)
risk potential 2. Morphine
Cognitive level: Analysis 3. Meperidine (Demerol)
4. Furosemide (Lasix)
6. The nurse is caring for a pediatric client Answer: 2. The nurse should anticipate admin-
with a decreased pulmonary blood flow heart istering morphine during a tet spell to de-
defect. Which sign would the nurse expect to crease the associated infundibular spasm.
observe? Propranolol may be administered as a preven-
1. Cyanosis, hypertension, clubbing, and tive measure in an infant with tetralogy of Fal-
lethargy lot but isn’t administered during a tet spell.
2. Cyanosis, hypotension, crouching, and Furosemide and meperidine aren’t appropri-
lethargy ate agents for an infant experiencing a tet
3. Cyanosis, crabbiness, clubbing, and spell.
crouching Client needs category: Physiological
4. Cyanosis, confusion, clonus, and integrity
crouching Client needs subcategory: Pharmaco-
logical therapies
Cognitive level: Kowledge
920127.qxd 8/7/08 3:13 PM Page 576
8. An infant is diagnosed with patent ductus 10. An infant client with a decreased pul-
arteriosus. Which drug may be administered monary blood flow or mixed blood flow heart
in hopes of achieving pharmacologic closure defect has blood drawn for a CBC, revealing
of the defect? an elevated RBC count. Which condition do
1. Digoxin (Lanoxin) these findings indicate?
2. Prednisone 1. Anemia
3. Furosemide (Lasix) 2. Dehydration
4. Indomethacin (Indocin) 3. Jaundice
Answer: 4. Indomethacin is administered to an 4. Hypoxia compensation
infant with patent ductus arteriosus in hopes Answer: 4. A decreased pulmonary blood flow
of closing the defect. Digoxin and furosemide or mixed blood flow heart defect alters blood
may be used to treat the symptoms associated flow through the heart and lungs, which pro-
with patent ductus arteriosus but they don’t duces hypoxia. To compensate for this, the
achieve closure. Prednisone isn’t used to treat body increases the oxygen-carrying capacity
the condition. by increasing RBC production, which causes
Client needs category: Physiological the hemoglobin (Hb) level and hematocrit
integrity (HCT) to increase. The Hb level and HCT typ-
Client needs subcategory: Pharmaco- ically are decreased in anemia. Altered elec-
logical therapies trolyte levels and other laboratory values pro-
Cognitive level: Comprehension vide better evidence of dehydration. An ele-
vated Hb level and HCT aren’t associated with
9. An infant, age 2 months, has a tentative di- jaundice.
agnosis of congenital heart defect. The nurse Client needs category: Physiological
notes that the infant has a pulse rate of integrity
168 beats/minute and respiratory rate of Client needs subcategory: Physio-
72 breaths/minute. In which position should logical adaptation
the nurse place the infant? Cognitive level: Analysis
1. Upright in an infant seat
2. Lying on the back
3. Lying on the abdomen
You gotta
4. Sitting in high Fowler’s position lotta heart, little
Answer: 1. Because these signs suggest devel- fella. I’ll be thinking
opment of respiratory distress, the nurse of you when I take
should position the infant with the head ele- the NCLEX.
vated at a 45-degree angle to promote maxi-
mum chest expansion. This can be accom-
plished by placing the infant in an infant seat.
Placing an infant flat on the back or abdomen
or in high Fowler’s position could increase
respiratory distress by preventing maximum
chest expansion.
integrity
logical adaptation
920128.qxd 8/7/08 3:13 PM Page 577
28 Respiratory
system
• Air then enters the lungs in response to the
In this chapter,
you’ll review:
Brush up on key pressure gradient between the atmosphere
and the lungs.
✐ parts of the respirato- concepts • The lungs adhere to the chest wall and di-
aphragm because of the vacuum created by
ry system and their
functions The primary function of the respiratory sys- negative pleural pressure.
tem is to distribute air to the alveoli in the • As the thorax expands, the lungs also ex-
✐ differences between
lungs, where gas exchange takes place. Gas pand, causing a decrease in pressure in the
the pediatric respira-
exchange includes: lungs.
tory system and the • the addition of oxygen to pulmonary capil- • The accessory muscles of inspiration,
adult system lary blood which include the scalene and sternocleido-
✐ tests used to diag- • the removal of carbon dioxide from pul- mastoid muscles, raise the clavicles, upper
nose respiratory dis- monary capillary blood. ribs, and sternum.
orders At any time, you can review the major points • To reach the capillary lumen, oxygen diffus-
✐ common respiratory of this chapter by consulting the Cheat sheet es from the alveoli across the alveolocapillary
disorders. on pages 578 and 579. membrane into the blood.
• Normal expiration is passive; the inspirato-
Upper and lower ry muscles cease to contract, and the elastic
The parts of the respiratory system include recoil of the lungs causes the lungs to con-
the upper airway and the lower airway. tract.
The upper airway includes: • These actions increase the pressure in the
• nasopharynx lungs above atmospheric pressure, moving
• oropharynx air from the lungs to the atmosphere.
• larynx.
The lower airway includes: Air system under construction
• trachea A child’s respirator y tract differs anatomi-
• bronchi cally from an adult’s in ways that predispose
• bronchioles the child to many respiratory problems:
• alveoli. • Lungs aren’t fully developed at birth.
• Alveoli continue to grow and increase in
Take a deep breath size through age 8.
Breathing delivers inspired gas to the lower • Until age 5, a child’s respiratory tract has a
respiratory tract and alveoli. Contraction and narrower lumen than an adult’s; the narrow
relaxation of the respiratory muscles move air airway makes the young child prone to air-
into and out of the lungs. Here are some im- way obstruction and respiratory distress from
portant aspects of the breathing process: inflammation, mucus secretion, or a foreign
• Ventilation begins with the contraction of body.
the inspiratory muscles: The diaphragm (the • Elastic connective tissue becomes more
major muscle of respiration) descends while abundant with age in the peripheral part of
the external intercostal muscles move the rib the lung.
cage upward and outward. • A child’s respiratory rate decreases as body
size increases.
920128.qxd 8/7/08 3:13 PM Page 578
et
heat she
C
Pediatric respiratory refresher
ASTHMA BRONCHOPULMONARY DYSPLASIA
• Diaphoresis • Crackles, rhonchi, wheezes
• Dyspnea • Dyspnea
• Prolonged expiration with an expiratory • Sternal retractions
wheeze; in severe distress, inspiratory wheeze Key test result
• Unequal or decreased breath sounds • Chest X-ray reveals pulmonary changes (bron-
• Use of accessory muscles chiolar metaplasia and interstitial fibrosis).
• Oxygen saturation via pulse oximetry may show • Chest physiotherapy
decreased oxygen saturation. • Continued ventilatory support and oxygen
• Arterial blood gas measurement may show in- • Bronchodilators such as albuterol (Proventil)
creased partial pressure of arterial carbon diox-
Key interventions
ide from respiratory acidosis.
• Monitor respiratory and cardiovascular status.
Key treatments • Monitor vital signs, pulse oximetry, and intake
• Bronchodilator: albuterol (Proventil) and output.
• Chromone derivative: cromolyn (Intal)
Key interventions CROUP
• Monitor respiratory and cardiovascular status. Key signs and symptoms
• Monitor vital signs. • A barking, brassy cough or hoarseness
During an acute attack • Inspiratory stridor with varying degrees of res-
• Allow the child to sit upright to ease breathing; piratory distress
provide moist oxygen, if necessary. Key test results
• Monitor for alterations in vital signs (especially • Laryngoscopy may reveal inflammation and ob-
cardiac stimulation and hypotension). struction in epiglottis and laryngeal areas.
Want to • Neck X-ray shows areas of upper airway nar-
get pumped BRONCHIOLITIS
rowing and edema in subglottic folds.
for the NCLEX? Key signs and symptoms
Review this Key treatments
• Sternal retractions
Cheat sheet. • Cool humidification during sleep with a cool
• Tachypnea
mist tent or room humidifier
Key test result • Inhaled racemic epinephrine and cortico-
• Bronchial mucus culture shows respiratory steroids such as methylprednisolone sodium suc-
syncytial virus. cinate
Key treatments • Tracheostomy, oxygen administration
• Humidified oxygen Key interventions
• I.V. fluids • Monitor vital signs and pulse oximetry.
Key interventions • Administer oxygen therapy and maintain the
• Monitor vital signs and pulse oximetry. child in a cool mist tent, if needed.
• Monitor respiratory and cardiovascular status. • Allow the parent to hold the child.
• Administer humidified oxygen therapy.
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Pediatric respiratory refresher (continued)

CYSTIC FIBROSIS Key test result
Key signs and symptoms • Lateral neck X-ray shows enlarged epiglottis.
• History of a chronic, productive cough and recurrent respirato- Key treatments
ry infections, often due to Pseudomonas infections • Emergency endotracheal intubation or a tracheotomy
• Parents’ report of a salty taste on the child’s skin • Oxygen therapy or cool mist tent
Key test result • 10-day course of parenteral antibiotics
• Sweat test using pilocarpine iontophoresis is positive. Key interventions
Key treatment • Monitor vital signs and pulse oximetry.
• Chest physiotherapy • Monitor respiratory and cardiovascular status.
• Oral pancreatic enzyme replacement • Defer inspecting the throat until the arrival of emergency per-
Key interventions sonnel and supplies.
• Monitor respiratory and cardiovascular status. SUDDEN INFANT DEATH SYNDROME (SIDS)
• Administer pancreatic enzymes with meals and snacks. Key sign and symptom
• Encourage breathing exercises and perform chest physiother- • Death takes place during sleep without noise or struggle
apy two to four times a day.
Key test result
EPIGLOTTITIS • Autopsy is the only way to diagnose SIDS.
Key signs and symptoms Key treatment
• Difficult and painful swallowing • Emotional and other support for the parents
• Increased drooling Key interventions
• Restlessness • Let parents touch, hold, and rock the infant.
• Stridor • Reinforce the fact that the death wasn’t the parents’ fault.
• Monitor the puncture site for bleeding or

Keep abreast of hematoma formation.
diagnostic tests Great expectorations

A sputum study is a laboratory test that pro-
Here are some important tests used to diag- vides a microscopic evaluation of sputum,
nose respiratory disorders, along with com- evaluating it for culture and sensitivity, Gram
mon nursing interventions associated with stain, and acid-fast bacillus.
each test.
Nursing actions
Check the gas • Obtain a specimen first thing in the morn-
Arterial blood gas (ABG) analysis is used ing by suctioning or expectoration
to assess the arterial blood for tissue oxy- • Before sending the specimen to the labora-
genation, ventilation, and acid-base status. tory, make sure the specimen contains spu-
tum, not saliva.
Nursing actions
• Explain the procedure to the parents and Oxygen observation
child. Pulse oximetr y is a painless alternative to
• After the sample is obtained, apply firm ABG analysis for measuring oxygen satura-
pressure to the arterial site for 5 to 10 min- tion only. This test may be less effective in
utes. jaundiced children or those with dark skin.
• Keep the sample on ice and transport it im-
mediately to the laboratory.
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Nursing actions sis, epiglottitis, and sudden infant death syn-

• Place the oximeter on a site with adequate drome.
circulation such as the finger, toe, or nose. For information about special respiratory
• Periodically rotate sites to prevent skin treatments for pediatric patients, see Respira-
breakdown. tory assistance for children.
• Before performing oximetry, ensure that
pulse readings from the site used correlate
with the child’s heart rate. Asthma
Lung function Asthma is a reversible, diffuse, obstructive
Pulmonar y function tests are used to mea- pulmonary disease that produces these ef-
sure lung volume, flow rates, and compliance. fects:
Pulmonary function test results may not be • inflammation of the mucous membranes
accurate if the young child has trouble follow- • smooth muscle bronchospasm
ing directions. • increased mucus secretion leading to air-
way obstruction and air trapping.
Nursing actions
• Explain the procedure to the child and his CAUSE
parents. • Hyperresponsiveness of the lower airway
• Instruct the child and his parents that he (may be idiopathic or intrinsic, or caused by a
should have only a light meal before the test. hyperresponsive reaction to an allergen, exer-
• If appropriate, tell the parents that the child cise, or environmental change)
shouldn’t be around second-hand smoke for 4
to 6 hours before the tests. DATA COLLECTION FINDINGS
• Tell the parents to withhold bronchodilators • Alteration in chest contour from chronic air
and intermittent positive-pressure breathing trapping
therapy. • Altered cerebral function
• Just before the test, tell the child to void and • Chronic cough
loosen tight clothing. • Diaphoresis during prolonged episodes of
respiratory distress
Chest check • Dyspnea
Chest X-rays show conditions such as atelec- • Exercise intolerance
Gasp! Asthma
typically causes tasis, pleural effusion, infiltrates, pneumotho- • Fatigue and apprehension
prolonged expiration rax, lesions, mediastinal shifts, and pulmon- • Prolonged expiration with an expiratory
with an expiratory ary edema. wheeze; in severe distress, may hear an inspi-
wheeze. During severe ratory wheeze
distress, you may also Nursing actions • Unequal or decreased breath sounds
hear an inspiratory • Ensure adequate protection by covering the • Use of accessory muscles
wheeze. child’s gonads and thyroid gland with a lead
apron. DIAGNOSTIC FINDINGS
• Oxygen saturation via pulse oximetry may
show decreased oxygen saturation.
• ABG measurement may show increased
Polish up on patient partial pressure of arterial carbon dioxide
from respiratory acidosis.
care • Pulmonary function tests show a reduced
peak expiratory flow rate.
Major respiratory disorders in pediatric pa- • Skin test identifies the source of the allergy.
tients include asthma, bronchiolitis, bron- • Sputum analysis rules out respiratory infec-
chopulmonary dysplasia, croup, cystic fibro- tion.
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Respiratory assistance for children

The oxygen tent, the cool mist tent, the COOL MIST TENT (CROUP TENT) • Administer saline nose drops or nasal
nasal cannula, and chest physiotherapy • Explain that the cool mist thins mucus, spray to moisten passages.
are specialized treatments used in pedi- facilitating expectoration. • Change tubing every 8 hours to prevent
atric respiratory disorders. Here are the • Provide the same care as with an oxy- infection or necrosis.
nursing actions associated with each gen tent.
CHEST PHYSIOTHERAPY
treatment. • Expect the child to be fearful if the mist
• Perform at least 30 minutes before
obscures vision.
OXYGEN TENT meals.
• Encourage the use of transitional ob-
• Keep the plastic sides down and tucked • Use a cupped hand over a covered rib
jects in the tent, except for stuffed toys,
in; because oxygen is heavier than air, cage for 2 to 5 minutes on the five major
which may become damp and promote
oxygen loss is greater at the bottom of positions (upper anterior lobes, upper
bacterial growth.
the tent. posterior lobes, lower posterior lobes,
• Keep the child dry by changing bed
• Keep the plastic away from the child’s and right and left sides) for a maximum of
linens and pajamas frequently.
face. 30 minutes; for infants, preformed rubber
• Maintain a steady body temperature.
• Prevent the use of toys that produce percussors are available.
• Teach the parents about cool mist va-
sparks or friction. • Avoid these measures during acute
porizers for home use; tell them to clean
• Frequently assess oxygen concentra- bronchoconstriction (such as with asth-
the vaporizers frequently to prevent
tion. ma) or airway edema (such as with
germs from being sprayed into the air.
• To return the child to a tent, put the tent croup) to prevent mucus plugs from loos-
sides down, turn on the oxygen, wait until NASAL CANNULA ening and causing airway obstruction.
the oxygen is at the prescribed concen- • Remove nasal secretions from the end • Administer aerosol-nebulized medica-
tration, and then place the child in the of tubing frequently. tions immediately before percussion and
tent. postural drainage.
NURSING DIAGNOSES INTERVENTIONS AND RATIONALES

• Anxiety • Monitor respiratory and cardiovascular sta-
• Impaired gas exchange tus. Tachycardia, tachypnea, and quiet breath
• Ineffective airway clearance sounds signal worsening respiratory status.
• Monitor vital signs to detect changes and pre-
TREATMENT vent complications.
• Chest physiotherapy (once edema has • Evaluate the nature of the child’s cough
abated) (hacking, unproductive progressing to pro-
• Hyposensitization through the use of aller- ductive), especially at night in the absence of
gy shots, if appropriate infection. Early detection and treatment lessens
• Parenteral fluids to thin mucus secretions. respiratory distress.
• Oxygen therapy, as tolerated • Modify the environment to avoid an allergic
reaction; remove the offending allergen. Aller-
Drug therapy gens can trigger an asthma attack.
• Bronchodilator: albuterol (Proventil) • Rinse the child’s mouth after he inhales
• Chromone derivative: cromolyn (Intal) to medication to promote comfort and prevent ir-
prevent the release of mast cell products after ritation to the oral mucosa.
an antigen-antibody union has taken place • For exercise-induced asthma, give prophy-
• Inhaled corticosteroids to decrease edema lactic treatments of cromolyn or beta-adrener-
of the mucous membranes (for chronic asth- gic blockers 10 to 15 minutes before the child
ma, daily doses to control chronic inflamma- exercises. Premedication may prevent an asth-
tion) ma attack. (See Living with asthma, page
582.)
920128.qxd 8/7/08 3:13 PM Page 582
• Forbid smoking in the child’s environment. • Possible air trapping and atelectasis
Living with Second-hand smoke can trigger an asthma at- • Sternal retractions
tack. • Tachypnea
asthma • Thick mucus
Encourage the parents During an acute attack • Wheezing
of a child with asthma • Allow the child to sit upright to ease breath-
to help the child lead ing; provide moist oxygen, if necessary. This DIAGNOSTIC FINDING
as normal a life as pos- position promotes chest expansion; moist oxygen • Bronchial mucus culture may show respira-
sible. Stress the impor- promotes mobilization of secretions. tory syncytial virus.
tance of not restricting • Monitor for alterations in vital signs (espe-
activities. Encourage cially cardiac stimulation and hypotension) to NURSING DIAGNOSES
participation in exer- detect signs of impending respiratory arrest and • Impaired gas exchange
cise and sports. Ex- cardiac decompensation. • Ineffective airway clearance
plain that aerobic ac- • Monitor urine for glucose if the child is re- • Ineffective breathing pattern
tivities, such as swim- ceiving corticosteroids to detect early signs of
ming, running, and hyperglycemia. TREATMENT
brisk walking actually • Administer inhaled medications via a • Cool mist tent
increase the efficiency metered-dose inhaler and monitor peak flow • Humidified oxygen
of the body’s use of rates. Peak flow rates indicate the degree of • I.V. fluids
oxygen. Prophylactic lung impairment.
use of medication typi- • Maintain a calm environment; provide emo- Drug therapy
cally allows participa- tional support and reassurance to decrease • Bronchodilator: albuterol (Proventil)
tion in almost any ac- anxiety and decrease oxygen demands. • Respiratory syncytial virus immune globu-
tivity, even those that • Monitor effectiveness of drug therapy. Fail- lin, administered I.V. if indicated
typically precipitate an ure to respond to drugs during an acute attack • Antiviral: ribavarin (Virazole)
attack. can result in status asthmaticus.
Teaching topics • Monitor vital signs and pulse oximetry to
• Breathing exercises to increase ventilatory determine oxygenation needs and to detect dete-
capacity rioration or improvement in the child’s condi-
• Properly using inhalers tion.
• Avoiding allergens • Monitor respiratory and cardiovascular sta-
• Identifying triggers tus. Tachycardia may result from hypoxia or ef-
During an acute • Maintaining follow-up care fects of bronchodilator use.
asthma attack, allow • Use gloves, gowns, and aseptic hand wash-
the child to sit upright ing as secretion precautions to prevent spread
to ease breathing.
Bronchiolitis of infection.
• Administer chest physiotherapy after air-
Bronchiolitis is a lower respiratory infection way edema has abated. Chest physiotherapy
that’s spread by contact with respiratory se- helps loosen mucus that may be blocking small
cretions. It typically affects children younger airways.
than age 2 years during the winter and spring • Administer humidified oxygen therapy to
months. Mortality from bronchiolitis in this liquefy secretions and reduce bronchial edema.
age-group is 1% to 6%. • Maintain I.V. therapy to promote hydration
and replace electrolytes.
CAUSE
• Respiratory syncytial virus Teaching topics
• Reviewing medications, dosages, and ad-
DATA COLLECTION FINDINGS verse reactions
• Anorexia • Providing adequate nutrition and hydration
• Crackles • Knowing the importance of a humidified en-
• Fever vironment
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• Avoiding people with cold symptoms • Chest X-ray reveals pulmonary changes
Oxygen may
• Preventing spread of infection (bronchiolar metaplasia and interstitial fibro- cause injury to the
sis) may also reveal atelectasis. immature lung.
Bronchopulmonary dysplasia NURSING DIAGNOSES

• Delayed growth and development
Bronchopulmonary dysplasia is a chronic • Imbalanced nutrition: Less than body re-
lung disease that begins in infancy. It occurs quirements
in newborns who require ventilatory support • Impaired gas exchange
with high positive airway pressure and oxy-
gen in the first 2 weeks of life. Infants at risk TREATMENT
may be born prematurely or may have a respi- • Chest physiotherapy
ratory disorder. • Continued ventilatory support and oxygen
In this disorder, an acute insult to the • Enteral or total parenteral nutrition
neonate’s lungs, such as respiratory distress • Supportive measures to enhance
syndrome, pneumonia, or meconium aspira- respiratory function
tion, requires positive-pressure ventilation
and a high concentration of oxygen over time. Drug therapy
These therapies result in tissue and cellular • Bronchodilators: albuterol (Proventil) to
injury to the immature lung that may cause counter increased airway resistance
permanent damage. • Dexamethasone (Decadron) therapy to re-
duce inflammation
CONTRIBUTING FACTORS • Diuretics: furosemide (Lasix)
• Damage to the bronchiolar epithelium
(from hyperoxia and positive pressure) INTERVENTIONS AND RATIONALES
• Difficulty clearing mucus from the lungs • Monitor respiratory and cardiovascular sta-
• Illness such as respiratory distress syn- tus. Monitoring is essential because children
drome, pneumonia, or meconium aspiration with bronchopulmonary dysplasia are suscepti-
• Oxygen toxicity from administration of high ble to lower respiratory tract infections, hyper-
concentration of oxygen and long-term assist- tension, and respiratory failure.
ed ventilation • Monitor vital signs, pulse oximetry, and in-
• Possibly genetic factors take and output to evaluate and maintain ade-
• Prematurity quate hydration, which is necessary to liquefy
secretions and to detect early signs of respirato-
DATA COLLECTION FINDINGS ry compromise.
• Crackles, rhonchi, wheezes • Provide adequate time for rest to decrease
• Delayed development oxygen demands.
• Dyspnea • Provide chest physiotherapy to mobilize se-
• Hepatomegaly (if right-sided heart failure) cretions that interfere with oxygenation.
• Hypoxia without ventilator assistance • Administer medications, as ordered, to im-
• Jugular vein distention prove pulmonary function and oxygenation.
• Fatigue, delayed muscle growth • Provide a quiet environment. Unnecessary
• Pallor, circumoral cyanosis noise or activity may increase the child’s anxi-
• Peripheral edema (if right-sided heart ety and cause respiratory distress.
failure)
• Prolonged capillary filling time Teaching topics
• Respiratory distress • Visiting and becoming involved in the
• Sternal retractions child’s care, especially if child requires
• Weight loss or difficulty feeding lengthy hospitalization
• Recognizing signs of respiratory infection
DIAGNOSTIC FINDINGS and knowing the importance of seeking
• ABG analysis reveals hypoxemia. prompt medical attention
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Croup Drug therapy

• Antipyretics: acetaminophen (Tylenol)
Croup is a group of related upper airway res- • Inhaled racemic epinephrine (Asthma-
piratory conditions that commonly affect tod- Nefrin) to alleviate respiratory distress
dlers. It includes acute spasmodic laryngitis, • Corticosteroid: methylprednisolone (Solu-
acute obstructive laryngitis, and acute laryn- Medrol) to reduce inflammation and swelling
gotracheobronchitis.
CAUSES • Monitor respiratory and cardiovascular sta-
• Virus (most cases) tus to detect any indications that obstruction is
• Bacteria worsening.
• Monitor vital signs and pulse oximetry to
DATA COLLECTION FINDINGS detect early signs of respiratory compromise.
• Barking, brassy cough or hoarseness, • Administer oxygen therapy and maintain
sometimes described as a “seal bark” cough the child in a cool mist tent, if needed. Cool
• Condition usually begins at night and dur- mist helps liquefy secretions.
ing cold weather and frequently recurs • Administer medications, as ordered, and
• Crackles and decreased breath sounds (in- note effectiveness to maintain or improve
We may sound dicate condition has progressed to bronchi) child’s condition.
alike, but one of us • Increased dyspnea and lower accessory • Allow the parents to hold the child to pro-
has croup… muscle use vide comfort.
• Inspiratory stridor with varying degrees of • Provide emotional support for the parents to
respiratory distress decrease anxiety.
…and • Onset may be sudden or gradual • Provide age-appropriate activities for the
one of us child confined to the mist tent to ease anxiety.
is just
asking for
DIAGNOSTIC FINDINGS • Monitor for rebound obstruction when ad-
applause. • If bacterial infection is the cause, throat cul- ministering racemic epinephrine; the drug’s ef-
tures may identify the organisms and their fects are short term and may result in rebound
sensitivity to antibiotics as well as rule out obstruction.
diphtheria.
• Laryngoscopy may reveal inflammation and Teaching topics
obstruction in epiglottal and laryngeal areas. • Keeping the child calm to ease respiratory
• Neck X-ray shows areas of upper airway effort and conserve energy
narrowing and edema in subglottic folds and • Knowing methods of decreasing laryngeal
rules out the possibility of foreign body ob- spasm, such as taking the child into the bath-
struction as well as masses and cysts. room, turning on the shower, and letting the
• Pulse oximetry may reveal hypoxia. room fill with steam or allowing the child to
breathe cool air outside during the night
NURSING DIAGNOSES • Using a vaporizer near the child’s bed
• Anxiety
• Risk for deficient fluid volume Cystic fibrosis
TREATMENT Cystic fibrosis is a generalized dysfunction of
• Clear liquid diet to keep mucus thin the exocrine glands that affects multiple or-
• Cool humidification during sleep with a cool gan systems. This disorder is characterized
mist tent or room humidifier by:
• Rest from activity • airway obstruction caused by the increased
• Tracheostomy, oxygen administration and constant production of mucus
• little or no release of pancreatic enzymes (li-
pase, amylase, and trypsin).
920128.qxd 8/7/08 3:13 PM Page 585
Transmitted as an autosomal recessive trait, • High-protein formula, such as Probana, if

cystic fibrosis is the one of the most common needed
inherited diseases in children and one of the
most common causes of childhood death. The Drug therapy
disease occurs equally in both sexes. With im- • Anti-inflammatory: prednisone (Medicor-
provements in treatment over the past dec- ten) or ibuprofen to decrease inflammation
ade, the average life expectancy has risen dra- • Mucolytic (dornase alfa Pulmozyme), bron-
matically. The clinical effects may become ap- chodilator, or antibiotic nebulizer inhalation
parent soon after birth or take years to treatment before chest physiotherapy
develop. • I.V. antibiotics for a Pseudomonas infection
when infection interferes with daily function-
CAUSE ing
• Genetic inheritance (Research suggests • Oral pancreatic enzyme replacement: pan-
that there may be as many as 300 genes that crelipase (Pancrease)
code for cystic fibrosis.) • Tobramycin (TOBI) administered with a
nebulizer
• Bulky, greasy, foul-smelling stools that con- INTERVENTIONS AND RATIONALES
tain undigested food • Monitor respiratory and cardiovascular sta-
• Distended abdomen and thin arms and legs tus to detect early signs of hypoxia.
from steatorrhea • Monitor vital signs and intake and output to
• Failure to thrive from malabsorption detect dehydration, which may worsen respira-
• History of a chronic, productive cough and tory status.
recurrent respiratory infections, often due to • Monitor pulse oximetry to detect early signs
Pseudomonas infections of hypoxia.
• Meconium ileus in the newborn from a lack • Administer pancreatic enzymes with meals
of pancreatic enzymes and snacks to aid digestion and absorption of
• Parents’ report of a salty taste on the child’s nutrients.
skin • Provide high-calorie, high-protein foods In cystic fibrosis,
• Voracious appetite from undigested food with added salt to replace sodium loss and pro- the child’s sweat
lost in stools mote normal growth. contains two to five
• Encourage breathing exercises and per- times the normal
DIAGNOSTIC FINDINGS form chest physiotherapy two to four times a levels of sodium and
• Chest X-ray indicates early signs of obstruc- day to mobilize secretions, to maintain lung ca- chloride. Parents may
tive lung disease. pacity, and to increase oxygenation. report a salty taste
on the child’s skin.
• Sweat test using pilocarpine iontophoresis • Encourage physical activity to promote nor-
is greater than 60 mEq/L mal development.
• Stool specimen analysis indicates the ab-
sence of trypsin. Teaching topics
• Avoiding cough suppressants and antihista-
NURSING DIAGNOSES mines because the child must be able to
• Imbalanced nutrition: Less than body re- cough and expectorate
quirements • Seeking genetic counseling for the family
• Ineffective airway clearance • Promoting as normal a life for the child as
• Risk for infection possible
TREATMENT
• Chest physiotherapy Epiglottitis
• Multivitamins twice per day, especially fat-
soluble vitamins Epiglottitis, a potentially life-threatening infec-
tion, causes inflammation and edema of the
920128.qxd 8/7/08 3:13 PM Page 586
epiglottis, a lidlike cartilaginous structure INTERVENTIONS AND RATIONALES

overhanging the entrance to the larynx that • Monitor vital signs and pulse oximetry to
serves to prevent food from entering the lar- detect any changes in oxygenation.
ynx and trachea while swallowing. Epiglottitis •Monitor respiratory and cardiovascular sta-
is most common among preschoolers. tus to determine the severity of the child’s condi-
tion and to prevent respiratory failure or arrest.
CAUSES • Have someone stay with the child at all
• Bacterial Haemophilus influenzae (most times. Airway obstruction can occur quickly.
common causative organism) • Defer inspecting the throat until emergency
• Pneumococci and group A beta-hemolytic personnel and supplies arrive to avoid a
streptococci spasm of the epiglottis that may lead to airway
occlusion.
DATA COLLECTION FINDINGS • Reduce the number of examining personnel
• Difficult and painful swallowing to decrease the child’s anxiety.
• Extending the neck in a sniffing position • Allow the child to sit on a parent’s lap; sit-
• Fever ting on a parent’s lap makes breathing easier
• Increased drooling and decreases the child’s anxiety.
• Irritability • Have equipment ready for a tracheotomy or
• Lower rib retractions intubation. Emergency intubation and trache-
• Pallor ostomy equipment should be on hand in case
• Rapid pulse rate complete obstruction occurs.
• Rapid respirations • Maintain oxygen therapy, if necessary. Hu-
• Refusal to drink midified oxygen prevents secretions from thick-
• Restlessness ening.
• Sore throat • Administer medications as ordered to treat
• Stridor infection and to improve respiratory function.
• Tripod sitting position • Provide emotional support for the child and
• Use of accessory muscles family to decrease anxiety.

• Lateral neck X-ray shows an enlarged • Understanding the signs and symptoms of
Remember, don’t
inspect the throat of epiglottis. this disorder and recognizing those who need
a child with • Throat examination reveals a large, edema- immediate medical attention
epiglottitis without tous, bright red epiglottis. • Understanding the importance of beginning
emergency personnel H. influenzae immunization at age 2 months
and supplies on hand NURSING DIAGNOSES
because airway • Anxiety
occlusion could result. • Ineffective airway clearance Sudden infant death
syndrome
TREATMENT
• Emergency endotracheal intubation or a tra- Sudden infant death syndrome (SIDS) is the
cheotomy sudden death of an infant in which a post-
• Oxygen therapy or cool mist tent mortem examination fails to confirm the
• I.V. fluid to prevent dehydration cause of death. The peak age is 3 months; 90%
of cases occur before age 6 months, especially
Drug therapy during the winter and early spring months.
• Parenteral antibiotics according to causative Children who are diagnosed with SIDS are
organism: 10-day course typically described as healthy with no previ-
ous medical problems. They are usually found
dead sometime after being put down to sleep.
920128.qxd 8/7/08 3:13 PM Page 587

• May result from an abnormality in the con- • Because most infants with SIDS can’t be re-
trol of ventilation, causing prolonged apneic suscitated, focus your interventions on pro- Memory
periods with profound hypoxia and cardiac ar- viding emotional support for the family. Keep jogger
rhythmias in mind grief may be coupled with guilt. Also, Try to
• Stomach sleeping (studies indicate a de- the parents may express anger at emergency remember
creased incidence of SIDS in infants who department personnel, each other, or anyone the phrase, “Back
sleep on their backs) involved with the child’s care. Stay calm and to sleep.” Research
• Undetected abnormalities, such as an im- let them express their feelings. Parents need indicates a de-
mature respiratory system and respiratory to express feelings to prevent dysfunctional creased incidence
dysfunction grieving. of SIDS in infants
• Let the parents touch, hold, and rock the in-
placed on their
backs to sleep.
DATA COLLECTION FINDINGS fant, if desired, and allow them to say good-
• History of low birth weight bye to the infant to facilitate the grieving
• History of siblings with SIDS process.
• History of prematurity • Provide literature on SIDS and support
• History of being one in a multiple birth groups; suggest psychological support for the
• Death takes place during sleep without surviving children to help prevent maladaptive
noise or struggle emotional responses to loss, to promote a realis-
tic perspective on the tragedy, and to promote
DIAGNOSTIC FINDINGS coping.
• Autopsy is the only way to diagnose SIDS. • Reinforce the fact that the death wasn’t the
Autopsy findings indicate pulmonary edema, parents’ fault to help alleviate guilt.
intrathoracic petechiae, and other minor
changes suggesting chronic hypoxia. Teaching topics
• Preparing the family for how the infant will
NURSING DIAGNOSES look and feel if members touch and hold him
• Ineffective tissue perfusion: Cardiopulmo- • Contacting a minister, priest, rabbi, or other
nary clergy; relatives; friends; and local support
• Ineffective breathing pattern groups for grieving parents
• Grieving
TREATMENT
• If parents bring the infant to the emergency
department, the doctor decides whether to
try to resuscitate.
• If successfully resuscitated, the child is tem-
porarily placed on mechanical ventilation. Af-
ter he’s extubated, the child is tested for in-
fantile apnea and the parents are given a
home apnea monitor and taught infant car-
diopulmonary resuscitation.
• Parents of an infant who has died of SIDS
require emotional and other support.
Drug therapy
Pump up on practice
• If resuscitation is attempted, drugs are ad-
ministered according to Pediatric Advanced
questions
Life Support protocols; drug therapy may in- 1. A parent brings her child to the pediatri-
clude epinephrine, atropine and, after ABG cian’s office because of difficulty breathing
analysis, sodium bicarbonate if appropriate.
920128.qxd 8/7/08 3:13 PM Page 588
and a “barking” cough. These signs are asso- Client needs category: Physiological
ciated with which of the following conditions? integrity
1. Cystic fibrosis Client needs subcategory: Reduction of
2. Asthma risk potential
3. Epiglottitis Cognitive level: Application
4. Croup
Answer: 4. A “seal bark” cough and difficulty 3. A child with croup is placed in a cool mist
breathing would indicate croup. Cystic fibro- tent. Which statement should the nurse in-
sis produces a chronic productive cough and clude when teaching the mother about this
recurrent respiratory infections. Asthma may type of therapy?
cause prolonged expiration with an expiratory 1. “You won’t be able to touch your child
wheeze on auscultation, dyspnea, and acces- while he’s in the cool mist tent.”
sory muscle use. Epiglottitis results in in- 2. “The cool mist is necessary because it
creased drooling, difficulty swallowing, will thin the child’s mucus, making it easi-
tachypnea, and stridor. er to expectorate.”
Client needs category: Physiological 3. “You can bring in your child’s favorite
integrity stuffed animal to comfort him while he’s in
Client needs subcategory: Physio- the cool mist tent.”
logical adaptation 4. “You can bring in any of your child’s fa-
Cognitive level: Knowledge vorite toys so he can play while he’s in the
cool mist tent.”
2. A woman whose child awakens at night Answer: 2. The mother should be taught the
with a “barking” cough asks the nurse for ad- purpose of the cool mist tent, which is to thin
vice. The nurse should instruct the mother to: mucus and facilitate expectoration. The moth-
1. take the child into the bathroom, turn er is able to touch her child while he’s in the
on the shower, and let the room fill with cool mist tent. She should be encouraged to
steam. bring in toys for the child to play with but to
2. bring the child to the emergency de- avoid stuffed toys, which may become damp
partment immediately. and promote bacterial growth, and toys that
3. notify the pediatrician immediately. produce sparks or friction.
4. call emergency medical services to Client needs category: Physiological
transport the child to the hospital for integrity
emergency tracheotomy. Client needs subcategory: Reduction of
Answer: 1. The nurse should instruct the risk potential
mother to take her child into the bathroom, Cognitive level: Application
close the door, turn on the shower’s hot-water
spigot full-force, and sit with the child as the 4. The physician orders chest physiotherapy
room fills with steam; this should decrease la- for a pediatric client. The nurse shouldn’t per-
ryngeal spasm associated with croup. If a form chest physiotherapy when the client is
child demonstrates symptoms associated with experiencing:
epiglottitis, not croup (increased drooling, 1. a productive cough.
stridor, tachypnea), the mother should notify 2. retained secretions.
the pediatrician immediately and call the 3. acute bronchoconstriction.
emergency medical services to transport the 4. hypoxia.
child to the hospital; emergency tracheotomy Answer: 3. The nurse shouldn’t administer
may be necessary. Epiglottitis is a potentially chest physiotherapy during episodes of acute
life-threatening infection that causes inflam- bronchoconstriction or airway edema (loos-
mation and edema of the epiglottis. Taking ening mucus plugs could cause airway ob-
the child to the hospital by herself could jeop- struction). Chest physiotherapy aids the elim-
ardize the child’s condition if that condition ination of secretions and reexpansion of lung
deteriorates en route. tissue. Successful treatment with chest phys-
920128.qxd 8/7/08 3:13 PM Page 589
iotherapy produces improved breath sounds, 6. Which of these test results is a key finding
improved oxygenation, and increased sputum in the child with cystic fibrosis?
production and airflow. Therefore, it should 1. Chest X-ray that reveals interstitial fi-
be performed when a productive cough, re- brosis
tained secretions, or hypoxia is present. 2. Neck X-ray showing areas of upper air-
Client needs category: Physiological way narrowing
integrity 3. Lateral neck X-ray revealing an en-
Client needs subcategory: Reduction of larged epiglottis
risk potential 4. Positive pilocarpine iontophoresis
Cognitive level: Application sweat test
Answer: 4. A child with cystic fibrosis has a
positive pilocarpine iontophoresis sweat test.
The child sweats normally, but this sweat con-
tains two to five times the normal levels of
sodium and chloride. Chest X-ray findings
that reveal bronchiolar metaplasia and inter-
stitial fibrosis are associated with bronchopul-
monary dysplasia. A neck X-ray that reveals
upper airway narrowing and edema in the
subglottic folds indicates croup. A lateral neck
X-ray that reveals an enlarged epiglottis indi-
cates epiglottitis.
5. When preparing to teach the parents of an integrity
infant about preventing SIDS, the nurse Client needs subcategory: Reduction of
should include: risk potential
1. positioning the infant on his stomach Cognitive level: Knowledge
when sleeping.
2. positioning the infant in an infant seat 7. When communicating with the grieving
to sleep. family after a death from SIDS, the nurse
3. positioning the infant on his back to should:
sleep. 1. instruct the parents to place other in-
4. positioning the infant in a side-lying po- fants on their backs to sleep.
sition to sleep. 2. stress that the death isn’t the parents’
Answer: 3. The parents should be instructed fault.
to position the infant on his back to sleep to 3. stress that an autopsy must be done to
decrease the risk of SIDS. Infants may be po- confirm diagnosis.
sitioned in an infant seat during periods of 4. stress that the parents are still young
respiratory distress to encourage lung expan- and can have more children.
sion but it shouldn’t be encouraged as a rou- Answer: 2. It’s most important for the nurse to
tine position for sleep. Research demonstrates stress that death from SIDS is not predictable
an increased incidence of SIDS in infants posi- or preventable and that it isn’t the parents’
tioned on their stomachs to sleep. The side- fault. Although it’s important to inform the
lying position should also be avoided because parents that an autopsy is necessary, that’s
those infants can reposition themselves into a secondary. Instructing the parents to place
prone (stomach-lying) position. other infants on their backs to sleep implies
Client needs category: Health promo- that the parents did something wrong to
tion and maintenance cause the infant’s death. Stressing that the
Client needs subcategory: None parents are still young and can have other
Cognitive level: Comprehension children minimizes their grief.
920128.qxd 8/7/08 3:13 PM Page 590
Client needs category: Psychosocial ing cough suppressants and antihistamines to

integrity their child. Administration of these drugs in-
Client needs subcategory: None terferes with the child’s ability to cough and
Cognitive level: Application expectorate. The parents should encourage
the child to be physically active and lead as
8. Which of these client histories is most con- normal a life as possible. Pancreatic enzymes
sistent with the diagnosis of SIDS? should be administered with meals and
1. The child was physically abused in the snacks.
past. Client needs category: Physiological
2. The infant had a history of many med- integrity
ical problems. Client needs subcategory: Reduction of
3. The infant was healthy and was found risk potential
shortly after being put down to sleep. Cognitive level: Knowledge
4. The infant was described as lethargic,
irritable, and feeding poorly before being 10. Which is the most appropriate nursing
put down to sleep. diagnosis for the child with epiglottitis?
Answer: 3. Children who are diagnosed with 1. Anxiety related to separation from par-
SIDS are typically described as healthy with ent
no previous medical problems. They are usu- 2. Decreased cardiac output related to
ally found dead sometime after being put bradycardia
down to sleep. Depending on how long the in- 3. Ineffective airway clearance related to
fant has been dead, the infant may have a laryngospasm
mottled complexion with extreme cyanosis of 4. Impaired gas exchange related to non-
the lips, fingertips, or pooling of blood in the compliant lungs
legs and feet that may be mistaken for bruis- Answer: 3. Epiglottitis is a life-threatening
ing. emergency that results from laryngospasm
Client needs category: Physiological and edema. Therefore, ineffective airway
integrity clearance is the most appropriate diagnosis
Client needs subcategory: Physio- for this child. Anxiety related to separation
logical adaptation shouldn’t apply because the child doesn’t
Cognitive level: Knowledge need to be separated from the parent. The
child will most likely be tachycardic, not
9. The nurse is teaching the parents of a bradycardic, unless respiratory failure en-
child with cystic fibrosis. The nurse should in- sues. The child has impaired gas exchange
struct the parents to avoid: from impeded airflow, not from a noncompli-
Whew! 1. encouraging their child to be physically ant lung.
Reviewing for the active. Client needs category: Physiological
NCLEX can be 2. administering pancreatic enzymes with integrity
exhausting. meals and snacks. Client needs subcategory: Physio-
3. administering cough suppressants. logical adaptation
4. encouraging their child to live as nor- Cognitive level: Analysis
mal a life as possible.
Answer: 3. The parents of a child with cystic fi-
brosis should be taught to avoid administer-
920129.qxd 8/7/08 3:14 PM Page 591
29 Hematologic & immune

systems
• leukocytes (white blood cells [WBCs]),
In this chapter,
you’ll learn:
Brush up on key which include lymphocytes, monocytes, and
granulocytes; these participate in the immune
✐ the pediatric hemato- concepts response
• thrombocytes (platelets), which contribute
logic and immune sys-
tems and their func- The hematologic and immune systems con- to clotting
sist of blood and blood-forming tissues as well • plasma (the fluid part of blood), which car-
tions
as such structures as the lymph nodes, thy- ries antibodies and nutrients to tissues and
mus, spleen, and tonsils. Reviewing the func- carries away wastes.
nose hematologic and tions of these systems and the development of
immune disorders a child’s immune response will lay the It’s common
✐ common hematologic groundwork for effective patient care. Communicable diseases and infections
and immune disor- At any time, you can review the major points are commonly seen during the time a child’s
ders. of this chapter by consulting the Cheat sheet immune system develops. Over time, a child
on pages 592 and 593. receives protection from communicable dis-
eases either naturally or artificially.
What blood does
The functions of blood include: It’s natural
• regulating body temperature by transfer- • Natural immunity is present at birth. Ex-
ring heat from deep within the body to small amples of natural immunity include barriers
vessels near the skin against disease, such as skin and mucous
• providing cell nutrition by carrying nutri- membranes, and bactericidal substances of
ents from the GI tract to the tissues and re- body fluids, such as intestinal flora and gastric
moving waste products by transporting them acidity.
to the lungs, kidneys, liver, and skin for excre- • With naturally acquired active immuni-
tion ty, the immune system makes antibodies after
• defending against foreign antigens by trans- exposure to disease. It requires contact with
porting leukocytes and antibodies to the sites the disease.
of infection, injury, and inflammation • With naturally acquired passive immu-
• transporting hormones from endocrine nity, no active immune process is involved.
glands to various parts of the body The antibodies are passively received through
• maintaining acid-base balance placental transfer by immunoglobulin (Ig) G
• carrying oxygen to tissues and removing (the smallest Ig) and breast-feeding
carbon dioxide. (colostrum).
Each little component does its part It’s artificial

Blood is composed of several components. Artificially acquired immunity can be active or
These include: passive. In artificially acquired active im-
• er ythrocytes (red blood cells [RBCs]), munity, medically engineered substances are
which carry oxygen to the tissues and re- ingested or injected to stimulate the immune
move carbon dioxide response against a specific disease. Immu-
920129.qxd 8/7/08 3:14 PM Page 592
et
heat she
C
Pediatric hematologic & immune refresher
ACQUIRED IMMUNODEFICIENCY SYNDROME – apply pressure to the site for 10 to 15 minutes
Key signs and symptoms – decrease the child’s anxiety.
• Failure to thrive IRON DEFICIENCY ANEMIA
• Mononucleosis-like prodromal symptoms
• Night sweats
• Fatigue, listlessness
• Recurring diarrhea
• Increased susceptibility to infection
• Weight loss
• Pallor
Key test results • Tachycardia
• CD4+ T-cell count measures the severity of im- • Numbness and tingling of the extremities
munosuppression. • Vasomotor disturbances
• Enzyme-linked immunosorbent assay and
Key test results
Western blot are positive for human immunodefi-
• Hemoglobin (Hb), hematocrit, and serum ferritin
ciency virus (HIV) antibody.
levels are low.
• Viral culture or p24 antigen test reveals pres-
• Serum iron levels are low, with high binding ca-
ence of HIV in children under age 18 months.
pacity.
Key treatments
Key treatments
• Antibiotic therapy according to sensitivity of in-
• Oral preparation of iron or a combination of iron
fecting organisms
and ascorbic acid (which enhances iron absorp-
• Antiviral agents such as zidovudine (Retrovir)
tion)
• Monthly gamma globulin administration
Key interventions
Key interventions
• Administer iron before meals with citrus juice.
• Monitor vital signs, intake and output, and
• Give liquid iron through a straw; for infants, ad-
growth and development.
minister by oral syringe toward the back of the
• Monitor respiratory and neurologic status.
mouth.
• Maintain standard precautions.
• Don’t give iron with milk products.
HEMOPHILIA
LEUKEMIA
• Multiple bruises without petechiae
• Fatigue
• Prolonged bleeding after circumcision, immu-
• History of infections
nizations, or minor injuries
• Low-grade fever
Key test result • Lymphadenopathy
• Prolonged partial thromboplastin time (PTT) • Pallor
Key treatments • Petechiae and ecchymosis
• Cryoprecipitate (frozen factor VIII) administra- • Poor wound healing and oral lesions
tion to maintain an acceptable serum level of the Key test results
clotting factor; usually done by the family at home • Blast cells appear in the peripheral blood.
• Fresh frozen plasma • Blast cells may be as high as 95% in the bone
Key interventions marrow.
• Monitor vital signs and intake and output. • Initial white blood cell count may be 10,000/μl at
• When bleeding occurs: time of diagnosis in a child with acute lymphocyt-
– elevate the affected extremity above the heart ic leukemia between ages 3 and 7.
– immobilize the site
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Pediatric hematologic & immune refresher (continued)

LEUKEMIA (continued) • Monitor fluid intake and output.
Key treatments • Monitor blood glucose levels.
• Bone marrow transplantation • Maintain seizure precautions.
• Radiation therapy • Keep head of bed at 30-degree angle.
• Chemotherapy • Maintain oxygen therapy, which may include intubation and
Key interventions mechanical ventilation.
• Administer blood products as necessary.
• Provide pain relief.
• Administer medications, as ordered, and monitor for adverse
effects.
• Inspect the skin frequently.
• Maintain hypothermia blanket as needed, and monitor temper-
• Provide nursing measures to ease adverse effects of radiation
ature every 15 to 30 minutes while in use.
and chemotherapy.
• Check for loss of reflexes and signs of flaccidity.
REYE’S SYNDROME
SICKLE CELL ANEMIA
• Stage 5: seizures, loss of deep tendon reflexes, flaccidity, re-
• In infants, colic and splenomegaly
spiratory arrest (Death is usually a result of cerebral edema or
• In toddlers and preschoolers, hypovolemia, shock, and pain at
cardiac arrest.)
site of crisis
Key test results • In school-age children and adolescents, enuresis, extreme
• Blood test results show elevated serum ammonia levels; pain at site of crisis, and priapism
serum fatty acid and lactate levels are also elevated.
Key test results
• Coagulation studies reveal prolonged prothrombin time and
• More than 50% Hb S indicates sickle cell disease; a lower level
PTT.
of Hb S indicates sickle cell trait.
• Liver biopsy shows fatty droplets distributed through cells.
• Liver function studies show aspartate aminotransferase and Key treatments
alanine aminotransferase elevated to twice normal levels. • Hydration with I.V. fluid administration
Key treatments • Transfusion therapy as necessary
• Treatment for acidosis
• Endotracheal intubation and mechanical ventilation
• Analgesics: morphine or hydromorphone (Dilaudid)
• Exchange transfusion
• Induced hypothermia Key interventions
Key interventions • Monitor vital signs and intake and output.
• Administer pain medications and note effectiveness.
• Monitor vital signs and pulse oximetry.
• Monitor cardiac, respiratory, and neurologic status.
nizations are an example of this kind of immu-

nity.
With artificially acquired passive immu-
Keep abreast of
nity, antibodies are injected without stimulat-
ing the immune response. Examples include
diagnostic tests
tetanus antitoxin, hepatitis B immune globu- Here are some important tests used to diag-
lin, and varicella zoster immune globulin. nose hematologic and immunologic disor-
ders, along with common nursing interven-
tions associated with each test.
Not my type?
Blood typing is used to classify blood accord-
ing to the presence of major antigens A and B
920129.qxd 8/7/08 3:14 PM Page 594
on RBC surfaces and according to serum anti- A look at the liver

bodies anti-A and anti-B. ABO blood typing is Liver function studies measure levels of he-
necessary before transfusion to prevent a patic enzymes, such as aspartate aminotrans-
lethal reaction. ferase (AST) and alanine aminotransferase
(ALT).
Nursing actions
• Explain the procedure to the child and his Nursing actions
family. • Before the test, prepare the child for
• Handle the sample gently to prevent hemo- venipuncture.
lysis. • After the test, check the venipuncture site
• Apply pressure to the venipuncture site to for bleeding.
prevent hematoma or bleeding.
Tuning into the immune system

Laboratory studies, such as CD4+ T-cell
count and enzyme-linked immunosorbent
assay (ELISA), are used to assess immuno-
suppression.
care
Major hematologic and immune disorders in
Nursing actions pediatric patients include acquired immuno-
• Explain the procedure to the child and his deficiency syndrome(AIDS), hemophilia, iron
family. deficiency anemia, leukemia, Reye’s syn-
• Handle the sample gently to prevent hemo- drome, and sickle cell anemia.
lysis.
• Apply pressure to the venipuncture site to
prevent hematoma or bleeding. Acquired immunodeficiency
Honing in on hematology syndrome
Hematology studies are used to analyze a
blood sample for WBC count and differential, With AIDS, the human immunodeficiency
hemoglobin level (Hb), hematocrit, and virus (HIV) attacks helper T cells. AIDS may
platelet count. be spread through sexual contact, percuta-
neous or mucous membrane exposure to nee-
Nursing actions dles or other sharp instruments contaminated
• Explain the procedure to the child and his with blood or bloody body fluid (for example,
family. in I.V. drug abuse), contaminated blood trans-
• Apply pressure to the venipuncture site to fusion, or mother to infant transmission be-
prevent hematoma and bleeding. fore or around the time of birth. Most chil-
dren in the United States with AIDS are born
Clot measure to mothers with HIV infection.
A coagulation study tests a blood sample to HIV has a much shorter incubation period
analyze prothrombin time (PT), international in children than adults. In adults, the incuba-
normalized ratio, partial thromboplastin time tion period may last 10 years or more. By con-
(PTT), and bleeding time. trast, children who receive the virus by pla-
cental transmission are usually HIV-positive
Nursing actions by age 6 months and develop clinical signs by
• Note the child’s current drug therapy be- age 3.
fore the procedure. Because of passive antibody transmission,
• Check the venipuncture site for bleeding af- all infants born to HIV-infected mothers test
ter the procedure. positive for antibodies to the HIV virus up to
about age 18 months. Confirmation of diagno-
920129.qxd 8/7/08 3:14 PM Page 595
sis during this time requires detection of the • Prophylactic antibiotic therapy with co-
HIV antigen. trimoxazole (Bactrim) to prevent Pneumocys-
tis carinii pneumonia
CAUSES • Routine immunizations (excluding varicella
• Contaminated blood products vaccine, which isn’t recommended for HIV-
As with
• Infected parent infected children.) adults, children
with AIDS exhibit
DATA COLLECTION FINDINGS INTERVENTIONS AND RATIONALES nonspecific signs
• Failure to thrive • Monitor vital signs and intake and output to and symptoms.
• Lymphadenopathy detect tachycardia, hypotension, or decreased
• Mononucleosis-like prodromal symptoms urine output, which may indicate fluid volume
• Neurologic impairment, such as loss of mo- deficit or electrolyte imbalance.
tor milestones and behavioral changes • Provide appropriate play ac-
• Night sweats tivities to provide stimulation
• Recurrent opportunistic infections and promote development.
• Recurring diarrhea • Encourage fluid intake to
• Weight loss prevent dehydration.
• Monitor respiratory and
DIAGNOSTIC FINDINGS neurologic status to detect early
• CD4+ T-cell count measures the severity of signs of compromise.
immunosuppression. • Maintain standard precau-
• Culture and sensitivity tests reveal infection tions to prevent the spread of in-
with opportunistic organisms. fection.
• ELISA and Western blot are positive for • Administer medications, as ordered, to help
HIV antibody. boost immune response and prevent opportunis-
• Viral culture or p24 antigen test reveals tic infections.
presence of HIV in children under age • Provide psychosocial support. An AIDS
18 months. diagnosis is devastating for a child and his
family.
NURSING DIAGNOSES
• Ineffective protection Teaching topics Children with HIV
• Imbalanced nutrition: Less than body re- • Avoiding consumption of raw or under- or AIDS and their
quirements cooked meats families must
maintain strict
• Deficient fluid volume • Avoiding swimming in a lake or river
personal hygiene.
• Avoiding contact with young farm animals
TREATMENT • Following infection-control techniques
• Blood administration, if necessary • Understanding risk factors from pets (espe-
• Follow-up laboratory studies cially cats)
• High-calorie diet provided in small frequent • Recognizing signs and symptoms of infec-
meals tion and getting immediate treatment
• I.V. fluids to maintain hydration • Practicing safe sex, if appropriate
• Nutrition supplements, if necessary
• Parenteral nutrition, if necessary
Hemophilia
Drug therapy
• Antibiotic therapy according to sensitivity of Hemophilia, which affects 1 in 5,000 males,
infecting opportunistic organism results from a deficiency in one of the coagu-
• Antiviral agents such as zidovudine (Retro- lation factors.
vir)
• Monthly gamma globulin administration
920129.qxd 8/7/08 3:14 PM Page 596
The types of hemophilia are: • Promoting vasoconstriction during bleeding

• hemophilia A (also called factor VIII defi- episodes by applying ice, pressure, and hemo-
ciency or classic hemophilia), the most com- static agents
mon type (75% of all cases)
• hemophilia B (also called factor IX deficien- Drug therapy
cy or Christmas disease) • Desmopressin acetate (DDAVP) to promote
• hemophilia C (factor XI deficiency). release of factor VIII in individuals with mild
Hemophilia is an X-linked recessive disor- or moderate hemophilia A
der. The inheritance pattern is described be-
low: INTERVENTIONS AND RATIONALES
• If the father has the disorder and the moth- • Monitor vital signs and intake and output to
er doesn’t, all daughters will be carriers, but evaluate renal status and monitor for fluid
sons won’t have the disease. overload or dehydration.
• If the mother is a carrier and the father • Monitor cardiovascular status and check for
doesn’t have hemophilia, each son has a 50% signs of bleeding; tachycardia or hypotension
chance of getting hemophilia and each daugh- may indicate hypovolemia.
ter has a 50% chance of being a carrier. • Measure the joint’s circumference and com-
pare it to that of an unaffected joint to evaluate
CAUSE for bleeding into the joint, which may lead to
• Genetic inheritance hypovolemia.
Prolonged • Note swelling, pain, or limited joint mobility.
bleeding after DATA COLLECTION FINDINGS Changes may indicate progressive decline in
minor injuries is • Bleeding into the throat, mouth, and thorax function.
a classic sign of • Hemarthrosis • Pad toys and other objects in the child’s en-
hemophilia. • Multiple bruises without petechiae vironment to promote child safety and prevent
• Peripheral neuropathies from bleeding near bleeding.
peripheral nerves • Recommend protective headgear, soft foam
• Prolonged bleeding after circumcision, im- Toothettes (instead of bristle toothbrushes),
munizations, or minor injuries and stool softeners as appropriate to prevent
bleeding.
DIAGNOSTIC FINDING • Discourage abnormal weight gain, which in-
• PTT is prolonged. creases the stress on joints.
NURSING DIAGNOSES When bleeding occurs

• Ineffective protection • Elevate the affected extremity above the
• Risk for deficient fluid volume heart to decrease circulation to affected area
• Risk for injury and promote venous return.
• Immobilize the site to prevent clots from dis-
TREATMENT lodging
• Avoiding aspirin, sutures, and cauterization, • Apply pressure to the site for 10 to 15 min-
which may aggravate bleeding utes to stop bleeding
• Blood transfusion if necessary • Decrease anxiety to lower the child’s heart
• Cryoprecipitate administration, to maintain rate.
an acceptable serum level of the clotting fac- • Apply ice to the site to promote vasoconstric-
tor; usually done by the family at home tion.
• Establishing HIV status (child is at in-
creased risk for acquiring HIV through blood To treat hemarthrosis
product transfusions) • Immobilize the affected extremity; elevate it
• Administration of fresh frozen plasma to rein a slightly flexed position to prevent further
store deficient coagulation factors injury.
• Decrease pain and anxiety to lower the
child’s heart rate and minimize blood loss.
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• Have the child avoid excessive handling or DATA COLLECTION FINDINGS

weight bearing for 48 hours to prevent bleed- Anemia progresses gradually, and many chil-
ing and to rest the site. dren are initially asymptomatic, except for
• Begin mild range-of-motion exercises after symptoms of an underlying condition. Chil-
48 hours to facilitate absorption of blood and dren with advanced anemia display the follow-
prevent contractures. ing symptoms:
• dyspnea on exertion
Teaching topics • fatigue
• Seeking genetic counseling for parents • headache
• Avoiding contact sports • inability to concentrate
• Performing home treatment for bleeding • irritability
episodes • listlessness
• pallor
• susceptibility to infection
Iron deficiency anemia • tachycardia.
In cases of chronic iron deficiency anemia,
The most common nutritional anemia during children display the following symptoms:
childhood, iron deficiency anemia is charac- • cracks in corners of the mouth
terized by poor RBC production. Insufficient • dysphagia
body stores of iron lead to: • neuralgic pain
• depleted RBC mass • numbness and tingling of the extremities
• decreased Hb concentration (hypochromia) • smooth tongue
• decreased oxygen-carrying capacity of the • spoon-shaped, brittle nails
blood. • vasomotor disturbances.
Most commonly, iron deficiency anemia oc-
curs when the child experiences rapid physi- DIAGNOSTIC FINDINGS
cal growth, low iron intake, inadequate iron • Bone marrow studies reveal depleted or
absorption, or loss of blood. absent iron stores and normoblastic hyper-
plasia.
CAUSES • Hb, hematocrit, and serum ferritin levels
• Blood loss secondary to drug-induced GI are low.
bleeding (from anticoagulants, aspirin, or ste- • Mean corpuscular Hb is decreased in se-
roids) or due to heavy menses, hemorrhage vere anemia.
from trauma, GI ulcers, or cancer • RBC count is low, with microcytic and
• Inadequate dietary intake of iron (less than hypochromic cells. (In early stages, RBC
1 to 2 mg/day), which may occur following count may be normal, except in infants and
prolonged unsupplemented breast-feeding or children.)
bottle-feeding of infants, or during periods of • Serum iron levels are low, with high bind-
stress such as rapid growth in children and ing capacity.
adolescents
• Iron malabsorption, as in chronic diarrhea, NURSING DIAGNOSES
partial or total gastrectomy, and malabsorp- • Imbalanced nutrition: Less than body re-
tion syndromes, such as celiac disease and quirements
pernicious anemia • Fatigue
• Intravascular hemolysis-induced hemoglo- • Impaired gas exchange
binuria or paroxysmal nocturnal hemoglobin-
uria TREATMENT
• Mechanical erythrocyte trauma caused by a • Increased iron intake (for children and ado-
prosthetic heart valve or vena cava filters lescents) by adding foods rich in iron to diet
or (for infants) adding iron supplements
• Treatment for any underlying condition
920129.qxd 8/7/08 3:14 PM Page 598

Blast it.
In leukemia, I • Oral preparation of iron or a combination of • Keeping iron supplements safely stored out
can’t get the iron and ascorbic acid (which enhances iron of the child’s reach at home
nutrition I absorption) • Brushing teeth after iron administration
need! • Cyanocobalamin (vitamin B12 ) if intrinsic • Reporting reactions to iron supplementa-
factor is lacking tion, such as nausea, vomiting, diarrhea, con-
• Iron dextran (InFeD) if additional therapy is stipation, fever, or severe stomach pain, which
needed may require a dosage adjustment

• Carefully collect data on the child’s drug Leukemia
history. Certain drugs, such as pancreatic en-
zymes and vitamin E, may interfere with iron Leukemia is the abnormal, uncontrolled pro-
metabolism and absorption and other drugs, liferation of WBCs. In leukemia, WBCs are
such as aspirin and steroids, may cause GI produced so rapidly that immature cells (blast
bleeding. cells) are released into the circulation. These
• Provide passive stimulation; allow frequent blast cells are nonfunctional, can’t fight infec-
rest periods; give small, frequent feedings; tion, and are formed continuously without re-
and elevate the head of the bed to decrease spect to the body’s needs. This proliferation
oxygen demands. robs healthy cells of sufficient nutrition.
• Implement proper hand washing to decrease In children, the most common type of
risk of infection. leukemia is acute lymphocytic leukemia
• Provide foods high in iron (liver, dark leafy (ALL). This type of leukemia is marked by ex-
vegetables, and whole grains) to replenish treme proliferation of blast cells. In adoles-
iron stores. cents, acute myelogenous leukemia is more
• Administer iron before meals with citrus common and is believed to result from a ma-
juice. Iron is best absorbed in an acidic envi- lignant transformation of a single stem cell.
ronment.
• Give liquid iron through a straw to prevent CAUSES AND CONTRIBUTING FACTORS
staining the child’s skin and teeth. For infants, • Chemical exposure and viruses
administer by oral syringe toward the back of • Chromosomal disorders
the mouth. • Down syndrome
• Don’t give iron with milk products. Milk • Radiation exposure
products may interfere with absorption of iron.
Marrow may • Be supportive of the family and keep them DATA COLLECTION FINDINGS
be transfused
informed of the child’s status to decrease Clinical findings for leukemia may appear
from a twin or
another HLA- anxiety. with surprising abruptness in children with
identical donor. few, if any, warning signs. The following are
common signs and symptoms of leukemia:
• blood in urine, stool, or vomitus
• bone and joint pain
• decrease in all blood cells when bone mar-
row undergoes atrophy (leads to anemia,
bleeding disorders, and immunosuppression)
• fatigue
• history of infections
• lassitude
• low-grade fever
• lymphadenopathy
• pallor
920129.qxd 8/7/08 3:14 PM Page 599
• pathologic fractures (when bone marrow • Inspect the skin frequently to evaluate for
Increased fluids
undergoes hypertrophy) skin breakdown. help to flush
• petechiae and ecchymosis • Give increased fluids to flush chemothera- chemotherapeutic
• poor wound healing and oral lesions. peutic drugs through the kidneys. drugs through the
• Provide a high-protein, high-calorie, bland kidneys. Drink up!
DIAGNOSTIC FINDINGS diet with no raw fruits or vegetables. Elimi-
• Blast cells appear in the peripheral blood nating raw fruits and vegetables helps prevent
(where they normally don’t appear). infection. A diet meeting the child’s caloric re-
• Blast cells may be as high as 95% in the quirements helps ensure that the child’s mainte-
bone marrow (they are normally less than 5%) nance and growth needs are met.
as measured by marrow aspiration in the pos- • Provide pain relief as ordered and docu-
terior iliac crest (the sternum can’t be used in ment effectiveness and adverse effects. Anal-
children). gesics depress the central nervous system
• Initial WBC count may be less than (CNS), thereby reducing pain.
10,000/µl at the time of diagnosis in a child • Monitor the patient for CNS changes, such
with ALL between ages 3 and 7. (This child as confusion, that may result from cerebral
has the best prognosis.) damage.
• Lumbar puncture indicates if leukemic cells • Provide nursing measures to ease the ad-
have crossed the blood-brain barrier. verse reactions of radiation and chemothera-
py to promote comfort and encourage adequate
NURSING DIAGNOSES nutritional intake.
• Ineffective protection
• Acute or chronic pain Teaching topics
• Risk for infection • Avoiding infection
• Adjusting to changes in body image
TREATMENT • Contacting support groups
• Bone marrow transplantation (Marrow • Recognizing signs and symptoms of infec-
from a twin or another donor with identical tion and the need to seek immediate medical
human leukocyte antigen [HLA], usually a attention
sibling, is transfused to repopulate the recipi-
ent’s bone marrow with normal cells.)
• High-protein, high-calorie, bland diet Reye’s syndrome
• I.V. fluids, as necessary
• Oxygen therapy if needed Reye’s syndrome is an acute illness that caus-
• Radiation therapy es fatty infiltration of the liver, kidneys, brain,
• Transfusion therapy as needed and myocardium. It can lead to hyperam-
Acute infection
monemia, encephalopathy, and increased in-
plus aspirin use equals
Drug therapy tracranial pressure (ICP). risk of Reye’s
• Analgesics syndrome.
• Antiemetics: hydroxyzine (Atarax) and on- CAUSES
dansetron (Zofran) • Acute viral infection, such as upper respira-
• Chemotherapy: intrathecal, usually with tory tract, type B influenza, or varicella
methotrexate (Folex) (Reye’s syndrome almost always follows with-
• Corticosteroids: prednisone (Deltasone) in 1 to 3 days of infection.)
• Concurrent aspirin use (high incidence)
• Monitor vital signs and intake and output to DATA COLLECTION FINDINGS
determine fluid volume deficit and renal status. Reye’s syndrome develops in five stages:
• Give special attention to mouth care to pre- • Stage 1: vomiting, lethargy, hepatic dysfunc-
vent infection and bleeding. tion
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• Stage 2: hyperventilation, delirium, hyperac- INTERVENTIONS AND RATIONALES

tive reflexes, hepatic dysfunction • Monitor vital signs and pulse oximetry to
• Stage 3: coma, hyperventilation, decorticate determine oxygenation status.
rigidity, hepatic dysfunction • Monitor cardiac, respiratory, and neurolog-
• Stage 4: deepening coma, decerebrate rigid- ic status to evaluate the effectiveness of inter-
To prevent Reye’s ity, large fixed pupils, minimal hepatic dys- ventions and monitor for complications such as
syndrome, use function seizures.
nonsalicylate • Stage 5: seizures, loss of deep tendon reflex- • Monitor fluid intake and output to prevent
analgesics and es, flaccidity, respiratory arrest. Death is usu- fluid overload.
antipyretics. ally a result of cerebral edema or cardiac ar- • Monitor blood glucose levels to detect hyper-
rest. glycemia or hypoglycemia and prevent compli-
The severity of signs and symptoms varies cations.
with degree of encephalopathy and cerebral • Maintain seizure precautions to prevent in-
edema. jury.
• Keep head of bed at 30-degree angle to de-
DIAGNOSTIC FINDINGS crease ICP and promote venous return.
• Blood test results show elevated serum am- • Maintain oxygen therapy, which may in-
monia levels; serum fatty acid and lactate lev- clude intubation and mechanical ventilation,
els are also increased. to promote oxygenation and maintain ther-
• Cerebrospinal fluid (CSF) analysis shows moregulation.
WBC count less than 10/µl; with coma, • Administer blood products as necessary to
there’s increased CSF pressure. increase oxygen-carrying capacity of blood and
• Coagulation studies reveal prolonged PT prevent hypovolemia.
and PTT. • Administer medications, as ordered, and
• Liver biopsy shows fatty droplets uniformly monitor for adverse effects to detect complica-
distributed throughout cells. tions.
• Liver function studies show AST and ALT • Maintain hypothermia blanket as needed,
are elevated to twice normal levels. and monitor temperature every 15 to 30 min-
utes while in use to prevent injury and main-
NURSING DIAGNOSES tain thermoregulation.
• Decreased intracranial adaptive capacity • Check for loss of reflexes and signs of flac-
• Ineffective thermoregulation cidity to determine degree of neurologic involve-
• Risk for deficient fluid volume ment.
• Provide good skin and mouth care and
TREATMENT range-of-motion (ROM) exercises to prevent
• Craniotomy alteration in skin integrity and to promote joint
• Endotracheal intubation and mechanical motility.
ventilation to control partial pressure of arte- • Provide postoperative craniotomy care if
rial carbon dioxide levels necessary to promote wound healing and pre-
• Enteral or parenteral nutrition as needed vent complications.
• Exchange transfusion • Be supportive of the family and keep them
• Induced hypothermia informed of the child’s status to decrease
• Transfusion of fresh frozen plasma anxiety.

• Osmotic diuretics: mannitol (Osmitrol) • Avoiding aspirin products
• Vitamins: phytonadione (AquaMEPHY- • Explaining all procedures and nursing care
TON) measures to the family
• Referring the family to support groups as
indicated
920129.qxd 8/7/08 3:14 PM Page 601
Sickle cell anemia DIAGNOSTIC FINDINGS Red blood

• Laboratory studies show Hb level is 6 to cells become
With sickle cell anemia, a defect in the Hb 9 g/dl (in a toddler). sickle-shaped?
molecule changes the oxygen-carrying capac- • More than 50% Hb S indicates sickle cell Oh my.
ity and shape of RBCs. The altered Hb mole- disease; a lower level of Hb S indicates sickle
cule is referred to as Hb S. In this disorder, cell trait.
RBCs acquire a sickle shape. • RBCs are crescent-shaped and prone to ag-
The child may experience periodic, painful glutination.
attacks called sickle cell crises. A sickle cell
crisis may be triggered or intensified by: NURSING DIAGNOSES
• dehydration •Ineffective tissue perfusion: Peripheral
• deoxygenation • Impaired gas exchange
• acidosis. • Acute pain
CAUSE TREATMENT
• Genetic inheritance (sickle cell anemia is an • Bed rest
autosomal recessive trait; the child inherits • Hydration with oral or I.V. fluid (may be in-
the gene that produces Hb S from two healthy creased to 3 L/day during crisis)
parents who carry the defective gene) • Short-term oxygen therapy (long-term oxy-
gen decreases bone marrow activity, further
DATA COLLECTION FINDINGS aggravating anemia)
Signs and symptoms vary with the age of the • Transfusion therapy as necessary
child. Before age 4 months, symptoms are • Treatment for acidosis as necessary
rare (because fetal Hb prevents excessive
sickling). Drug therapy
• Analgesic: morphine or hydromorphone
In infants (Dilaudid)
• Colic from pain caused by an abdominal in- • Hydroxyurea (Droxia)
farction • Pneumococcal vaccine
• Dactylitis or hand-foot syndrome from in- Findings for sickle
farction of the small bones of the hands and INTERVENTIONS AND RATIONALES cell anemia vary with
feet • Administer sufficient pain medication (con- age. For example, the
• Splenomegaly from sequestered RBCs cerns regarding addiction are clinically un- spleen is enlarged in a
founded) to promote comfort. young child. As the
In toddlers and preschoolers • Monitor cardiovascular, respiratory, and child grows, the spleen
• Hypovolemia and shock from sequestration neurologic status. Tachycardia, dyspnea, or hy- atrophies.
of large amounts of blood in spleen potension may indicate fluid volume deficit or
• Pain at site of vaso-occlusive crisis electrolyte imbalance. Change in level of con-
sciousness may signal neurologic involvement.
In school-age children and adolescents • Monitor for symptoms of acute chest syn-
• Delayed growth and development and de- drome from a pulmonary infarction to identify
layed sexual maturity early complications.
• Enuresis • Check vision to monitor for retinal infarc-
• Extreme pain at site of crisis tion.
• History of pneumococcal pneumonia and • Encourage the child to receive the pneumo-
other infections due to atrophied spleen coccal vaccine to prevent infection.
• Poor healing of leg wounds from inadequate • Give large amounts of oral or I.V. fluids to
peripheral circulation of oxygenated blood prevent fluid volume deficit and prevent compli-
• Priapism cations.
• Teach the child relaxation techniques to de-
crease the child’s stress level.
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• Maintain the child’s normal body tempera- 1. Phenytoin (Dilantin)

ture to prevent stress and maintain adequate 2. Furosemide (Lasix)
metabolic state. 3. Phytonadione (AquaMEPHYTON)
• Monitor vital signs and intake and output to 4. Aspirin
determine renal function and hydration status. Answer: 4. Aspirin use has been implicated in
• Provide proper skin care to prevent skin the development of Reye’s syndrome in chil-
breakdown. dren with a history of recent acute viral infec-
• Reduce the child’s energy expenditure to tion. Phenytoin, furosemide, and phytona-
improve oxygenation. dione aren’t associated with the development
• Remove tight clothing to prevent inadequate of Reye’s syndrome.
circulation. Client needs category: Physiological
• Suggest family screening and initiate genet- integrity
ic counseling to identify possible carriers of the Client needs subcategory: Reduction of
disease. risk potential
• Provide support to the child and his family Cognitive level: Application
to reduce anxiety and feelings of helplessness.
2. The nurse is teaching the mother of a
Teaching topics child diagnosed with iron deficiency anemia.
• Avoiding activities that promote a crisis, Which statement is true?
such as excessive exercise, mountain climb- 1. Iron shouldn’t be administered with
ing, or deep sea diving foods containing ascorbic acid because
• Avoiding high altitudes they delay absorption.
• Seeking early treatment of illness to prevent 2. Iron should be administered with milk
dehydration products because they enhance absorp-
• Avoiding aspirin use, which enhances acido- tion.
sis and promotes sickling 3. Liquid iron should be administered to
an infant toward the front of the mouth us-
ing an oral syringe.
4. Iron shouldn’t be administered with
milk products because they delay absorp-
tion.
Answer: 4. Iron shouldn’t be administered
with milk products because they delay ab-
sorption. Iron should be administered before
meals with citrus juice (contains ascorbic
acid) because iron is best absorbed in an
acidic environment. To prevent staining of the
teeth, liquid iron should be administered to-
ward the back of the mouth, not the front.
Pump up on practice integrity
questions logical therapies
1. The nurse is taking a history from the
mother of a pediatric client suspected of hav- 3. The nurse is teaching the mother of a pedi-
ing Reye’s syndrome. The history reveals the atric client with sickle cell anemia. Which
use of several medications. Which medication statement by the mother indicates a need for
might be implicated in the development of further teaching?
Reye’s syndrome?
920129.qxd 8/7/08 3:14 PM Page 603
1. “My child can’t possibly have sickle cell Answer: 3. Naturally acquired passive immuni-
anemia. He’s 4 months old and he’s never ty is received through placental transfer and
been sick before.” breast-feeding. Natural immunity is present at
2. “I know my child should receive a pneu- birth. Naturally acquired active immunity oc-
mococcal vaccine when the doctor sug- curs when the immune system makes anti-
gests.” bodies after exposure to disease. Artificially
3. “ I know I should call the pediatrician acquired active immunity occurs when med-
immediately if my child begins to vomit.” ically engineered substances (immunizations)
4. “I know I should try to keep my child’s are ingested or injected to stimulate the im-
body temperature normal by keeping him mune response against a specific disease.
away from fluctuations in temperature.” Client needs category: Safe, effective
Answer: 1. Further teaching is indicated if the care environment
mother states that her child can’t have sickle Client needs subcategory: Safety and
cell anemia because he’s 4 months old and infection control
has never been sick before. Symptoms of Cognitive level: Application
sickle cell anemia rarely appear before age
4 months because the predominance of fetal
hemoglobin prevents excessive sickling. The
child should receive a pneumococcal vaccine
when appropriate. The mother should notify
the physician if the child vomits so that treat-
ment can be initiated to prevent dehydration,
which can precipitate a crisis. Changes in
body temperature may also trigger a crisis
and should be avoided.
integrity
Client needs subcategory: Reduction of 5. The physician prescribes iron supplements
risk potential for a child with iron deficiency anemia. Which
Cognitive level: Analysis adverse reactions may occur as a result of
iron supplementation?
4. The nurse is teaching a mother about the 1. Tachycardia, hypotension, and vomit-
benefits of breast-feeding her infant. Which ing
type of immunity is passed on to the infant 2. Tachycardia, hypertension, and vomit-
during breast-feeding? ing
1. Natural immunity 3. Vomiting, severe stomach pain, and di-
2. Naturally acquired active immunity arrhea
3. Naturally acquired passive immunity 4. Vomiting, severe stomach pain, and pe-
4. Artificially acquired active immunity techiae
Answer: 3. Nausea, vomiting, diarrhea, consti-
pation, fever, and severe stomach pain are ad-
verse reactions associated with iron supple-
mentation. If these occur, the physician
should be notified and the dosage adjusted.
Tachycardia, hypotension, and petechiae may
be present with bleeding disorders but aren’t
associated with iron supplementation. Hyper-
tension isn’t an adverse effect of iron supple-
mentation.
920129.qxd 8/7/08 3:14 PM Page 604
Client needs category: Physiological 7. The nurse is teaching a child with sickle
integrity cell anemia and the child’s mother about ac-
Client needs subcategory: Pharmaco- tivities that may promote a vaso-occlusive cri-
logical therapies sis. Which activity is acceptable for this child?
Cognitive level: Knowledge 1. Skiing
2. Mountain climbing
3. Deep sea diving
4. Softball in the park
Answer: 4. The child with sickle cell anemia

6. The nurse is providing dietary teaching for should be instructed to avoid activities that
the mother of a child with iron deficiency ane- can promote a crisis, such as excessive exer-
mia. Which iron-rich foods should the mother cise, mountain climbing, or deep sea diving.
include in her child’s diet? Extremes in temperature can also promote a
1. Liver, dark leafy vegetables, and whole crisis, so skiing should be avoided. Mountain
grains climbing and deep sea diving may expose the
2. Dark leafy vegetables, chicken, and child to altered atmospheric pressures and a
whole grains deoxygenated state. These conditions can
3. Whole grains, citrus fruit, and yogurt lead to a sickle cell crisis.
4. Citrus fruit, liver, and whole grains Client needs category: Physiological
Answer: 1. The mother should be instructed integrity
to give her child iron-rich foods, such as liver, Client needs subcategory: Reduction of
dark leafy vegetables, and whole grains. risk potential
Chicken is a good source of protein, but it Cognitive level: Application
isn’t high in iron. Citrus fruits aid iron absorp-
tion but aren’t high in iron. Yogurt is a good
source of calcium but isn’t high in iron.
integrity
and comfort
920129.qxd 8/7/08 3:14 PM Page 605
8. A neonate experiences prolonged bleeding

after his circumcision and has multiple bruis-
es without petechiae. These data collection
findings suggest:
1. iron deficiency anemia.
2. hemophilia.
3. sickle cell anemia.
4. leukemia.
Answer: 2. Signs of hemophilia include pro-
longed bleeding after circumcision, immu-
nizations, or minor injuries; multiple bruises
without petechiae; peripheral neuropathies
from bleeding near peripheral nerves; bleed-
ing into the throat, mouth, and thorax; and
hemarthrosis. Signs and symptoms associat-
ed with iron deficiency anemia include dys-
pnea on exertion, fatigue, and listlessness.
Signs and symptoms associated with sickle 9. A child with hemophilia is hospitalized
cell anemia include pain at the site of occlu- with bleeding into the knee. Which action
sion, poor healing of leg wounds, priapism, should the nurse take first?
enuresis, and delayed growth and sexual ma- 1. Prepare to administer a whole blood
turity. Signs and symptoms associated with transfusion.
leukemia include history of infections, lymph- 2. Prepare to administer a plasma transfu-
adenopathy, hematuria, hematemesis, blood sion.
in stools, petechiae, and ecchymosis. 3. Immediately perform active ROM exer-
Client needs category: Physiological cises on the knee
integrity 4. Elevate and immobilize the knee.
Client needs subcategory: Reduction of Answer: 4. Immobilizing and elevating the
risk potential knee help to prevent further injury. The nurse
Cognitive level: Application should anticipate transfusing the missing clot-
ting factor—not whole blood or plasma, which
won’t stop the bleeding promptly and may
pose a risk of fluid overload. Excessive mo-
tion should be avoided for at least 48 hours.
ROM exercises may be initiated after 48
hours but not immediately.
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10. A nurse is caring for a child with AIDS. nuclei, such as clients with tuberculosis. Pro-
Which of the following precautions must the tective isolation is instituted for clients who
nurse maintain? require added protection from infection, such
1. Airborne precautions as those who have undergone bone marrow
2. Standard precautions transplant or those with burns. Strict hand
3. Protective isolation washing should be performed when caring
4. Strict hand washing for all clients.
Answer: 2. The nurse caring for a child with Client needs category: Safe, effective
AIDS should maintain standard precautions. care environment
Airborne precautions are instituted for clients Client needs subcategory: Safety and
known or suspected to be infected with mi- infection control
croorganisms transmitted by airborne droplet Cognitive level: Comprehension
You finished the

chapter on the
pediatric hematologic
and immune systems.
You deserve a hug!
920130.qxd 8/7/08 3:57 PM Page 607
30 Neurosensory
system
• Tear glands begin to secrete within the first
In this chapter,
you’ll learn:
Brush up on key 2 weeks of life.
• Transient strabismus (deviation of the eye)
✐ the function of the concepts is a normal finding in the first few months.
• An infant can fixate on an object and follow
neurosensory system
✐ development of a The central ner vous system (CNS) is the a bright light or toy by 5 to 6 weeks of age.
body’s communication network. It receives • An infant can reach for objects at varying
child’s hearing and
sensory stimuli through the five senses and distances at age 3 to 4 months.
sight
either perceives, integrates, interprets, or • Vision reaches 20/20 when the child is
✐ tests used to diag- retains the stimulus in memory. In an infant, about 4 years old.
nose neurosensory early responses are primarily reflexive; the
disorders infant learns to discriminate stimuli and bring
✐ common neurosenso- motor responses under conscious control.
ry disorders. Language helps the older child improve and
increase perception. In pediatric patients, flac-
Keep abreast of
cid muscles usually indicate a CNS disorder.
diagnostic tests
of this chapter by consulting the Cheat sheet Here are some important tests used to
on pages 608 to 610. diagnose pediatric neurosensory disorders,
along with common nursing interventions
Upward, then downward associated with each test.
In children younger than age 3, the ear canal
is directed upward. In older children, the ear Head check
In time, my most canal is directed downward and forward. A A basic assessment of cerebral function
primitive, reflex-driven
child’s hearing develops as follows: includes:
responses are
replaced by motor • Sound discrimination is present at birth. • level of consciousness
responses that are • By age 5 to 6 months, the infant is able to • communication
under conscious localize sounds presented on a horizontal • mental status.
control. plane and begins to imitate selected sounds.
• By age 7 to 12 months, the infant can local- 3-D pics
ize sounds in any plane. Computed tomography (CT) scan is a
• By age 18 months, the child can hear and radiologic process that produces three-
follow a simple command without visual cues. dimensional images. It can be invasive (if
Children who have difficulty with language contrast medium is used) or noninvasive.
development by age 18 months should have
their hearing evaluated. Nursing actions
• Explain the purpose of test to the parents
First, just alert and the child.
At birth, visual function is limited to alert- • Make sure that the child holds still during
ness to visual stimuli 8⬙ to 12⬙ (20.3 to the test.
30.5 cm) from the eyes. Normal newborns • Make sure that written, informed consent
already have a blink reflex. After that, these has been obtained if a contrast medium is
findings are noted: used. (Text continues on page 610.)
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et
heat she
C
Pediatric neurosensory refresher
ATTENTION DEFICIT HYPERACTIVITY • Range-of-motion (ROM) exercises to minimize
DISORDER contractures
Key signs and symptoms • Muscle relaxants or neurosurgery to decrease
• Decreased attention span spasticity, if appropriate
• Difficulty organizing tasks and activities Key interventions
• Easily distracted • Assist with locomotion, communication, and
Key test results educational opportunities.
• Complete psychological, medical, and neuro- • Divide tasks into small steps.
logic evaluations rule out other problems. • Perform ROM exercises if the child is spastic.
Key treatments DOWN SYNDROME
• Behavioral modification and psychological ther- Key signs and symptoms
apy • Flat, broad forehead
• Amphetamines: methylphenidate (Ritalin), dex- • Mild to moderate retardation
troamphetamine sulfate (Dexedrine), ampheta- • Short stature with pudgy hands
mine sulfate, and amphetamine aspartate (Adder- • Small head with slow brain growth
all) • Small jaw
Key interventions • Upward slanting eyes
• Give one simple instruction at a time. Key test result
• Provide consistency in child’s daily routine. • Amniocentesis allows prenatal diagnosis.
• Reduce environmental stimuli.
Key treatment
CEREBRAL PALSY • Treatment for coexisting conditions—congeni-
A Cheat sheet. Key signs and symptoms tal heart problems, visual defects, or hypothy-
Way cool for the roidism
• Abnormal muscle tone and coordination (the
pediatric
most common associated problem) Key interventions
neurosensory system.
• Difficulty sucking or keeping a nipple or food in • Provide activities appropriate for the child’s
the mouth mental rather than chronological age.
• Infrequent voluntary movement or arm or leg • Set realistic, reachable, short-term goals; break
tremors with voluntary movement tasks into small steps.
• Legs crossed when lifted from behind • Provide stimulation and communicate at a level
Key test results appropriate to the child’s mental age rather than
• Neuroimaging studies determine the site of chronological age.
brain impairment. HYDROCEPHALUS
• Cytogenic studies (genetic evaluation of the
child and other family members) rule out other
• High-pitched cry
potential causes.
• Rapid increase in head circumference and full,
• Metabolic studies rule out other causes.
tense, bulging fontanels (before cranial sutures
Key treatments close)
• Braces or splints and special appliances, such
Key test result
as adapted eating utensils and a low toilet seat
• Skull X-rays show thinning of the skull with sep-
with arms, to help child perform activities inde-
aration of the sutures and widening of fontanels.
pendently
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Pediatric neurosensory refresher (continued)

HYDROCEPHALUS (continued) • Severe, deep, throbbing pain (from pressure behind the tym-
Key treatments panic membrane)
• Ventriculoperitoneal shunt insertion to allow cerebrospinal flu- • Pain that suddenly stops (if tympanic membrane ruptures)
id (CSF) to drain from the lateral ventricle in the brain • Signs of upper respiratory tract infection (sneezing, coughing)
• Anticonvulsants: carbamazepine (Tegretol), phenobarbital Acute secretory otitis media
(Luminal), diazepam (Valium), phenytoin (Dilantin) • Popping, crackling, or clicking sounds on swallowing or with
Key interventions jaw movement
• Monitor vital signs and intake and output. • Sensation of fullness in the ear
• Monitor neurologic status. Chronic otitis media
• After the shunt is inserted, don’t lay the child on the side of the • Cholesteatoma (cystlike mass in the middle ear)
body where it’s located. • Decreased or absent tympanic membrane mobility
• Lay the child flat. • Painless, purulent discharge in chronic suppurative otitis
• If the caudal end of the shunt must be externalized because of media
infection, keep the bag at ear level. Key test results
Acute suppurative otitis media
MENINGITIS • Otoscopy reveals obscured or distorted bony landmarks of the
Key signs and symptoms tympanic membrane.
• Nuchal rigidity that may progress to opisthotonos Acute secretory otitis media
• Positive Brudzinski’s sign (flexion of the knees and hips in re- • Otoscopy reveals clear or amber fluid behind the tympanic
sponse to passive neck flexion) membrane and tympanic membrane retraction, which causes
• Positive Kernig’s sign (inability to extend leg when hip and knee the bony landmarks to appear more prominent. If hemorrhage
are flexed) into the middle ear has occurred, as in barotrauma, the tympanic
Key test results membrane appears blue-black.
• Lumbar puncture shows increased CSF pressure, cloudy color, Chronic otitis media
increased white blood cell count and protein level, and a de- • Otoscopy shows thickening, sometimes scarring, and de-
creased glucose level if the meningitis is caused by bacteria. creased mobility of the tympanic membrane.
• Airborne precautions; should be maintained until at least Acute suppurative otitis media
24 hours of effective antibiotic therapy have elapsed; continued • Myringotomy for children with severe, painful bulging of the
precautions recommended for meningitis caused by Hae- tympanic membrane
mophilus influenzae or Neisseria meningitidis • Antibiotic therapy, usually amoxicillin (Amoxil)
• Seizure precautions Acute secretory otitis media
• Analgesics to treat pain of meningeal irritation • Inflation of the eustachian tube by performing Valsalva’s
• Corticosteroids such as dexamethasone (Decadron) maneuver several times a day, which may be the only treatment
• Parenteral antibiotics: ceftazidime (Fortaz), ceftriaxone (Ro- required
cephin); possibly intraventricular administration of antibiotics • Nasopharyngeal decongestant therapy
Key interventions Chronic otitis media
• Elimination of eustachian tube obstruction
• Excision of cholesteatoma
• Monitor the child’s neurologic status frequently.
• Mastoidectomy
• Examine the young infant for bulging fontanels and measure
• Antibiotic therapy, usually amoxicillin (Amoxil)
head circumference.
Key interventions
OTITIS MEDIA • Watch for and report headache, fever, severe pain, or disorien-
Key signs and symptoms tation.
Acute suppurative otitis media • Instruct parents not to feed their infant in a supine position or
• Fever (mild to very high) put him to bed with a bottle.
(continued)
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Pediatric neurosensory refresher (continued)

OTITIS MEDIA (continued) SPINA BIFIDA
• After myringotomy, maintain drainage flow; place sterile cotton Key signs and symptoms
loosely in the external ear and change cotton frequently. Spina bifida occulta
• After tympanoplasty, reinforce dressings and observe for • Dimple on the skin over the spinal defect
excessive bleeding from the ear canal. • No neurologic dysfunction (usually), except occasional foot
• Warn the child against blowing his nose or getting the ear wet weakness or bowel and bladder disturbances
when bathing. Meningocele
SEIZURE DISORDERS • No neurologic dysfunction (usually)
• Saclike structure protruding over the spine
Myelomeningocele
• Aura just before the seizure’s onset (reports of unusual tastes, • Permanent neurologic dysfunction (paralysis below the spinal
feelings, or odors) defect, bowel and bladder incontinence)
• Eyes deviating to a particular side or blinking
Key test results
• Usually unresponsive during tonic-clonic muscular contrac-
tions; may experience incontinence • Amniocentesis reveals neural tube defect.
• Irregular breathing with spasms • Elevated alpha-fetoprotein levels in mother’s blood may indi-
cate the presence of a neural tube defect.
Key test result
• Acetylcholinesterase measurement can be used to confirm the
• EEG results help differentiate epileptic from nonepileptic diagnosis.
seizures. Each seizure has a characteristic EEG tracing.
Key interventions
Key treatments
• Teach parents how to cope with their infant’s physical prob-
• I.V. diazepam (Valium) or lorazepam (Ativan) lems.
• Phenobarbital (Luminal) or fosphenytoin (Cerebyx) • Teach parents how to recognize early signs of complications,
• Phenytoin (Dilantin) or carbamazepine (Tegretol) to keep neu- such as hydrocephalus, pressure ulcers, and urinary tract infec-
ron excitability below the seizure threshold tions.
Key interventions Before surgery
• Monitor neurologic status. • Watch for signs of hydrocephalus. Measure head circumfer-
• Stay with the child during a seizure. ence daily. Be sure to mark the spot where the measurement
• Move the child to a flat surface. was made.
• Place the child on his side to allow saliva to drain out. • Watch for signs of meningeal irritation, such as fever and
• Don’t try to interrupt the seizure. nuchal rigidity.
After surgery
• Watch for hydrocephalus, which commonly follows surgery.
Measure the infant’s head circumference as ordered.
• Monitor vital signs often.
• If a contrast medium is used, check for al- Nursing actions

lergies to contrast media, shellfish, or iodine. • If the child has any surgically implanted
metal objects (for example, pins and clips),
MRI = More realistic image notify the radiology department because
Magnetic resonance imaging (MRI) shows these objects can interfere with the picture.
the CNS in greater detail than a CT scan. A • Explain the procedure to the parents and
noniodinated contrast medium may be used the child.
to enhance lesions. Advances in MRI allow • Make sure the child holds still during the
visualization of cerebral arteries and venous test.
sinuses without administration of a contrast
medium.
920130.qxd 8/7/08 3:57 PM Page 611
Electrifying activity • Make sure that written, informed consent

Electroencephalography (EEG) shows ab- has been obtained.
normal electrical activity in the brain (for ex- • Identify allergies to contrast media, shell-
ample, from a seizure, a metabolic disorder, fish, or iodine before the test.
or a drug overdose). • Make sure the child holds still during the
test, and monitor him for allergic reaction.
Nursing actions • Immobilize the site after the test, and moni-
• Explain the purpose of the test, and make tor it for pulses and evidence of bleeding.
sure the child holds still during the test. • Monitor neurovascular status distal to the
insertion site.
Wavy reflections
Ultrasonography reveals carotid lesions or Pressure check
changes in carotid blood flow and velocity. Intracranial pressure (ICP) monitoring is
High-frequency sound waves reflect back the a direct, invasive method of identifying trends During
velocity of blood flow, which is then reported in ICP. A subarachnoid screw and an intraven- neurosensory testing,
as a graphic recording of a waveform. tricular catheter convert CSF pressure read- it’s important for the
ings into waveforms that are displayed digital- child to hold still.
Nursing actions ly on an oscilloscope monitor. Another option
• Explain the purpose of the test to the par- is to insert a fiber-optic catheter into the
ents and the child. ventricle, subarachnoid space, subdural
• Make sure the child holds still during the space, or brain parenchyma. Pressure
test. changes are reported digitally or in
waveform.
Fluid check
With lumbar puncture, a needle is inserted Nursing actions
into the subarachnoid space of the spinal Before the procedure
cord, usually between L3 and L4 (or L4 and • Explain the procedure to the parents
L5). This allows aspiration of cerebrospinal and the child.
fluid (CSF) for analysis and for measuring • Make sure that written, informed con-
CSF pressure. sent has been obtained.
After the procedure
Nursing actions • Monitor waveforms and pressure
• Before the procedure, make sure that writ- readings. Identify trends and alert the
ten, informed consent has been obtained. doctor to changes in trends.
• Keep the child in a side-lying, knee-chest • Maintain sterile technique during care of
position during the procedure. monitoring equipment.
• Have the child rest for 1 hour after the pro- • Monitor the site for signs of infection.
cedure.
Nerve times
Vessel visualization Electromyography detects lower motor neu-
With cerebral arteriography, also known as ron disorders, neuromuscular disorders, and
angiography, a catheter is inserted into an nerve damage. A needle inserted into select-
artery—usually the femoral artery—and is in- ed muscles at rest and during voluntary con-
directly threaded up to the carotid artery. traction picks up nerve impulses and mea-
Then a radiopaque dye is injected, allowing sures nerve conduction time.
X-ray visualization of the cerebral vasculature.
Nursing actions
Nursing actions • Explain the procedure to the parents and
• Explain the procedure to the parents and the child.
the child.
920130.qxd 8/7/08 3:57 PM Page 612
• Check the child’s medications for those that Attention deficit hyperactivity
may interfere with the test (cholinergics, anti-
cholinergics, skeletal muscle relaxants). disorder
has been obtained. ADHD, which was previously called attention
• Make sure the child holds still during the deficit disorder, includes the following
procedure. long-term behaviors:
• Monitor the site for infection or bleeding af- • hyperactivity
ter the procedure. • impulsiveness
• inattention.
Exploring the ear These manifestations occur in all facets of
Otoscopic examination allows visualization the child’s life and frequently worsen when
of the canal and inner structures of the ear. sustained attention is required, for example,
during school. To qualify as ADHD, behaviors
Nursing actions must be present in two or more settings, must
• Provide a speculum that fits appropriately be present before age 7, and must result in a
into the ear canal. significant impairment in social or academic
• Help keep the child still during the exami- functioning.
nation.
CAUSE
Getting an eyeful • Deficit in neurotransmitters (possibly)
Ophthalmoscopic examination helps visu-
alize interior eye structures. DATA COLLECTION FINDINGS
• Climbs, runs, or talks excessively
Nursing actions • Decreased attention span
• Explain the procedure to the parents and • Difficulty organizing tasks and activities
the child. • Difficulty waiting for turns
• Allow the child to hold a favorite toy during • Easily distracted
the test to decrease anxiety and promote co- • Fails to give close attention to school work
operation. or activity
• Fails to listen when spoken to directly
• Fidgets or squirms in seat
• Frequent forgetfulness and losing things
Memory
Polish up on patient needed for tasks
• Impulsive behavior
jogger care • Unable to follow directions
Here’s a
tip for re- Major neurologic disorders in pediatric pa- DIAGNOSTIC FINDINGS
membering diagnos- tients are attention deficit hyperactivity disor- • Complete psychological, medical, and neu-
tic criteria for der (ADHD), cerebral palsy, Down syndrome, rologic evaluations rule out other problems.
ADHD: think of a hydrocephalus, meningitis, otitis media, • To diagnose ADHD, the findings are com-
child who can’t SIT seizure disorder, and spina bifida. bined with data from several sources, includ-
still. ing parents, teachers, and the child.
Seven (age by which
symptoms appear) NURSING DIAGNOSES
Impaired social or • Imbalanced nutrition: Less than body re-
academic function quirements
• Risk for impaired parenting
Two or more set-
• Risk for injury
tings
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TREATMENT Cerebral palsy

• Behavioral modification and psychological
therapy Cerebral palsy is a neuromuscular disorder
• Interdisciplinary interventions: pathologic arising from a malfunction of motor centers For a child
assessment and diagnosis of specific learning and neural pathways in the brain. The disor- with ADHD, first
needs der is most commonly seen in children born reduce stimuli
during learning
prematurely. Cerebral palsy can’t be cured;
times. Then allow
Drug therapy treatment includes interventions that encour- him to expend
• Amphetamines: methylphenidate (Ritalin); age optimum development. Defects are com- energy.
dextroamphetamine sulfate (Dexedrine), sac- mon, including musculoskeletal,
charate, amphetamine sulfate, and ampheta- neurologic, GI, and nutritional
mine aspartate (Adderall) to help the child defects as well as other
concentrate systemic complications
• Selective norepinephrine reuptake inhibitor: (abnormal reflexes, fa-
atomoxetine (Strattera) tigue, growth failure, geni-
• Other medications: imipramine (Tofranil), tourinary complaints, res-
clonidine (Catapres) piratory infections).
Classifications of cere-
INTERVENTIONS AND RATIONALES bral palsy include:
• Monitor growth. If the child is receiving • ataxic type—the least
methylphenidate, growth may be slowed. common type; essentially
• Give one simple instruction at a time so the a lack of coordination caused by
child can successfully complete the task, which disturbances in movement and balance
promotes self-esteem. • athetoid type—characterized by involun-
• Give medications in the morning and at tary, uncoordinated motion with varying de-
lunch to avoid interfering with sleep. grees of muscle tension (Children with this
• Ensure adequate nutrition; medications and type of cerebral palsy experience writhing
hyperactivity may cause increased nutrient muscle contractions whenever they attempt
needs. voluntary movement. Facial grimacing, poor
• Reduce environmental stimuli to decrease swallowing, and tongue movements cause
distraction. drooling and poor speech articulation.
• Formulate a schedule for the child to pro- Despite their abnormal appearance, these
vide consistency and routine. children commonly have average or above-
average intelligence.) Cerebral palsy
Teaching topics • rigid type—an uncommon type of cerebral arises from a
• Allowing the child to expend energy after palsy characterized by rigid postures and lack malfunction of motor
being in restrictive environments such as of active movement centers and neural
school • spastic type—the most common type; fea- pathways in the brain.
• Monitoring for adverse reactions to medica- turing hyperactive stretch reflex in associated Well, I’ll be.
tions muscle groups, hyperactive deep tendon
• Structuring learning to minimize distrac- reflexes, rapid involuntary muscle con-
tions traction and relaxation, contractions af-
• Taking breaks from caregiving to avoid fecting extensor muscles, and scissoring
strain (the child’s legs are crossed and the toes
• Teaching important material in the morning are pointed down, so the child stands on
(when medication levels peak) his toes).
• mixed type—more than one type of
cerebral palsy. (These children are usual-
ly severely disabled.)
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Abnormal muscle
CAUSES Spastic cerebral palsy
tone and coordination • Anoxia before, during, or after birth • Hyperactive stretch reflex in associated
characterize all forms • Infection muscle groups
of cerebral palsy. • Trauma (hemorrhage) • Hyperactive deep tendon reflexes
• Rapid involuntary muscle contraction and
Risk factors relaxation
• Low birth weight • Contractures affecting the extensor mus-
• Low Apgar score at 5 minutes cles
• Metabolic disturbances • Scissoring
• Seizures
Mixed cerebral palsy
DATA COLLECTION FINDINGS • Signs of more than one type of cerebral
All types palsy
• Abnormal muscle tone and coordination • Severely disabled
(the most common associated problem)
• Dental anomalies DIAGNOSTIC FINDINGS
• Mental retardation of varying degrees in • Neuroimaging studies determine the site of
18% to 50% of cases (Most children with cere- brain impairment.
bral palsy have at least a normal IQ but can’t • Cytogenic studies (genetic evaluation of the
demonstrate it on standardized tests.) child and other family members) rule out oth-
• Seizures er potential causes.
• Speech, vision, or hearing disturbances • Metabolic studies rule out other causes.
• Difficulty sucking or keeping a nipple or
food in the mouth NURSING DIAGNOSES
• Infrequent voluntary movement or arm or • Impaired physical mobility
leg tremors with voluntary movement • Delayed growth and development
• Legs crossed when lifted from behind • Impaired verbal communication
(rather than being pulled up or “bicycling” as
Although cerebral with a normal infant) TREATMENT
palsy can’t be cured, • Difficulty separating legs, making diaper • High-calorie diet, if appropriate
treatment encourages changing difficult • Artificial urinary sphincter for the inconti-
the child to reach his • Persistent use of only one hand (as infant nent child who can use hand controls
full potential. ages, good hand use but poor leg use) • Braces or splints and special appliances,
such as adapted eating utensils and a low toi-
Ataxic cerebral palsy let seat with arms, to help child perform activ-
• Poor balance and muscle coordination ities independently
• Unsteady, wide-based gait • Neurosurgery to decrease spasticity, if ap-
propriate
Athetoid cerebral palsy • Orthopedic surgery to correct contractures
• Slow state of writhing muscle contractions • Range-of-motion (ROM) exercises to mini-
whenever voluntary movement is attempted mize contractures
• Facial grimacing • Special feeding techniques to overcome ab-
• Poor swallowing normal tongue movements and promote swal-
• Drooling lowing
• Poor speech articulation
Drug therapy
Rigid cerebral palsy • Muscle relaxants to decrease spasticity, if
• Rigid posture appropriate
• Lack of active movement • Anticonvulsants: phenytoin (Dilantin), phe-
nobarbital (Luminal)
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INTERVENTIONS AND RATIONALES leukemia, and a weak immune response to

Provide a safe
• Assist with locomotion, communication, and infection). environment for the
educational opportunities to enable the child to child with cerebral
attain optimal developmental level. CAUSE palsy.
• Increase caloric intake for the child with in- • Genetic nondisjunction, with three chromo-
creased motor function to keep up with in- somes on the 21st pair (total of 47 chromo-
creased metabolic needs. somes), known as trisomy
• Make food easy to manage to decrease stress
during mealtimes. Risk factors
• Promote normal swallowing using special • Maternal age (the older the mother, the
feeding techniques to prevent inadequate nu- greater the risk of genetic nondisjunction)
tritional intake.
• Provide a safe environment, for example, by DATA COLLECTION FINDINGS
using protective headgear or bed pads to pre- • Brushfield’s spots (marbling and speckling
vent injury. of the iris)
• Provide rest periods to promote rest and • Flat, broad forehead
reduce metabolic needs. • Flat nose and low-set ears
• Perform ROM exercises if the child is spas- • Hypotonia
tic to maintain proper body alignment and mo- • Mild to moderate retardation
bility of joints. • Protruding tongue (because of a small oral
• Promote age-appropriate mental activities cavity)
and incentives for motor development to pro- • Short stature with pudgy hands
mote growth and development. • Simian crease (a single crease across the
• Divide tasks into small steps to promote self- palm)
care and activity and increase self-esteem. • Small head with slow brain growth
• Refer the child for speech, nutrition, and • Small jaw
physical therapy to maintain or improve func- • Upward slanting eyes
tioning.
• Use assistive communication devices if the DIAGNOSTIC FINDINGS
child can’t speak to promote a positive self- • Amniocentesis allows prenatal diagnosis. Amniocentesis
concept. It’s recommended for women older than age allows prenatal
34 regardless of a negative family history, or a diagnosis of Down
syndrome. It’s
Teaching topics woman of any age if she or the father carries
recommended for any
• Contacting appropriate social service agen- a translocated chromosome. pregnant patient over
cies, child development specialist, mental • Karyotype shows the specific chromosomal age 34.
health services, home care assistance abnormality.
• Understanding the child’s condition and
prognosis NURSING DIAGNOSES
• Risk for injury
Down syndrome • Risk for aspiration
The first disorder researchers attributed to a TREATMENT

chromosomal aberration, Down syndrome is • Treatment for coexisting conditions—con-
characterized by: genital heart problems, visual defects, or hy-
• mental retardation pothyroidism
• dysmorphic facial features • Skeletal, immunologic, metabolic, biochemi-
• other distinctive physical abnormalities cal, and oncologic problems treated according
(60% of patients have congenital heart defects, to specific problem
respiratory infections, chronic myelogenous
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Drug therapy CAUSES

• Megavitamin therapy (controversial) to pro- • Arnold-Chiari malformation (downward dis-
mote growth and development potential placement of cerebellar components through
the foramen magnum into the cervical spinal
INTERVENTIONS AND RATIONALES canal); common in hydrocephalus with spina
• Provide activities and toys appropriate for bifida
the child’s mental rather than chronological • Overproduction of CSF by the choroid
age to support optimal development. plexus
• Set realistic, reachable, short-term goals; • Scarring, congenital anomalies, or hemor-
break tasks into small steps to encourage their rhage; causes CSF to be absorbed abnormally
successful accomplishment. after it reaches the subarachnoid space (in
• Use behavior modification, if applicable, to communicating hydrocephalus)
promote safety and prevent injury to the child • Tumors, hemorrhage, or structural abnor-
and others. malities; block CSF flow, causing fluid to accu-
• Provide stimulation and communicate at a mulate in the ventricles (in noncommunicat-
level appropriate to the child’s mental age ing hydrocephalus)
rather than chronological age to promote a
healthy emotional environment. DATA COLLECTION FINDINGS
• Provide a safe environment to prevent • “Cracked pot” sound when the skull is per-
injury. cussed
• Mainstream daily routines to promote nor- • Distended scalp veins
malcy. • High-pitched cry
• Provide emotional support to the parents • Inability to support the head when upright
to promote healthy coping skills and reduce • Irritability or lethargy; decreased attention
anxiety. span
• Rapid increase in head circumference and
Teaching topics full, tense, bulging fontanels (before cranial
• Contacting early intervention programs sutures close)
• Contacting support groups for caregivers • Sunset sign (sclera visible above the iris; a
• Establishing self-care skills to promote inde- late sign)
With hydrocephalus, pendence • Widening suture lines
an excessive amount of • Vomiting (usually upon awakening in the
CSF accumulates in morning and not related to food intake)
the ventricular spaces Hydrocephalus
of the brain. DIAGNOSTIC FINDINGS
Hydrocephalus is an increase in the amount • Angiography, CT scan, and MRI differenti-
of CSF in the ventricles and subarachnoid ate hydrocephalus from intracranial lesions
spaces of the brain. The ventricles become and may demonstrate Arnold-Chiari malfor-
dilated because of an imbalance in the rate of mation.
production and absorption of CSF. This condi- • Light reflects off the opposite side of the
tion may be congenital or acquired. skull with skull transillumination.
With noncommunicating hydrocephalus, an • Skull X-rays show thinning of the skull with
obstruction occurs in the free circulation of separation of the sutures and widening of
CSF, causing increased pressure on the brain fontanels.
or spinal cord. In most cases, congenital hy-
drocephalus is noncommunicating. NURSING DIAGNOSES
Communicating hydrocephalus involves the • Risk for injury
free flow of CSF between the ventricles and • Delayed growth and development
the spinal theca. Increased pressure on the • Decreased intracranial adaptive capacity
spinal cord is caused by defective absorption
of CSF.
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TREATMENT Meningitis Meningitis is

• Ventriculoperitoneal shunt insertion to al- transmitted by
low CSF to drain from the lateral ventricle in Meningitis is an inflammation of the brain and the spread of
the brain spinal cord meninges. It’s most common in droplets.
infants and toddlers. The incidence of menin-
Drug therapy gitis is greatly reduced with routine Haemo-
• Anticonvulsants: carbamazepine (Tegretol), philus influenzae type B vaccine.
phenobarbital (Luminal), diazepam (Valium),
phenytoin (Dilantin) CAUSES
• Viral or bacterial agents transmitted by the
INTERVENTIONS AND RATIONALES spread of droplets (organisms enter the blood
• Measure head circumference to aid in diag- from nasopharynx or middle ear)
nosis of hydrocephalus.
• Monitor vital signs and intake and output to DATA COLLECTION FINDINGS
evaluate for fluid volume excess, which can fur- • Coma
ther elevate ICP. • Delirium
• Monitor neurologic status to identify • Fever
changes indicative of increased ICP. • Headache
• After the shunt is inserted, don’t position • High-pitched cry
the child on the side of the body where it’s lo- • Irritability
cated to promote CSF drainage and prevent • Nuchal rigidity that may progress to
shunt occlusion. opisthotonos (arching of the back)
• Position the child flat to avoid rapid decom- • Gradual or abrupt onset following an upper
pression. respiratory infection
• Observe for shunt blockage with increased • Petechial or purpuric lesions possibly pres-
ICP (identified by increased head circumfer- ent in bacterial meningitis
ence and full fontanel) to prevent complica- • Positive Brudzinski’s sign (flexion of the
tions. knees and hips in response to passive neck
• Observe for signs of infection. Signs of flexion)
shunt infection usually occur within the first • Positive Kernig’s sign (inability to extend
month after shunt insertion. leg when hip and knee are flexed)
• If the caudal end of the shunt must be exter- • Projectile vomiting
nalized because of infection, keep the bag at • Seizures
ear level to promote CSF drainage.
• Support the head when child is upright to DIAGNOSTIC FINDINGS
prevent injury and promote CSF drainage. • Lumbar puncture shows increased CSF
• Provide proper skin care to the head; turn pressure, cloudy color, increased WBC count
the patient’s head frequently to avoid skin and protein level, and a decreased glucose
breakdown. level if the meningitis is caused by bacteria.
Teaching topics NURSING DIAGNOSES

• Recognizing signs of increasing ICP • Decreased intracranial adaptive capacity
• Understanding care required after shunt in- • Ineffective breathing pattern
sertion • Risk for injury
TREATMENT
• Burr holes to evacuate subdural effusion, if
present
• Airborne precautions; should be maintained
until at least 24 hours of effective antibiotic
therapy have elapsed; continued precautions
920130.qxd 8/7/08 3:57 PM Page 618
recommended for meningitis caused by H. in- causing pain and, possibly, rupture or perfora-
My, oh
my…meningitis fluenzae or Neisseria meningitidis tion. This condition may be chronic or acute
management • Hypothermia blanket and suppurative or secretory.
mandates • Oxygen therapy, may require intubation Acute otitis media is common in children.
meticulous and mechanical ventilation to induce hyper- Its incidence increases during the winter
monitoring: Check ventilation to decrease ICP months, paralleling the seasonal increase in
vital signs, head • Seizure precautions nonbacterial respiratory tract infections. With
circumference, • Treatment for coexisting conditions prompt treatment, the prognosis for acute oti-
intake, output, and tis media is excellent; however, prolonged ac-
neurologic status. Drug therapy cumulation of fluid in the middle ear cavity
• Analgesics to treat pain of meningeal irrita- causes chronic otitis media and, possibly, per-
tion foration of the tympanic membrane.
• Corticosteroids: dexamethasone (Deca-
dron) CAUSES
• Parenteral antibiotics: ceftazidime (Fortaz), All types
ceftriaxone (Rocephin); possibly intraventric- • Obstructed eustachian tube
ular administration of antibiotics • Wider, shorter, more horizontal eustachian
tubes and increased lymphoid tissue in chil-
INTERVENTIONS AND RATIONALES dren as well as other anatomic anomalies
• Monitor vital signs and intake and output to
assess for fluid volume excess. Acute suppurative otitis media
• Monitor the child’s neurologic status fre- • Bacterial infection with pneumococci, H.
quently to detect signs of increased ICP. influenzae (the most common cause in chil-
• Provide a dark and quiet environment. Envi- dren under age 6), Moraxella (Branhamella)
ronmental stimuli can increase ICP or stimu- catarrhalis, beta-hemolytic group A strepto-
late seizure activity. cocci, staphylococci (most common cause in
• Maintain seizure precautions to prevent in- children age 6 or older), or gram-negative
jury. bacteria
• Administer medications as ordered to com- • Respiratory tract infection, allergic reaction,
bat infection and decrease ICP. nasotracheal intubation, or position changes
• Move the child gently to prevent a rise in that allow nasopharyngeal flora to reflux
ICP. through the eustachian tube and colonize the
• Maintain isolation precautions, as ordered, middle ear
The I’s have it with to prevent the spread of infection.
otitis media: incidence • Provide emotional support for the family to Chronic suppurative otitis media
of inflamed areas that decrease anxiety. • Inadequate treatment of acute otitis media
may be infected • Examine the young infant for bulging episodes
increase in winter. fontanels and measure head circumference; • Infection by resistant strains of bacteria
hydrocephalus is a complication that can result • Tuberculosis (rarely)
from meningitis.
Acute secretory otitis media
Teaching topics • Barotrauma (pressure injury caused by in-
• Understanding the importance of isolation ability to equalize pressure between the envi-
and sanitation ronment and the middle ear), as occurs dur-
ing rapid aircraft descent in a person with up-
per respiratory tract infection or during rapid
Otitis media underwater ascent in scuba diving (barotitis
media)
Otitis media is inflammation of the middle ear • Obstruction of the eustachian tube sec-
that’s sometimes accompanied by infection. ondary to eustachian tube dysfunction from
The fluid presses on the tympanic membrane, viral infection or allergy, which causes a
920130.qxd 8/7/08 3:57 PM Page 619
buildup of negative pressure in the middle ear DIAGNOSTIC FINDINGS

that promotes transudation of sterile serous Acute suppurative otitis media
fluid from blood vessels in the membrane of • Culture of the ear drainage identifies the
the middle ear causative organism.
• Otoscopy reveals obscured or distorted
Chronic secretory otitis media bony landmarks of the tympanic membrane.
• Persistent eustachian tube dysfunction from • Pneumatoscopy may show decreased tym- In acute
mechanical obstruction (adenoidal tissue panic membrane mobility, but this procedure suppurative otitis
media, pulling the
overgrowth or tumors), edema (allergic rhini- is painful with an obviously bulging, erythe-
pinna doesn’t
tis or chronic sinus infection), or inadequate matous tympanic membrane. worsen the pain.
treatment of acute suppurative otitis media
Acute secretory otitis media
DATA COLLECTION FINDINGS • Otoscopy reveals clear or amber fluid be-
Acute suppurative otitis media hind the tympanic membrane and tympanic
• Bulging and erythema of tympanic mem- membrane retraction, which causes the
brane bony landmarks to appear more
• Dizziness prominent. If hemorrhage into the
• Ear pain that suddenly stops (if tympanic middle ear has occurred, as in baro-
membrane ruptures) trauma, the tympanic membrane ap-
• Fever (mild to very high) pears blue-black.
• Hearing loss (usually mild and conductive)
• Nausea and vomiting Chronic otitis media
• Pain pattern (pulling the pinna doesn’t exac- • Otoscopy shows thickening, sometimes
erbate pain) scarring, and decreased mobility of the tym-
• Pulling on the ear panic membrane.
• Purulent drainage in the ear canal from • Pneumatoscopy shows decreased or absent
tympanic membrane rupture tympanic membrane movement.
• Severe, deep, throbbing ear pain (from
pressure behind the tympanic membrane) NURSING DIAGNOSES
• Signs of upper respiratory tract infection • Hyperthermia
(sneezing and coughing) • Acute pain
• Tinnitus (ringing in the ears) • Disturbed sensory perception (auditory)
Acute secretory otitis media TREATMENT

• Echo heard by child when speaking; vague Acute suppurative otitis media
feeling of top-heaviness (caused by accumula- • Myringotomy for patients with severe,
tion of fluid) painful bulging of the tympanic membrane
• Popping, crackling, or clicking sounds on Drug therapy
swallowing or with jaw movement • Antibiotic therapy, usually amoxicillin
• Sensation of fullness in the ear (Amoxil); antibiotics must be used with dis-
• Severe conductive hearing loss cretion to prevent development of resistant
strains of bacteria in patients with recurring
Chronic otitis media otitis media
• Cholesteatoma (cystlike mass in the middle • Amoxicillin-clavulanate potassium (Aug-
ear) mentin) in areas with a high incidence of
• Decreased or absent tympanic membrane beta-lactamase-producing H. influenzae and in
mobility patients who aren’t responding to amoxicillin
• Painless, purulent discharge in chronic sup- • Cefaclor (Ceclor) or co-trimoxazole
purative otitis media (Bactrim) for patients allergic to penicillin de-
• Thickening and scarring of the tympanic rivatives
membrane
920130.qxd 8/7/08 3:57 PM Page 620
• Prevention: broad-spectrum antibiotics, • For children with acute secretory otitis me-
such as amoxicillin-clavulanate potassium dia, watch for and immediately report pain
(Augmentin) or cefuroxime (Ceftin) in high- and fever to detect early signs of secondary in-
risk patients fection.
• Tell the parents to avoid feeding the infant
Acute secretory otitis media in a supine position or putting him to bed with
• Concomitant treatment of the underlying a bottle to prevent reflux of nasopharyngeal
cause, such as elimination of allergens or ade- flora.
noidectomy for hypertrophied adenoids • Encourage the child to perform Valsalva’s
• Inflation of the eustachian tube by perform- maneuver several times daily to promote eu-
ing Valsalva’s maneuver several times a day, stachian tube patency.
which may be the only treatment required • After myringotomy, maintain drainage flow;
• Myringotomy and aspiration of middle ear place sterile cotton loosely in the external ear
fluid if decongestant therapy fails, followed by to absorb drainage, and change the cotton fre-
insertion of a polyethylene tube into the tym- quently to prevent infection.
Mastoidectomy is panic membrane for immediate and pro- • After tympanoplasty, reinforce dressings,
removal of the longed equalization of pressure; the tube falls and observe for excessive bleeding from the
mastoid process or out spontaneously after 9 to 12 months ear canal to determine fluid volume deficit.
mastoid cells of the
Drug therapy
temporal bone.
• Nasopharyngeal decongestant therapy for Teaching topics
at least 2 weeks; sometimes used indefinitely, • Avoiding blowing the nose or getting the
with periodic evaluation ear wet when bathing
• Instilling nasopharyngeal decongestants
Chronic otitis media properly, if prescribed
• Elimination of eustachian tube obstruction • Recognizing upper respiratory tract infec-
• Excision of cholesteatoma tions and getting early treatment
• Mastoidectomy • Returning for follow-up examination after
• Treatment of otitis externa; myringoplasty completion of antibiotic therapy
and tympanoplasty to reconstruct middle ear
structures when thickening and scarring are
present Seizure disorder
Drug therapy
• Broad-spectrum antibiotics, such as A seizure is a sudden, episodic, involuntary al-
amoxicillin-clavulanate potassium (Aug- teration in consciousness, motor activity, be-
mentin) or cefuroxime (Ceftin), for exacerba- havior, sensation, or autonomic function. (See
tions of otitis media Classifying seizures.) Epilepsy is a common,
recurrent seizure disorder.
• Monitor vital signs to determine baseline val- CAUSES
ues and detect early signs of worsening infec- • Excessive neuronal discharges (epilepsy)
tion. • Hyperexcitable nerve cells that surpass the
• Watch for and report headache, fever, se- seizure threshold
vere pain, or disorientation to detect early signs • Neurons overfiring without regard to stim-
of complications. uli or need
• Administer analgesics as needed, or apply
heat to the ear to relieve pain. DATA COLLECTION FINDINGS
• Identify and treat allergies to prevent recur- • Aura just before the seizure’s onset (reports
rences of otitis media. of unusual tastes, feelings, or odors)
• Encourage the child and his parents to com- • Eyes deviating to a particular side or blink-
plete the prescribed course of antibiotic treating
ment to prevent reinfection. • Irregular breathing with spasms
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Classifying seizures
Seizures can take various forms, depending on their origin and whether they’re localized to one area of the brain, as occurs in par-
tial seizures, or occur in both hemispheres, as happens in generalized seizures. This chart describes each type of seizure and lists
common signs and symptoms.
Type Description Signs and symptoms
Partial
Simple Symptoms confined to one hemisphere Possibly motor (change in posture), sensory (hal-
partial lucinations), or autonomic (flushing, tachycardia)
symptoms; no loss of consciousness
Complex Begins in one focal area but spreads to both hemispheres Loss of consciousness, aura of visual distur-
partial (more common in adults) bances, postictal symptoms
Generalized
Absence Sudden onset; lasts 5 to 10 seconds; can have 100 daily; pre- Loss of responsiveness but continued ability to
(petit mal) cipitated by stress, hyperventilation, hypoglycemia, or fatigue; maintain posture control and not fall; twitching
differentiated from daydreaming eyelids; lip smacking; no postictal symptoms
Myoclonic Movement disorder (not a seizure) that occurs as child awak- No loss of consciousness; sudden, brief, shock-
ens or falls asleep; may be precipitated by touch or visual like involuntary contraction of one muscle group
stimuli; may be focal or generalized and symmetrical or asym-
metrical
Clonic Opposing muscles contract and relax alternately in rhythmic Mucus production
pattern; may occur in one limb more than others
Tonic Muscles are maintained in continuous contracted state (rigid Variable loss of consciousness; pupils dilate;
posture) eyes roll up; glottis closes; possible incontinence;
may foam at mouth
Tonic-clonic Violent total body seizure Aura; tonic first (20 to 40 seconds), followed by
(grand mal, clonic; postictal symptoms
major motor)
Atonic Drop and fall attack; needs to wear protective helmet Loss of posture tone
Akinetic Sudden, brief loss of muscle tone or posture Temporary loss of consciousness
(continued)
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Classifying seizures (continued)
Type Description Signs and symptoms
Miscellaneous
Febrile Seizure threshold lowered by elevated temperature; occurs Lasts less than 5 minutes; generalized, transient,
when temperature is rapidly rising; only one seizure per fever; and nonprogressive; doesn’t generally result in
common in 4% of population younger than age 5 brain damage; EEG is normal after 2 weeks
Status Prolonged or frequent repetition of seizures without interrup- Consciousness not regained between seizures;
epilepticus tion; results in anoxia and cardiac and respiratory arrest lasts more than 30 minutes
• Usually lack of responsiveness during tonic- INTERVENTIONS AND RATIONALES

clonic muscular contractions, possibly accom- • Monitor vital signs to determine baseline val-
panied by incontinence ues and detect any changes.
• May be disoriented to time and place, • Monitor neurologic status to detect changes.
drowsy, and uncoordinated immediately after • Stay with the child during a seizure to pre-
a seizure vent injury.
• Move the child to a flat surface to prevent
DIAGNOSTIC FINDINGS falling.
• EEG results help differentiate epileptic • Place the child on his side to allow saliva to
from nonepileptic seizures. Each seizure has drain out to ensure a patent airway.
a characteristic EEG tracing. • Don’t try to interrupt the seizure to promote
safety.
When a seizure NURSING DIAGNOSES • Gently support the head and keep the
occurs, collect
• Ineffective airway clearance child’s hands from inflicting self-harm, but
data on neurologic
status, move the • Risk for injury don’t restrain the child to prevent injury.
child to a flat • Disturbed sensory perception (tactile) • Don’t use tongue blades; use of tongue
surface, place him blades during seizure activity may cause trau-
on his side, and TREATMENT ma to the mouth and result in airway obstruc-
stay with him. • Drug therapy; if not responsive, ablative tion from an aspirated tooth or laryngospasm.
therapy • Reduce external stimuli to avoid worsening
• Supportive care (maintaining airway, pro- seizure activity.
tecting from injury) until seizure ends • Loosen tight clothing to promote comfort.
• Ketogenic diet when drug therapy fails • Record seizure activity. Description of
seizure activity helps to diagnose the type, which
Drug therapy will aid in developing a treatment plan.
• Sedatives: I.V. diazepam (Valium) or loraze- • Pad the crib or bed to prevent injury.
pam (Ativan) • Monitor serum levels of anticonvulsant
• Anticonvulsants: phenobarbital (Luminal) medications, such as phenytoin, to prevent tox-
or fosphenytoin (Cerebyx); phenytoin (Dilan- icity or subtherapeutic levels.
tin), or carbamazepine (Tegretol) to keep
neuron excitability below the seizure thresh- Teaching topics
old • Controlling seizures
• Instituting safety measures during seizure
activity
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Spina bifida Myelomeningocele

• Arnold-Chiari syndrome
Spina bifida has two main forms. Spina bifida • Clubfoot
occulta, the more common and less severe • Curvature of the spine
form, is characterized by incomplete closure • Knee contractures
of one or more vertebrae without protrusion • Permanent neurologic dysfunction (paraly-
of the spinal cord or meninges (membranes sis below the spinal defect, bowel and bladder
covering the spinal cord). Spina bifida cystica, incontinence)
the more severe form, is distinguished by in- • Possible mental retardation
complete closure of one or more vertebrae • Saclike structure protruding over the spine
that causes protrusion of the spinal contents
in an external sac or cystic lesion. DIAGNOSTIC FINDINGS
Spina bifida cystica has two classifications: • Amniocentesis reveals neural tube defect.
• Elevated alpha-fetoprotein levels in moth- Hmmm… Spina
meningocele, an external sac that con- er’s blood may indicate the presence of a bifida occulta and
tains meninges and CSF neural tube defect. meningocele rarely
cause neurologic
• Acetylcholinesterase measurement can be
dysfunction. However,
myelomeningocele, an external sac that used to confirm the diagnosis. myelomeningocele may
contains meninges, CSF, and a portion of the • After birth, spinal X-ray can show the bone cause permanent
spinal cord or nerve roots. defect. problems.
• Fetal karyotype should be done in addition
CAUSES to the biochemical tests because of the associ-
• Combination of genetic and environmental ation of neural tube defects with chromoso-
factors mal abnormalities.
• Exposure to a teratogen • Myelography can differentiate spina bifida
• Part of a multiple malformation syndrome from other spinal abnormalities, especially
(for example, chromosomal abnormalities spinal cord tumors.
such as trisomy 18 or 13 syndrome) • Ultrasound may identify the open neural
• Low intake of folic acid by mother before tube or ventral wall defect.
and during pregnancy
NURSING DIAGNOSES
DATA COLLECTION FINDINGS • Delayed growth and development
Spina bifida occulta • Impaired physical mobility
• Dimple on the skin over the spinal defect • Risk prone health behavior
• No neurologic dysfunction (usually), except
occasional foot weakness or bowel and blad- TREATMENT
der disturbances • Meningocele: surgical closure of the pro-
• Port wine nevi on the skin over the spinal truding sac and continual assessment of
defect growth and development
• Soft fatty deposits on the skin over the • Myelomeningocele: repair of the sac
spinal defect (doesn’t reverse neurologic deficits) and sup-
• Trophic skin disturbances (ulcerations, portive measures to promote independence
cyanosis) and prevent further complications
• Tuft of hair on the skin over the spinal de- • Spina bifida occulta: usually no treatment
fect
Meningocele Before surgery
• No neurologic dysfunction (usually) • Hold and cuddle the infant on your lap and
• Saclike structure protruding over the spine position him on his abdomen; handle the in-
fant carefully, and don’t apply pressure to the
defect to prevent injury at the site of the defect.
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• Clean the defect, inspect it often, and cover After surgery

it with sterile dressings moistened with sterile • Watch for hydrocephalus, which commonly
normal saline solution to prevent infection. follows surgery. Measure the infant’s head
• Usually, the infant can’t wear a diaper or a circumference, as ordered, to detect signs of
shirt until after surgical correction because it hydrocephalus and prevent associated complica-
will irritate the sac, so keep him warm in an tions.
infant Isolette to prevent hypothermia. • Monitor vital signs often to detect early signs
• Watch for signs of hydrocephalus. Measure of shock, infection, and increased ICP.
head circumference daily. Be sure to mark • Change the dressing regularly, as ordered,
the spot where the measurement was made to and check for and report any signs of drain-
ensure accurate readings. age, wound rupture, and infection to promote
• Watch for signs of meningeal irritation, early treatment and prevent complications.
such as fever and nuchal rigidity, to detect • Place the infant in the prone position to pro-
signs of meningitis. tect and assess the site.
• Perform passive range-of-motion exercises • If leg casts have been applied to treat defor-
and casting to minimize contractures. To pre- mities, watch for signs that the child is out-
vent hip dislocation, moderately abduct the growing them. Regularly check distal pulses
hips with a pad between the knees, or with to ensure adequate circulation.
sandbags and ankle rolls. • When spina bifida is diagnosed prenatally,
• Monitor intake and output. Watch for de- refer the prospective parents to a genetic
creased skin turgor and dryness to detect de- counselor, who can provide information and
hydration. support the couple’s decisions on how to man-
• Provide a diet high in calories and protein to age the pregnancy.
ensure adequate nutrition.
Teaching topics
• Handling the infant without applying pres-
sure to the defect
• Coping with the infant’s physical problems
Teaching for spina • Recognizing early signs of complications,
bifida focuses on coping such as hydrocephalus, pressure ulcers, and
skills, long-term treatment urinary tract infections
goals, and recognizing
• Maintaining a positive attitude and working
complications.
through feelings of guilt, anger, and helpless-
ness
• Conducting intermittent catheterization and
conduit hygiene
• Recognizing developmental lags (a possible
result of hydrocephalus)
• Ensuring maximum mental development
• Planning activities appropriate to the child’s
age and abilities
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2. The nurse is collecting data on a child who

may have a seizure disorder. Which of the fol-
lowing is a description of an absence seizure?
1. Sudden, momentary loss of muscle
tone
2. Minimal or no alteration in muscle
tone, with a brief loss of responsiveness
3. Loss of muscle tone and temporary loss
of consciousness
4. Brief, sudden contraction of a muscle or
muscle group
Answer: 2. Absence seizures are character-
ized by a brief loss of responsiveness with
Pump up on practice minimal or no alteration in muscle tone. They
may go unrecognized because the child’s be-
questions havior changes very little. A sudden, momen-
tary loss of muscle tone describes atonic
seizures. Loss of muscle tone and temporary
1. The nurse is collecting data on a child who loss of consciousness characterize akinetic
may have meningitis. For which findings seizures. A brief, sudden contraction of mus-
should the nurse watch? cles describes a myoclonic seizure.
1. Flat fontanel Client needs category: Physiological
2. Irritability, fever, and vomiting integrity
3. Jaundice, drowsiness, and refusal Client needs subcategory: Physiolog-
to eat ical adaptation
4. Negative Kernig’s sign Cognitive level: Knowledge
Answer: 2. Data collection findings associated
with acute bacterial meningitis include irri- 3. The nurse is caring for a child who’s expe-
tability, fever, and vomiting along with seizure riencing a seizure. Which nursing interven-
activity. Fontanels would be bulging as ICP tion takes highest priority when caring for
rises. Jaundice, drowsiness, and refusal to eat this child?
may indicate a GI disturbance rather than 1. Protect the child from injury.
meningitis. Kernig’s sign would be present 2. Use a padded tongue blade to protect
due to meningeal irritation. the airway.
Client needs category: Physiological 3. Shout at the child to end the seizure.
integrity 4. Allow seizure activity to end without in-
Client needs subcategory: Physiolog- terference.
ical adaptation Answer: 1. The nurse should identify the
Cognitive level: Knowledge seizure type and protect the child from injury.
A padded tongue blade should never be used
because it can cause damage to the mouth
and airway. Shouting will only agitate or con-
fuse the child. Interfering with seizure activity
may cause injury to the child. Allowing the
seizure activity to end without interference
may cause the child injury. The nurse should
position the child on his side to ensure a
patent airway and place the child on the
ground if he’s likely to fall and sustain injury.
920130.qxd 8/7/08 3:57 PM Page 626
Client needs category: Physiological 2. Deep-set eyes, which appear to look up-
integrity ward only
Client needs subcategory: Reduction of 3. Rapid increase in head size and irritabil-
risk potential ity
Cognitive level: Analysis 4. Motor and sensory dysfunction in the
foot and leg
Answer: 3. Hydrocephalus is an increase in
the amount of CSF in the ventricles and sub-
arachnoid spaces of the brain. Data collection
findings associated with hydrocephalus in-
clude a rapid increase in head size, irritability,
suture line separation, and bulging fontanels.
The eyes appear to look downward only, with
the cornea prominent over the iris (sunset
sign). The loss of sensory and motor function
is related to the spinal cord defect of spina bi-
fida—not hydrocephalus.
integrity
risk potential
4. The nurse is caring for a child with spina Cognitive level: Comprehension
bifida. Which factor determines the extent of
sensory and motor function loss in the lower
limbs of the child?
1. Maternal age at conception
2. Degree of spinal cord abnormality
3. Uterine environmental factors such as
cloudy amniotic fluid
4. Time frame from diagnosis to birth of
the infant
Answer: 2. The extent of motor and sensory
loss primarily depends on the degree of spinal
cord abnormality. Secondarily, it depends on
traction or stretch resulting from an abnor-
mally tethered cord, trauma to exposed neu- 6. The nurse is teaching a father whose in-
ral tissue during delivery, and postnatal dam- fant has had several episodes of otitis media.
age resulting from drying or infection of the Which statement made by the father indicates
neural plate. Maternal age and uterine envi- that he needs further teaching?
ronment haven’t been identified as factors. 1. “Children who live in homes where
The time from diagnosis to birth isn’t related. family members smoke have fewer infec-
Client needs category: Physiological tions.”
integrity 2. “The eustachian tube in infants is short-
Client needs subcategory: Physiolog- er and less angled than in older children.”
ical adaptation 3. “Breast-feeding is one way to help de-
Cognitive level: Knowledge crease the number of infections.”
4. “I wrap him up and always put a hat on
5. The nurse is caring for an infant with spina him when we go out.”
bifida. Which data collection findings suggest Answer: 1. Children who live in households
hydrocephalus? where smoking occurs have more, not fewer,
1. Depressed fontanels and suture lines respiratory infections that lead to otitis media.
920130.qxd 8/7/08 3:57 PM Page 627
The other statements about otitis media are 8. The nurse is teaching the mother of a
correct. child with ADHD how to manage the child.
Client needs category: Safe, effective Which statement by the mother indicates that
care environment she needs further teaching?
Client needs subcategory: Safety and 1. “I only give him one direction at a
infection control time.”
Cognitive level: Application 2. “I encourage my child to ride his bike
after school.”
3. “My child enjoys rollerblading with
friends.”
4. “I have my child do homework right af-
ter school.”
Answer: 4. Children with ADHD need time to
expend their energy after being in a restric-
tive environment such as school. They need
time to participate in activities that they enjoy,
such as running, bike riding, or inline skat-
ing. Homework should be done later in the
evening, not right after school.
integrity
7. The school nurse is monitoring several Cognitive level: Application
children with ADHD who are taking
methylphenidate (Ritalin). The nurse should
conduct monthly follow-up examinations to
monitor:
1. if the child is experiencing a dry
mouth.
2. if the child is growing in height.
3. the parent’s coping abilities from the
child’s perspective.
4. when the child is taking the medication.
Answer: 2. Common adverse reactions to
methylphenidate include slowed growth in
height, sleeplessness, decreased appetite, and
crying. Dry mouth is a common adverse reac-
tion to tricyclic antidepressants. Knowing how 9. The nurse is caring for an infant with spina
the parents are coping from the child’s per- bifida. What’s the most important technique
spective may be helpful information, but it for diagnosing hydrocephalus?
isn’t the most important. Knowing when the 1. Measurement of head circumference
child takes the medication would be impor- 2. Skull X-ray showing a thinning skull
tant if the child has problems with sleepless- 3. Angiography revealing hydrocephalus
ness. 4. MRI revealing hydrocephalus
Client needs category: Physiological Answer: 1. Measuring head circumference is
integrity the most important monitoring technique for
Client needs subcategory: Pharmaco- diagnosing hydrocephalus and is a key part of
logical therapies routine infant screening. Skull X-rays, angiog-
Cognitive level: Application raphy, and MRI may be used to confirm the
diagnosis.
920130.qxd 8/7/08 3:57 PM Page 628
Client needs category: Health promo- Answer: 2. After the shunt is inserted, the
tion and maintenance nurse should avoid positioning the child on
Client needs subcategory: None the side of the body where the shunt is locat-
Cognitive level: Comprehension ed. The child should lie supine to avoid rapid
decompression. The child shouldn’t be in an
10. The nurse is caring for a child after shunt upright, semi-Fowler’s, or prone position.
insertion to relieve hydrocephalus. Which in- Client needs category: Physiological
tervention should the nurse perform? integrity
1. Position the child in an upright posi- Client needs subcategory: Reduction of
tion. risk potential
2. Avoid positioning the child on the side Cognitive level: Application
where the shunt is located.
3. Position the child in semi-Fowler’s
position.
4. Position the child in a prone position.
Congratulations!
Finishing this
chapter shows you
have a lot of nerve!
920131.qxd 8/7/08 3:58 PM Page 629
31 Musculoskeletal
system
• Greenstick fractures of the long bones are
In this chapter,
you’ll learn:
Brush up on key related to the increased flexibility of the
young child’s bones. (The compressed side of
✐ the function of the pe- concepts the bone bends while the side under tension
fractures.)
diatric musculoskele-
tal system The musculoskeletal system is a complex
system of bones, muscles, ligaments, ten-
dons, and other connective tissues. The
nose musculoskeletal
disorders
functions of the musculoskeletal system
include:
Keep abreast of
✐ common pediatric
musculoskeletal dis-
• giving the body form and shape
• protecting vital organs
diagnostic tests
orders. • making movement possible Here are some important tests used to diag-
• storing calcium and other minerals nose musculoskeletal disorders, along with
• providing the site for hematopoiesis (blood common nursing interventions associated
cell formation). with each test.
At any point, you can review the major Using physical examination to assess the
points of this chapter by consulting the Cheat pediatric patient’s musculoskeletal function
sheet on pages 630 and 631. and ability is also an important element in di-
agnosis.
Growing pains
Here are a few facts about the pediatric Look inside the joint
musculoskeletal system: Arthroscopy is the visual examination of the
Growing • Bones and muscles grow and develop interior of a joint with a fiber-optic endoscope.
is my throughout childhood.
business. • Bone lengthening occurs in the epiphyseal Nursing actions
plates at the ends of bones; when the epiphy- • Explain the procedure to the parents and
ses close, growth stops. child.
• Bone healing occurs much faster in the • Make sure that written, informed consent
child than in the adult because the child’s has been obtained.
bones are still growing. • Tell the child and his parents that he will
• The younger the child, the faster the bone need to fast after midnight before the proce-
heals. dure.
• Bone healing takes approximately 1 week • Note allergies because local anesthesia is
for every year of life up to age 10. used.
• Tell the child he may feel a thumping sensa-
Fractured logic tion as the cannula is inserted into the joint
The most common fractures in the child are capsule.
clavicular fractures and greenstick frac- • After the procedure, explain activity restric-
tures: tions and ice application to control swelling.
• Clavicular fractures may occur during vagi-
nal birth because the shoulders are the
widest part of the body.
920131.qxd 8/7/08 3:58 PM Page 630
et
heat she
C
Pediatric musculoskeletal refresher
CLUBFOOT Key treatments
Key signs and symptoms • A hip-spica cast or corrective surgery for older
• Can’t be corrected manually (distinguishes true children
clubfoot from apparent clubfoot) • Bryant’s traction
Key test result • Casting or a Pavlik harness to keep the hips and
knees flexed and the hips abducted for at least
• X-rays show superimposition of the talus and
3 months
calcaneus and a ladderlike appearance of the
metatarsals. Key interventions
Key treatments • Give reassurance that early, prompt treatment
will probably result in complete correction.
• Correcting deformity with a series of casts or
• Assure the parents that the child will adjust to
surgical correction
restricted movement and return to normal sleep-
• Maintaining correction until foot gains normal
ing, eating, and playing in a few days.
muscle balance
• Observing foot closely for several years to pre- DUCHENNE’S MUSCULAR DYSTROPHY
vent foot deformity from recurring Key signs and symptoms
Key interventions • Eventual muscle weakness and wasting
• Ensure that shoes fit correctly. • Gowers’ sign (use of hands to push self up from
• Prepare for surgery, if necessary. floor)
Don’t worry. If you • Pelvic girdle weakness, indicated by waddling
use the Cheat sheet, I DEVELOPMENTAL HIP DYSPLASIA
gait and falling
promise I won’t tell. Key signs and symptoms
Key test results
• Affected side exhibits an increased number of
• Electromyography typically demonstrates short,
folds on posterior thigh when child is supine with
weak bursts of electrical activity in affected mus-
knees bent
cles.
• Appearance of shortened limb on affected side
• Muscle biopsy shows variation in the size of
when child is supine
muscle fibers and, in later stages, shows fat and
• Restricted abduction of hips
connective tissue deposits, with no dystrophin.
Key test results
Key treatments
• Barlow’s sign: A click is felt when the infant is
• Physical therapy
placed supine with hips flexed 90 degrees and
• Surgery to correct contractures
when the knees are fully flexed and the hip is
• Use of such devices as splints, braces, trapeze
brought into midabduction.
bars, overhead slings, and a wheelchair to help
• Ortolani’s click: It can be felt by the fingers at
preserve mobility
the hip area as the femur head snaps out of and
back into the acetabulum. It’s also palpable dur- Key interventions
ing examination with the child’s legs flexed and • Perform range-of-motion exercises.
abducted. • If respiratory involvement occurs, encourage
• Positive Trendelenburg’s test: When the child coughing, deep-breathing exercises, and di-
stands on the affected leg, the opposite pelvis aphragmatic breathing.
dips to maintain erect posture. • Encourage adequate fluid intake, increase
dietary fiber, and obtain an order for a stool
softener.
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Pediatric musculoskeletal refresher (continued)

FRACTURES Key treatments
Key signs and symptoms • Heat therapy: warm compresses, baths
• Loss of motor function • Splint application
• Muscle spasm Key intervention
• Pain or tenderness • Monitor joints for deformity.
• Skeletal deformity
• Swelling SCOLIOSIS
• X-rays may be used to confirm location and extent of fracture. • Disappearance of the curve in the spinal column
Nonstructural scoliosis
Key treatments
• When the child bends at the waist to touch the toes, the curve
• Casting in the spinal column disappears.
• Reduction and immobilization of the fracture Structural scoliosis
• Surgery: open reduction and external fixation of the fracture • Failure of the spinal curve to straighten and asymmetry of the
Key interventions hips, ribs, shoulders, and shoulder blades when the child bends
• Keep the child in proper body alignment. forward with the knees straight and the arms hanging down to-
• Provide support above and below the fracture site when mov- ward the feet
ing the child. Key test result
• Elevate the fracture above the level of the heart. • X-rays may aid diagnosis.
• Apply ice to the fracture to promote vasoconstriction.
Key treatments
• Monitor pulses distal to the fracture every 2 to 4 hours.
• Monitor color, temperature, and capillary refill. • Nonstructural scoliosis: postural exercises, shoe lifts
• Structural scoliosis: steel rods, prolonged bracing, spinal
JUVENILE RHEUMATOID ARTHRITIS fusion
• Inflammation around joints After spinal fusion and insertion of rods
• Stiffness, pain, and guarding of affected joints • Turn the child by logrolling only.
Key test results • Maintain the child in correct body alignment.
• Hematology studies reveal an elevated erythrocyte sedimenta- • Maintain the bed in a flat position.
tion rate, a positive antinuclear antibody test, and the presence
of rheumatoid factor.
Soft-tissue sighting • Tell the child to hold still during the proce-
A computed tomography (CT) scan is used dure.
to identify injuries to the soft tissue, liga- • Tell the child that he’ll be placed in a tube-
ments, tendons, and muscles. like circle for the study and pictures will be
taken of the extremity.
Nursing actions
• Explain the procedure to the parents and Cross-section check
child. Magnetic resonance imaging (MRI) allows
• Make sure written, informed consent has cross-sectional imaging of bones and joints.
been obtained if a contrast medium is used. MRI, which uses a strong magnetic field and
• If a contrast medium is being used, check radio waves, has largely replaced arthrogra-
for allergies to shellfish, contrast media, or io- phy for assessing joint anatomy.
dine.
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MRI is also used to assess certain muscle and destruction as well as measure bone den-
X-rays are a great
tool for identifying and soft tissue injuries. No ionizing radiation sity.
calcifications, bone is used.
deformities, and Nursing actions
fractures as well as Nursing actions • Explain the test to the parents and child.
measuring bone • Explain the procedure to the parents and • Tell the child he must hold still during the
density. child. X-ray. Cover the genital area with a lead
• Instruct the child to hold still during the apron.
procedure.
• Note if the child has any metal implants,
which may interfere with the study.
Spinal vision
Myelography is an invasive procedure used
to evaluate abnormalities of the spinal canal
care
and cord. It entails injection of a radiopaque Major musculoskeletal disorders in pediatric
contrast medium into the subarachnoid space patients are clubfoot (talipes), developmental
of the spine. Serial X-rays are then used to vi- hip dysplasia (dislocated hip), Duchenne’s
sualize the progress of the contrast medium muscular dystrophy, fractures, juvenile
as it passes through the subarachnoid space. rheumatoid arthritis, and scoliosis.
Nursing actions
• Explain the procedure to the parents and Clubfoot
child.
• Make sure that written, informed consent Clubfoot, also known as talipes, is a congenital
has been obtained. disorder in which the foot and ankle are twist-
• Before the test, check for allergies to the ed and can’t be manipulated into correct posi-
Combos are contrast medium. tion. Clubfoot occurs in these five forms:
common. Nearly all •If metrizamide (Amipaque) is used as the • talipes equinovarus: combination of posi-
cases of clubfoot are contrast medium, discontinue phenothiazines tions
equinovarus, involving 48 hours before the test. • talipes calcaneus: dorsiflexion, as if walking
a combination of
• When the contrast medium is injected, tell on one’s heels
abnormal positions.
the child that he may experience a burning • talipes equinus: plantar flexion, as if point-
sensation, warmth, headache, salty taste, nau- ing one’s toes
sea, and vomiting. • talipes valgus: eversion of the ankles, with
• After the test, have the child sit in his room the feet turning out
or lie in bed with his head elevated 60 de- • talipes varus: inversion of the ankles, with
grees. He must not lie flat for at least 8 hours. the soles of the feet facing each other.
• Encourage the child to drink extra fluids.
• Check that the child voids within 8 hours CAUSES
after returning to his room. • Arrested development during the 9th and
• Instruct the child and his parents to imme- 10th weeks of embryonic life, when the feet
diately report pain, weakness, irritability, se- are formed
vere headache, or headache that lasts longer • Deformed talus and shortened Achilles
than 24 hours. tendon
• Possible genetic predisposition
Hard tissue check
X-rays are probably the most useful diagnos- DATA COLLECTION FINDINGS
tic tool to evaluate musculoskeletal disorders. • Deformity usually obvious at birth
They can help to identify joint disruption, cal- • Can’t be corrected manually (distinguishes
cifications, and bone deformities, fractures, true clubfoot from apparent clubfoot)
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DIAGNOSTIC FINDINGS mur is still cartilaginous and the acetabulum

• X-rays show superimposition of the talus (socket) is shallow; as a result, the head of
and calcaneus and a ladderlike appearance of the femur comes out of the hip socket. It can
the metatarsals. affect one or both hips and occurs in varying Memory
degrees of dislocation, from partial (subluxa- jogger
NURSING DIAGNOSES tion) to complete.
• Delayed growth and development When you
• Impaired physical mobility CAUSES think OTB,
• Risk for peripheral neurovascular dysfunc- • Breech delivery
don’t think Off
Track Betting.
tion • Fetal position in utero Instead think of
• Genetic predisposition Ortolani, Trendelen-
TREATMENT • Laxity of the ligaments burg, and Barlow—
Treatment is administered in three stages: • Multiple fetuses all key tests in
diagnosing hip dys-
Correcting the deformity with either sur- DATA COLLECTION FINDINGS plasia.
gical correction or a series of casts to gradual- • On the affected side, an increased number
ly stretch and realign the angle of the foot of folds on the posterior thigh when the child
and, after cast removal, application of Denis is supine with knees bent
Browne splint at night until age 1 • Appearance of a shortened limb on the af-
fected side
Maintaining the correction until the foot • Restricted abduction of the hips
gains normal muscle balance
DIAGNOSTIC FINDINGS
Observing the foot closely for several • Barlow’s sign is present: A click is felt when
years to prevent the deformity from recur- the infant is placed in a supine position with
ring. hips flexed 90 degrees, knees fully flexed, and
the hip brought into midabduction.
INTERVENTIONS AND RATIONALES • Ortolani’s click is present: It can be felt by What’s the
• Monitor neurovascular status to ensure cir- the fingers at the hip area as the femur head common goal of
culation to the foot with cast in place. snaps out of and back into the acetabulum. treatment for
• Ensure that shoes fit correctly to promote It’s also palpable during examination with the developmental hip
dysplasia? Enlarging
comfort and prevent skin breakdown. child’s legs flexed and abducted.
and deepening the
• Prepare the child for surgery, if necessary, • Sonography and MRI may be used to assess acetabulum through
to maintain or promote healing process and to reduction. pressure.
decrease anxiety. • Trendelenburg’s test is positive: When the
child stands on the affected leg, the opposite
Teaching topics pelvis dips to maintain erect posture.
• Using a blow-dryer on the cool setting to • Ultrasonography shows the involved carti-
provide relief of itching lage and acetabulum.
• Importance of placing nothing inside the • X-rays show the location of the femur head
cast and a shallow acetabulum; X-rays can also be
• Keeping corrective devices on as much as used to monitor progression of the disorder.
possible
• Walking as exercise after surgical repair NURSING DIAGNOSES
Developmental hip dysplasia • Risk for impaired skin integrity
Developmental hip dysplasia (dislocated hip) TREATMENT

results from an abnormal development of the • A hip-spica cast or corrective surgery for
hip socket. It occurs when the head of the fe- older children
920131.qxd 8/7/08 3:58 PM Page 634
• Bryant’s traction, if the acetabulum doesn’t CAUSE

deepen • Sex-linked recessive trait
• Casting or a Pavlik harness to keep the hips
and knees flexed and the hips abducted for at DATA COLLECTION FINDINGS
least 3 months • Cardiac or pulmonary failure
• Decreased ability to perform self-care activi-
INTERVENTIONS AND RATIONALES ties
• Monitor circulation before application of • Delayed motor development
cast or traction; after application, have the • Eventual contractures and muscle hypertro-
child wiggle his toes to detect signs of impaired phy
circulation. The nurse should be able to place • Eventual muscle weakness and wasting
one finger between the child’s skin and the • Gowers’ sign (use of hands to push self up
cast. from floor)
• Provide skin care to prevent skin breakdown. • Pelvic girdle weakness, indicated by wad-
• Give reassurance that early, prompt treat- dling gait and falling
ment will probably result in complete correc- • Toe-walking
tion to decrease anxiety.
• Assure the parents that the child will adjust DIAGNOSTIC FINDINGS
to restricted movement and return to normal • Electromyography typically demonstrates
sleeping, eating, and play in a few days to ease short, weak bursts of electrical activity in af-
anxiety. fected muscles.
• Inspect skin, especially around bony promi- • Muscle biopsy shows variations in the size
nences, to detect cast complications and skin of muscle fibers and, in later stages, shows fat
breakdown. and connective tissue deposits, with no dys-
trophin.
Teaching topics
• Correctly splinting or bracing the hips NURSING DIAGNOSES
• Receiving frequent checkups • Impaired gas exchange
• Coping with restricted movement • Impaired physical mobility
• Removing braces and splints while bathing • Impaired walking
Here’s a piece of
the muscular the child and replacing them immediately af-
dystrophy puzzle: terward TREATMENT
Duchenne’s begins • Stressing good hygiene • Gene therapy (under investigation to pre-
with a waddling gait vent muscle degeneration)
and falling, indicating • High-fiber, high-protein, low-calorie diet
pelvic girdle weakness. Duchenne’s muscular • Physical therapy
• Surgery to correct contractures
dystrophy • Use of such devices as splints, braces,
trapeze bars, overhead slings, and a wheel-
A genetic disorder that occurs only in males, chair to help preserve mobility
Duchenne’s muscular dystrophy (also called
pseudohypertrophic dystrophy) is marked by INTERVENTIONS AND RATIONALES
muscular deterioration that progresses • Perform range-of-motion (ROM) exercises
throughout childhood. It generally results in to promote joint mobility.
death from cardiac or respiratory failure in • Provide emotional support to the child and
the late teens or early 20s because of a defect his parents to decrease anxiety and promote
on the X chromosome that prevents produc- coping mechanisms.
tion of dystrophin. The absence of dystrophin • If respiratory involvement occurs, encour-
results in breakdown of muscle fibers. Muscle age coughing, deep-breathing exercises, and
fibers are replaced with fatty deposits and col- diaphragmatic breathing to maintain a patent
lagen in muscles. There’s no known cure.
920131.qxd 8/7/08 3:58 PM Page 635
airway and mobilize secretions to prevent com- DATA COLLECTION FINDINGS

plications associated with retained secretions. • Bony crepitus
• Encourage the use of a footboard or high- • Bruising
topped sneakers and a foot cradle to increase • Impaired sensation
comfort and prevent footdrop. • Loss of motor function
• Encourage adequate fluid intake, increase • Muscle spasm
dietary fiber, and obtain an order for a stool • Pain or tenderness
softener to prevent constipation associated with • Paralysis
inactivity. • Paresthesia
• Skeletal deformity
Teaching topics • Swelling
• Recognizing early signs of respiratory com-
plications DIAGNOSTIC FINDING
• Avoiding long periods of bed rest and inac- • X-rays confirm the location and extent of
tivity, if necessary, by limiting television view- the fracture.
ing and other sedentary activities
• Planning a low-calorie, high-protein, high- NURSING DIAGNOSES
fiber diet (because child is prone to obesity • Ineffective tissue perfusion (peripheral)
from reduced physical activity) • Acute pain
• Helping the child maintain peer relation- • Risk for impaired skin integrity
ships and realize his intellectual potential (En-
courage parents to keep child in regular TREATMENT
school as long as possible.) • Casting
• Referring parents to a local support group • Reduction and immobilization of the frac-
ture
• Surgery: open reduction and external fixa-
Fractures tion of the fracture
Accidents are the
• Traction, depending on the site of the frac-
number one cause of
A fracture is a break in the bone’s integrity. ture (see Common orthopedic treatments, fractures during
With a complete fracture, the bone is entirely page 636) childhood.
broken across, resulting in a break in the
bone’s continuity. An incomplete fracture ex- INTERVENTIONS AND RATIONALES
tends only partially through the bone without • Keep the child in proper body alignment to
completely destroying the bone’s continuity. A promote bone healing and prevent tissue
closed (or simple) fracture doesn’t puncture damage.
the skin surface, whereas an open (or com- • Provide support above and below the
pound) fracture punctures through the skin fracture site when moving the child to
surface. promote comfort.
Common sites of fractures include the arm, • Monitor for any pressure areas
clavicle, knee, and femur. The outcome usual- caused by traction, the child’s cast,
ly depends on the severity of the fracture and or bedclothes to prevent a break in
the treatment provided. Potential complica- skin integrity and tissue damage.
tions include fat emboli, improper bone • Elevate the fracture above the lev-
growth, compartment syndrome, and infec- el of the heart to promote venous re-
tion. turn and decrease edema.
• Apply ice to the fracture to pro-
CAUSES mote vasoconstriction, which inhibits
• Childhood accidents, such as falls and mo- edema and pain.
tor vehicle accidents (most common cause) • Monitor pulses distal to the fracture
• Child abuse every 2 to 4 hours to monitor blood flow to the
• Pathologic conditions distal extremity.
920131.qxd 8/7/08 3:58 PM Page 636
Common orthopedic treatments

The use of casts, traction, and braces are • Keep the cast level but on a slant, with • Provide stimulation appropriate for the
common orthopedic treatments. the head of the bed raised: child.
– The body and cast should stay at Bryant’s traction
CASTS
180 degrees. This is the only skin traction designed
A cast is a hard mold that encases a
– The head of the bed is raised on specifically for the lower extremities of
body part, usually an extremity, to provide
shock blocks or the mattress is raised the child under age 2; the child’s body
immobilization without discomfort.
using a wedge pillow so that the child weight provides countertraction.
General cast care is on a slant with the head up. • Legs are kept straight and extend
• Turn the cast frequently to dry all sides; – Urine and stools drain downward 90 degrees toward the ceiling from the
use palms to lift or turn a wet cast to pre- away from the cast. trunk; both legs are suspended even if
vent indentations. – A Bradford frame can be used for this only one is affected.
• Expose as much of the cast to air as purpose. • The buttocks are kept slightly off the
possible, but cover exposed body parts. • Use a mattress firm enough to support bed to ensure sufficient and continuous
• Be aware of discomfort to the child be- the cast; use pillows to support parts of traction on the legs.
cause chemical changes in the drying the cast, if needed. • Traction may be followed by application
cast cause temperature extremes • Reposition frequently to avoid pressure of a hip-spica cast.
against the child’s skin. on the skin and the bony prominences;
• After it’s dry, maintain a dry cast; wet- check for pressure as the child grows. BRACES
ting the cast softens it and may cause • Provide sponge baths to prevent the A brace is a plastic shell or metal-hinged
skin irritation. cast from becoming wet. appliance that aids mobility and posture.
• Smooth out the cast’s rough edges, and • Inspect cast for cracks, dents, soften- Brace-related care
petal the edges. ing, and drainage. • Provide good skin care, especially at
• Monitor circulation: Note the color, • Increase fluid intake but avoid fruit the bony prominences.
temperature, and edema of digits. Note juices that may cause diarrhea. • Check to ensure accurate fit as the
the child’s ability to wiggle the extremi- • Increase dietary fiber and fluids to pre- child grows.
ties without tingling or numbness. vent constipation. • When applying full body braces to the
• Observe for any drainage or foul odor spastic child, put the feet in first.
from the cast. TRACTION Milwaukee brace
• Prevent small objects or food from Traction decreases muscle spasms and
• Attempts to slow the progression of
falling into the cast. realigns and positions bone ends. It
spinal curvature of less than 40 degrees
• Don’t use powder on the skin near the works by pulling on the distal ends of
until bone growth stops
cast; it becomes a medium for bacteria bones.
• Extends from the iliac crest of the pelvis
when it absorbs perspiration. • Skin traction pulls indirectly on the
to the chin
• Instruct the child and his family to notify skeleton by pulling on the skin with adhe-
• Must be fitted
the doctor if numbness, tingling, burning, sive, moleskin, or elastic bandage.
• Can be used until the child reaches
stinging, increased swelling, increased • Skeletal traction pulls directly on the
skeletal maturity
pain, or loss of movement distal to the skeleton with pins or tongs.
• Must be worn 20 to 23 hours a day; may
cast occur. Traction-related care be removed for bathing and swimming
Hip-spica cast • Check that the weights hang free. Boston brace
A hip-spica cast is a body cast extending • Check for skin irritation, infection at pin
• Functions the same as a Milwaukee
from midchest to legs. sites, and neurovascular response of the
brace
• The legs are abducted with a bar be- extremity.
• Extends from the axillary area to the ili-
tween them; never lift or turn the child • Prevent constipation by increasing flu-
ac crest; must be fitted
with the crossbar. ids and fiber.
• Can be easily covered by clothing
• Perform cast care as listed above but • Prevent respiratory congestion by pro-
with additional measures. moting pulmonary hygiene using blowing
• Line the back edges of the cast with games.
plastic or other waterproof material. • Provide pain relief if necessary.
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• Monitor color, temperature, and capillary CAUSES

refill to determine whether the affected extremi- • Autoimmune response
ty is adequately perfused. • Genetic predisposition
• Monitor sensation to determine whether per-
fusion to the nerves is intact. DATA COLLECTION FINDINGS
• Use pediatric pain assessment tools to deter- • Inflammation around the joints
mine the level of pain. • Stiffness, pain, and guarding of the affected
• Turn and reposition the child every 2 hours joints
to help relieve skin pressure and prevent skin
breakdown. DIAGNOSTIC FINDINGS
• Protect cast from moisture and petal the • Hematology studies reveal an elevated ery-
edges to promote healing of the fracture and throcyte sedimentation rate, a positive antinu-
prevent skin breakdown. clear antibody test, and the presence of
rheumatoid factor.
Teaching topics • Slit-lamp evaluation may show iridocyclitis
• Caring for a child in cast or traction (inflammation of the iris and the ciliary body).
• Preventing injury
• Reporting signs of infection or complica- NURSING DIAGNOSES
tions • Disturbed body image
• Chronic pain
Juvenile rheumatoid arthritis
TREATMENT
Juvenile rheumatoid arthritis (JRA) is an • Heat therapy: warm compresses, baths
autoimmune disease of the connective tissue. • Splint application
It’s characterized by chronic inflammation of • Exercise
the synovia and possible joint destruction.
Episodes recur with remissions and exacerba- Drug therapy
tions. • Low-dose corticosteroids
The three main forms of JRA are: • Low-dose methotrexate (Rheumatrex) used JRA usually
• pauciarticular JRA—asymmetrical involve- as a second-line medication involves the joints but
ment of fewer than five joints, usually affect- • Nonsteroidal anti-inflammatory drugs: can also affect the
ing large joints, such as the knees, ankles, naproxen (Naprosyn), ibuprofen (Motrin) heart, lungs, liver, and
and elbows. spleen.
• polyarticular JRA—symmetrical involve- INTERVENTIONS AND RATIONALES
ment of five or more joints, especially hands • Monitor joints for deformity to detect early
and weight-bearing joints, such as hips, changes as a complication of this disease
knees, and feet. Involvement of the temporo- process.
mandibular joint may cause earache; involve- • Administer medications, as prescribed, and
ment of the sternoclavicular joint may cause note their effectiveness to relieve pain and
chest pain. prevent further joint damage.
• systemic disease with polyarthritis—in- • Assist with ROM and other exercises to
volves the lining of the heart and lungs, blood maintain joint mobility.
cells, and abdominal organs. Exacerbations • Apply warm compresses or encourage the
may last for months. Fever, rash, and lymph- child to take a warm bath in the morning to
adenopathy may occur. promote comfort and increase mobility.
• Apply splints to maintain a functional posi-
tion and prevent contractures.
• Provide assistive devices if necessary to
encourage the normal performance of daily
activities.
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Nonstructural
Teaching topics DIAGNOSTIC FINDING
scoliosis is • Understanding how stress and climate can • X-rays may aid the diagnosis.
marked by a C influence exacerbations
curve that • Receiving preventive eye care NURSING DIAGNOSES
disappears when • Delayed growth and development
the child bends • Disturbed body image
at the waist… Scoliosis • Impaired physical mobility
Scoliosis is a lateral curvature of the spine, TREATMENT

which occurs more commonly among fe- Nonstructural scoliosis
males. It’s commonly identified at puberty • Postural exercises
and throughout adolescence. Scoliosis stops • Shoe lifts
progressing when bone growth stops.
Structural scoliosis
CAUSES • Electrical stimulation for mild to moderate
Nonstructural (functional or postural) curvatures
scoliosis • Harrington, Luque, or Cotrel-Dubousset
• Nonprogressive C curve from some other rods for curves greater than 40 degrees (to
condition, such as poor posture, or unequal realign the spine or when curves fail to re-
leg length spond to orthotic treatment)
• Possible prolonged bracing (Milwaukee or
Structural (progressive) scoliosis Boston brace)
• Progressive S curve with a primary and • Skin traction or halo femoral traction
compensatory curvature resulting in spinal • Spinal fusion with bone from the iliac crest
…Whereas and rib changes
structural scoliosis • Unknown origin INTERVENTIONS AND RATIONALES
is characterized by • Birth defect After spinal fusion and insertion of rods
an S curve that • Neuromuscular, connective tissue, or • Monitor vital signs and intake and output to
doesn’t disappear,
rheumatoid disease detect early signs of dehydration.
even when the child
bends. • Injury • Turn the child only by logrolling to prevent
• Abnormal growth or tumor injury.
• Maintain correct body alignment to promote
DATA COLLECTION FINDINGS joint mobility and prevent injury.
Nonstructural scoliosis • Maintain the bed in a flat position to prevent
• Disappearance of the curve in the spinal injury and complications.
column when the child bends at the waist to • Help the child adjust to the increase in
touch the toes height and altered self-perception to promote
self-esteem and decrease anxiety.
Structural scoliosis
• Failure of the spinal curve to straighten and Teaching topics
asymmetry of the hips, ribs, shoulders, and • Performing stretching exercises for the
shoulder blades when the child bends for- spine
ward with the knees straight and the arms • Helping the child maintain self-esteem
hanging down toward the feet
920131.qxd 8/7/08 3:58 PM Page 639
Answer: 3. Because a local anesthetic is used

before the procedure, the mother should
make sure the physician is aware of her
child’s allergy to lidocaine. The child may feel
a thumping sensation as the cannula is insert-
ed in the joint capsule. The child may need to
fast after midnight before the procedure. The
arthroscopy procedure requires that written,
informed consent be obtained.
integrity
risk potential
Pump up on practice Cognitive level: Knowledge
questions
1. A child is diagnosed with developmental
hip dysplasia. Which treatment is effective in
reducing hip dysplasia in older children?
1. Body cast
2. Frejka pillow
3. Double pillow
4. Hip-spica cast
Answer: 4. The hip-spica cast is the effective
method for reducing hip dysplasia in older
children. The hip-spica cast is used when an 3. A child is diagnosed with developmental
abduction brace is ineffective or if an adduc- hip dysplasia. Which device other than the
tion contracture is present. The other devices hip-spica cast is used in the treatment of this
aren’t effective for hip dysplasia. condition?
Client needs category: Physiological 1. Pillow
integrity 2. Denis Browne splint
Client needs subcategory: Physiolog- 3. Pavlik harness
ical adaptation 4. Foot cast
Cognitive level: Knowledge Answer: 3. A Pavlik harness is used to stabi-
lize the hip. A regular pillow isn’t sufficient. A
2. A child must undergo arthroscopy. You Denis Browne splint is used to treat talipes
know your teaching about the procedure has equinovarus. A foot cast isn’t effective for hip
been effective when the mother states: dysplasia.
1. “I’m glad he won’t feel anything during
the procedure.”
2. “I’m glad he doesn’t have to fast before
the procedure.”
3. “I need to tell the doctor that he’s aller-
gic to lidocaine.”
4. “I don’t need to sign a consent form for
the procedure.”
920131.qxd 8/7/08 3:58 PM Page 640
Client needs category: Physiological Answer: 3. A blow-dryer on the cool setting

integrity should be directed toward the itchy area to
Client needs subcategory: Physiolog- provide relief. Nothing should be put inside
ical adaptation the cast because this can cause further skin
Cognitive level: Knowledge irritation. Water would wet the cast and
wouldn’t be helpful. Hydrocortisone cream
can ball up and be irritating, and it would be
difficult to apply inside the cast.
integrity
risk potential
4. A child has been placed in a hip-spica cast.

The cast is properly positioned if:
1. it’s snug, allowing some movement of
the extremity.
2. it allows no extremity movement but al-
lows one finger to fit between the skin and
the cast.
3. it’s snug, allowing no movement of the
extremity.
4. it’s snug without disturbing the client’s
neurovascular status.
Answer: 2. The nurse should be able to place 6. A child has undergone repair of a clubfoot
one finger between the child’s skin and the and is allowed full activity. The nurse is teach-
cast. The child should be unable to move the ing the child’s parents about activities for the
extremity, but the cast shouldn’t fit snugly. child. Which activity would benefit the child
Client needs category: Safe, effective most?
care environment 1. Walking
Client needs subcategory: Safety and 2. Playing catch
infection control 3. Standing
Cognitive level: Knowledge 4. Swimming
Answer: 1. Walking stimulates all of the in-
5. A child’s clubfoot has been placed in a volved muscles and helps to strengthen them.
cast. The child develops itching under the All the options are good exercises for club-
cast and asks the nurse for help. The nurse foot, but walking is the best choice.
should: Client needs category: Physiological
1. use sterile applicators to relieve the integrity
itch. Client needs subcategory: Physiolog-
2. apply water under the cast. ical adaptation
3. apply cool air under the cast with a Cognitive level: Application
blow-dryer.
4. apply hydrocortisone cream.
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7. The nurse is treating a child with JRA. Client needs category: Physiological
Which factors can exacerbate the condition? integrity
1. Stress and climate Client needs subcategory: Reduction of
2. Dehydration and climate risk potential
3. Exposure to cold Cognitive level: Comprehension
4. Exercise
Answer: 1. Exacerbations of JRA can be pre-
cipitated by exposure to stress and climate.
Dehydration and exposure to cold can precipi-
tate vaso-occlusive crisis in the client with
sickle cell anemia. Exposure to cold can pre-
cipitate an exacerbation of Raynaud’s disease.
Exercise should be encouraged in the child
with JRA.
integrity
risk potential
Cognitive level: Knowledge 9. The nurse is developing a dietary teaching
plan for a child with Duchenne’s muscular
8. A child is admitted with an undiagnosed dystrophy. The nurse should include instruc-
musculoskeletal condition. Which diagnostic tions for which type of diet in the child’s
tool is most useful in evaluating a musculo- teaching plan?
skeletal disorder? 1. Low-calorie, high-protein, and high-
1. Myelography fiber diet
2. MRI 2. Low-calorie, high-protein, and low-fiber
3. CT scan diet
4. X-rays 3. High-calorie, high-protein diet, and re-
Answer: 4. X-rays are the most useful diagnos- stricted fluids
tic tool to evaluate musculoskeletal diseases. 4. High-calorie, high-protein, and high-
They can be used to help identify joint disrup- fiber diet
tion, bone deformities, calcifications, and Answer: 1. A child with muscular dystrophy is
bone destruction and fractures as well as to prone to constipation and obesity, so dietary
measure bone density. Myelography is an in- intake should include a diet low in calories,
vasive procedure used to evaluate abnormali- high in protein, and high in fiber. Adequate
ties of the spinal canal and cord. MRI, a form fluid intake should also be encouraged.
of cross-sectional imaging using a strong Client needs category: Physiological
magnetic field and radio waves, has largely re- integrity
placed arthrography for assessing joint anato- Client needs subcategory: Basic care
my. A CT scan can be used to identify injuries and comfort
of soft tissue, ligaments, tendons, and mus- Cognitive level: Knowledge
cles.
920131.qxd 8/7/08 3:58 PM Page 642
10. The nurse is teaching the mother of a Answer: 2. Teaching is successful when the
child with scoliosis. The nurse knows that mother shows concern about her daughter’s
teaching has been successful when the moth- feelings toward wearing a brace for scoliosis
er makes which statement? correction. Although scoliosis ceases to
1. “I’m glad my daughter will outgrow this progress when bone growth stops, the child
deformity.” won’t outgrow the deformity. Stretching exer-
2. “I’m afraid that my daughter will feel cises for the spine may help improve scolio-
unattractive because she must wear a sis. Prolonged bracing is usually indicated to
brace.” correct the deformity.
3. “I’ll make sure that my daughter Client needs category: Physiological
doesn’t do any stretching exercises that integrity
could worsen her spine.” Client needs subcategory: Reduction of
4. “I’m glad my daughter will only need to risk potential
wear a brace for a short period of time.” Cognitive level: Analysis
Boning up on the
pediatric musculoskeletal
system before taking the
NCLEX was smart. Now get
ready to muscle your way
through the next chapter.
920132.qxd 8/7/08 3:59 PM Page 643
32 Gastrointestinal
system
• Increased myelination of nerves to the anal
In this chapter,
you’ll learn:
Brush up on key sphincter allows for physiologic control of
bowel function, usually around age 2.
✐ parts of the GI system concepts • The liver’s slow development of glycogen
storage capacity makes the infant prone to
and their function
✐ tests used to diag- The GI tract, also known as the alimentar y hypoglycemia.
canal, consists of a long, hollow, muscular • From ages 1 to 3, composition of intestinal
nose GI disorders
tube that includes several glands and accesso- flora becomes more adultlike and stomach
✐ common pediatric
ry organs. It performs the crucial task of sup- acidity increases, reducing the number of GI
GI disorders. plying essential nutrients to fuel the other or- infections.
gans and body systems. Because the GI sys-
tem is so crucial to the rest of the body Nutrient breakdown
systems, any problem in this system can The GI tract breaks down food (carbohy-
quickly affect the overall health, growth, and drates, fats, and proteins) into molecules
development of the child. small enough to permeate cell membranes,
At any time, you can review the major points thus providing cells with the necessary ener-
of this chapter by consulting the Cheat sheet gy to function properly. The GI tract prepares
on pages 644 and 645. food for cellular absorption by altering its
physical and chemical composition. (See Di-
GI junior gestive organs and glands, page 647. )
Listed here are characteristics of the pediatric
GI system: Malfunction junction
• Peristalsis occurs within 21⁄2 to 3 hours in A malfunction along the GI tract can produce
the neonate and extends to 3 to 6 hours in old- far-reaching metabolic effects, eventually
er infants and children. threatening life itself. A common indication of
• Stomach capacity of the neonate is 30 to GI problems is referred pain, which makes di-
60 ml, which gradually increases to 200 to agnosis especially difficult.
350 ml by age 12 months and to 1,500 ml
Thanks to the
by adolescence.
GI tract, I can get
• The neonatal abdomen is larger than the
a good meal.
chest up to age 8 weeks, and the musculature
is poorly developed.
Keep abreast of
• The sucking and extrusion reflex persists to
age 3 to 4 months (extrusion reflex protects
diagnostic tests
the infant from foods that its system is too im- Here are some important tests used to diag-
mature to digest). nose GI system disorders, along with com-
• At age 4 months, saliva production begins mon nursing interventions associated with
and aids in the process of digestion. each test.
• Spit-ups are frequent in the neonate be-
cause of the immature muscle tone of the low- Swallow this
er esophageal sphincter and the low volume Barium swallow is primarily used to exam-
capacity of the stomach. ine the esophagus.
920132.qxd 8/7/08 3:59 PM Page 644
et
heat she
C
Pediatric gastrointestinal refresher
ACETAMINOPHEN POISONING Key treatments
Key signs and symptoms • Cheiloplasty performed between 2 and
• Diaphoresis 3 months of age to unite lip and gum edges in
• Nausea and vomiting anticipation of teeth eruption, providing route for
Key test results adequate nutrition and sucking
• Cleft palate repair surgery; scheduled at about
• Serum aspartate aminotransferase and serum
age 18 months to allow for growth of palate and
alanine aminotransferase levels become elevat-
to be done before infant develops speech pat-
ed soon after ingestion.
terns; infant must be free from ear and respirato-
• Acetaminophen levels are greatly elevated.
ry infections
Key treatment
Key interventions
• Gastric lavage
• Be alert for respiratory distress when feeding.
Key interventions Before cleft lip repair surgery
• Monitor vital signs and intake and output. • Hold the infant while feeding and promote suck-
• Monitor cardiovascular and GI status. ing between meals.
CELIAC DISEASE After cleft lip repair surgery
• Observe for cyanosis as the infant begins to
breathe through the nose.
• Generalized malnutrition and failure to thrive
• Keep infant’s hands away from the mouth by us-
due to protein and carbohydrate malabsorption
ing restraints or pinning the sleeves to the shirt;
• Steatorrhea and chronic diarrhea due to fat
use adhesive strips to hold the suture line in place.
malabsorption
• Anticipate the infant’s needs.
• Weight and height below normal for age-group
• Place the infant on the right side to prevent as-
Key test result piration.
• Immunologic assay screen is positive for celiac • Clean the suture line after each feeding by dab-
disease. bing it with half-strength hydrogen peroxide or
Key treatment normal saline solution.
• Gluten-free diet After cleft palate repair surgery
Key interventions • Position the toddler on the abdomen or side.
• Monitor growth and development. • Anticipate edema and a decreased airway from
• Give small, frequent meals. palate closure, which may make the toddler ap-
pear temporarily dyspneic, and assess for signs
CLEFT LIP AND PALATE of altered oxygenation.
Key signs and symptoms • Keep hard or pointed objects (utensils, straws,
• Cleft lip: can range from simple notch on upper frozen dessert sticks) away from the mouth.
lip to complete cleft from lip edge to floor of the ESOPHAGEAL ATRESIA AND
nostril, on either side of the midline but rarely TRACHEOESOPHAGEAL FISTULA
along the midline itself; is obvious at birth (with or
without cleft palate)
• Cleft palate without cleft lip: may not be detect- • Esophageal atresia: excessive salivation and
ed until mouth examination or development of drooling due to inability to pass food through the
feeding difficulties esophagus
Key test result • Tracheoesophageal fistula: choking, coughing,
• Prenatal ultrasound may indicate severe de- and intermittent cyanosis during feeding due to
fects. food that goes through the fistula into the trachea
920132.qxd 8/7/08 3:59 PM Page 645
Pediatric gastrointestinal refresher (continued)

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL • X-rays confirm the diagnosis. Abdominal films show the pres-
FISTULA (continued) ence and location of intestinal gas or fluid.
Key test result Key treatment
• Neonates are fed first with a few sips of sterile water to detect • I.V. therapy to correct fluid and electrolyte imbalances
these anomalies and to prevent aspiration of formula or breast Key interventions
milk into the lungs. • Monitor vital signs frequently.
Key treatment • Monitor cardiovascular status; observe the child closely for
• Surgical correction by ligating the tracheoesophageal fistula signs of shock (pallor, rapid pulse, and hypotension).
and reanastomosing the esophageal ends; in many cases, done • Stay alert for signs and symptoms of metabolic alkalosis
in stages (changes in sensorium; slow, shallow respirations; hypertonic
Key intervention muscles; tetany) or acidosis (dyspnea on exertion; disorientation;
• Monitor respiratory status. and, later, deep, rapid breathing, weakness, and malaise).
• Watch for signs and symptoms of secondary infection.
FAILURE TO THRIVE
Key signs and symptoms PYLORIC STENOSIS
• Altered body posture (child is stiff or floppy and doesn’t cuddle) Key signs and symptoms
• Disparities between chronological age and height and weight • Projectile vomiting during or shortly after feedings, preceded
• History of insufficient stimulation and inadequate parental by reverse peristaltic waves (going left to right) but not by nau-
knowledge of child development sea; child resumes eating after vomiting
Key test result Key test result
• Negative nitrogen balance indicates inadequate intake of pro- • Ultrasound reveals hypertrophied sphincter.
tein or calories. Key treatment
Key treatments • Pyloromyotomy performed by laparoscopy
• High-calorie diet Key interventions
• Parent counseling • Provide small, frequent, thickened feedings with the head of
• Vitamin and mineral supplements the bed elevated; burp the child frequently.
Key interventions • Position the child on his right side to prevent aspiration.
• Properly feed and interact with the child. SALICYLATE POISONING
• Provide the child with visual and auditory stimulation.
• When caring for child in parent’s presence, act as role model
for effective parenting skills. Demonstrate comfort measures and • High fever from the stimulation of carbohydrate metabolism
show the mother how to hold the infant in en face position. • Petechiae and bleeding tendency
Key test results
INTESTINAL OBSTRUCTION • Prothrombin time is prolonged.
Key signs and symptoms • Serum salicylate levels are elevated.
• Complete small-bowel obstruction: bowel contents propelled Key treatments
toward mouth (instead of rectum) by vigorous peristaltic waves; • Gastric lavage or emesis induction with ipecac syrup
persistent epigastric or periumbilical pain • I.V. fluids
• Partial large-bowel obstruction: leakage of liquid stool around • Sodium bicarbonate
the obstruction (common).
Key interventions
Key test results
• Administer oral and I.V. fluids.
• With large-bowel obstruction, barium enema reveals a dis- • Monitor urine pH.
tended, air-filled colon or, in sigmoid volvulus, a closed loop of • Monitor cardiovascular and GI status.
sigmoid with extreme distention.
920132.qxd 8/7/08 3:59 PM Page 646
Gastrografin is now used instead of barium Nursing actions

It’s alimentary.
Barium—or for certain patients. Like barium, Gastrografin • Explain the procedure to the child and his
Gastrografin—is facilitates imaging through X-rays. Unlike bar- parents.
swallowed to help ium, however, if Gastrografin escapes from • Usually, the child will follow a liquid diet for
visualize the GI the GI tract, it’s absorbed by the surrounding 24 hours before the test. Bowel preparations
tract. tissue. Escaped barium isn’t absorbed and can are administered before the examination.
cause complications. • Tell the child X-rays will be taken on a test
table and he must hold still.
Nursing actions • Cover the genital area with a lead apron
• Explain the procedure to the child and his during X-ray.
parents.
• Maintain the child on nothing-by-mouth Stool search
(NPO) status beginning midnight before the A stool specimen can be examined for sus-
test. pected GI bleeding, infection, or malabsorp-
• Tell the child he must hold still during the tion. Certain tests require several specimens,
X-ray. such as the guaiac test for occult blood, a mi-
• After the test, monitor bowel movements croscopic stool examination for ova and para-
for excretion of barium. Also monitor GI func- sites, and tests for fat.
tion.
Nursing actions
Upper GI imaging • Obtain the specimen in the correct contain-
For an upper GI series, swallowed barium er (container may need to be sterile or con-
sulfate proceeds into the esophagus, stomach, tain preservative).
and duodenum to reveal abnormalities. The • Be aware that the specimen may need to be
barium outlines stomach walls and delineates transported to the laboratory immediately or
ulcer craters and filling defects. placed in the refrigerator.
A small-bowel series, an extension of the
upper GI series, visualizes barium flowing Fiber-optic findings
through the small intestine to the ileocecal With esophagogastroduodenoscopy, inser-
valve. tion of a fiber-optic scope allows direct visual
inspection of the esophagus, stomach and,
Nursing actions sometimes, duodenum. Proctosigmoidos-
• Explain the procedure to the child and his copy permits inspection of the rectum and
parents. distal sigmoid colon. Colonoscopy allows in-
• Maintain the child on NPO status beginning spection of the descending, transverse, and
midnight before the test. ascending colon. Biopsies may be obtained
• Tell the child he must hold still during the during the procedures.
X-ray.
• Make sure the lead apron is properly placed Nursing actions
over the genital area. • Explain the procedure to the child and his
• After the test, monitor bowel movements parents.
for excretion of barium. Also monitor GI func- • Make sure that written, informed consent
tion. has been obtained.
• A mild sedative may be administered before
Lower GI look the examination.
A barium enema (lower GI series) allows • The child may be kept on NPO status from
X-ray visualization of the colon and is used to midnight beforehand (upper GI tests).
detect lesions, obstructions, and motility • The child may be placed on a liquid diet for
problems. 24 hours before the examination or require
enemas or laxatives until bowel contents are
clear (lower GI examinations).
920132.qxd 8/7/08 3:59 PM Page 647
Digestive organs and glands

Here’s a quick rundown of the major organs and glands that facilitate digestion.
SALIVARY GLANDS
The salivary glands provide saliva to moisten the mouth, lubricate food to ease swallowing, and be-
gin food breakdown using the enzyme ptyalin. After food is swallowed, it enters the esophagus and
is transported to the stomach.
STOMACH
The stomach is a muscular, saclike organ located between the esophagus and small intestine in the
left upper quadrant of the abdomen. Food and fluids enter the stomach and are mixed with stomach
secretions. Contractions called peristalsis push the food gradually into the small intestine through
the pyloric opening at the lower end of the stomach.
INTESTINE
The intestine extends from the pyloric opening to the anus. It’s made up of the small and large in-
testines:
• The small intestine is made up of the duodenum, jejunum, and ileum and is about 20⬘ (6 m) long.
Most digestion takes place in the small intestine; digested food is absorbed through the walls of the
small intestine and into the blood for distribution throughout the body.
• The large intestine is about 5⬘ (1.5 m) long and includes the cecum (and appendix), colon, and rec-
tum. Indigestible food passes into the large intestine, where it’s formed into solid feces and eliminat-
ed through the rectum.
LIVER
The liver, which is located in the right upper quadrant of the abdomen, stores and filters blood; se-
cretes bile; processes sugars, fats, proteins, and vitamins; and detoxifies drugs, alcohol, and other
substances.
GALLBLADDER
The gallbladder is located beneath the liver and serves as a storage place for bile. Bile is a greenish
fluid that helps the small intestine to emulsify and absorb fat and fat-soluble vitamins.
PANCREAS
The pancreas is a large gland located behind the stomach. It has both exocrine and endocrine
functions. The exocrine function involves cells that secrete digestive enzymes, bicarbonate, and
hormones into the small intestine to aid digestion. The endocrine function involves the islets of Esophagogastro-
duodenoscopy?
Langerhans, which contain alpha and beta cells. Alpha cells secrete glucagon, which stimulates
No problem!
glycogenolysis in the liver. Beta cells secrete insulin to promote carbohydrate metabolism.
Fluoroscopic findings Nursing actions

Endoscopic retrograde cholangiopancre- Before the procedure
atography is the radiographic examination of • Explain the procedure to the child and his
the pancreatic ducts and hepatobiliary tree parents.
following the injection of contrast media into • Make sure that written, informed consent
the duodenal papilla. It’s done on children has been obtained.
with suspected pancreatic disease or obstruc- • Check the child’s history for allergies to
tive jaundice. cholinergics and iodine.
• Administer a sedative and monitor the child
for the drug’s effect.
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After the procedure

Children who are
intubated require • Monitor the child’s gag reflex, and keep the
child on NPO status until his gag reflex re-
diligent oral and nasal
care, close monitoring, turns.
• Protect the child from aspiration of mucus
care
and emotional support
to minimize fear. by positioning him on his side. Pediatric GI disorders discussed in this chap-
• Monitor the child for urine retention. ter include acetaminophen poisoning, celiac
disease, cleft lip and palate, esophageal atre-
Tube topics sia and tracheoesophageal fistula, failure to
Certain GI disorders require nasogastric thrive, intestinal obstruction, pyloric stenosis,
(NG) or oralgastric intubation: and salicylate poisoning.
• to empty the stomach and intestine
• to aid diagnosis and treatment
• to decompress obstructed areas Acetaminophen poisoning
• to detect and treat GI bleeding
• to administer medications or feedings. Acetaminophen is an analgesic antipyretic
Tubes usually inserted through the nose in- agent that achieves its effect without inhibit-
clude short NG tubes (Levin and Salem ing platelet aggregation. Because acetamino-
Sump) and long intestinal tubes (Cantor and phen is an over-the-counter medication com-
Miller-Abbott). The larger Ewald tube is usu- monly found in the home, it’s a common
ally inserted orally. cause of poisoning in children.
With acetaminophen poisoning, hepato-
Nursing actions toxicity occurs at plasma levels greater than
For a child who has an NG or oralgastric tube 200 mg/ml at 4 hours after ingestion and
in place greater than 50 mg/ml by 12 hours after in-
• Maintain accurate intake and output gestion.
records. Measure gastric drainage every
8 hours; record amount, color, odor, and CAUSE
consistency. When irrigating the tube, note • Acetaminophen overdose
the amount of saline solution instilled and as-
pirated. DATA COLLECTION FINDINGS
• Check for fluid and electrolyte imbalances. • Anorexia
• Provide good oral and nasal care. Make • Central nervous system changes (restless-
sure the tube is secure but isn’t causing pres- ness, agitation, seizures)
sure on the nostrils. Change the tape to the • Diaphoresis
nose every 24 hours. Gently wash the area • Encephalopathy
around the tube, and apply a water-soluble lu- • Hepatic failure, death, or resolution of
bricant to soften crusts. These measures help symptoms 7 to 8 days after ingestion
prevent sore throat and nose, dry lips, nasal • Hypothermia
excoriation, and parotitis. • Liver dysfunction
• To support the short tube’s weight, anchor • Nausea and vomiting
it to the child’s clothing. • Oliguria
• After removing the tube from a child with • Pallor
GI bleeding, watch for signs and symptoms of • Right-upper-quadrant tenderness usually oc-
recurrent bleeding, such as hematemesis, de- curs 24 to 48 hours after ingestion; jaundice
creased hemoglobin (Hb) levels, pallor, chills, evident 72 to 96 hours after ingestion
diaphoresis, hypotension, and rapid pulse. • Severe hypoglycemia
• Provide emotional support because many • Shock
children panic at the sight of a tube. Maintain-
ing a calm, reassuring manner can help mini- DIAGNOSTIC FINDINGS
mize the child’s fear. • Blood glucose levels are decreased.
920132.qxd 8/7/08 3:59 PM Page 649
• Serum aspartate aminotransferase and • Monitoring cough and cold preparations

serum alanine aminotransferase levels be- that may contain acetaminophen; reading la-
come elevated soon after ingestion. bels carefully
• Prothrombin time (PT) is prolonged.
• Acetaminophen levels are greatly elevated.
Celiac disease
NURSING DIAGNOSES
• Imbalanced nutrition: Less than body re- Celiac disease, also known as gluten enteropa-
quirements thy or sprue, is characterized by poor food ab-
• Risk for deficient fluid volume sorption and intolerance of gluten, which is a
• Hypothermia protein found in such grains as wheat, rye,
oats, and barley.
TREATMENT With celiac disease, the child experiences a
• Gastric lavage decrease in the amount and activity of en-
• Hyperthermia blanket zymes in the intestinal mucosal cells. This
• I.V. fluid causes the villi of the proximal small intestine
• Oxygen therapy (intubation and mechanical to atrophy, decreasing intestinal absorption. It
ventilation may be required) also affects fat and vitamin absorption. Celiac
disease usually becomes apparent between
Drug therapy ages 6 and 18 months as foods containing
• Acetylcysteine (Mucomyst) gluten are introduced into the infant’s diet.
• Activated charcoal
• Ipecac CAUSES
• Gluten intolerance (inability to absorb rye,
INTERVENTIONS AND RATIONALES oat, wheat, and barley glutens)
• Monitor liver function studies to detect signs • Immunoglobulin A deficiency
of liver damage and to monitor effectiveness of • Too-early introduction of protein solids
treatment.
• Monitor vital signs and intake and output. DATA COLLECTION FINDINGS
Tachycardia and decreased urine output may • Abdominal distention and pain
signify dehydration. • Anorexia and vomiting
• Monitor cardiovascular and GI status to de- • Generalized malnutrition and failure to
termine the effectiveness of treatment. thrive due to malabsorption of protein and
• Administer hyperthermia therapy by using carbohydrates
a warming blanket, limiting exposure during • Irritability
routine nursing care, and covering the child • Steatorrhea and chronic diarrhea due to fat
with warm blankets to help the child become malabsorption
normothermic. • Weight and height below normal for age-
• Administer oral acetylcysteine in a carbon- group
ated beverage or fruit juice. Acetylcysteine has
an offensive odor and taste. Administering this DIAGNOSTIC FINDINGS
drug in a carbonated beverage will help the • Blood chemistry tests reveal hypocalcemia
child swallow it. With small children, adminis- and hypoalbuminemia.
ter it directly into an NG tube to avoid this dif- • Hematology tests reveal decreased Hb level
ficulty. and hypothrombinemia.
• Immunologic assay screen is positive for
Teaching topics celiac disease.
• Storing medication safely and other steps to • Intestinal biopsy is used to confirm the diag-
prevent poisoning nosis.
• Reticulin antibody levels are elevated.
• Stool specimen reveals high fat content.
920132.qxd 8/7/08 3:59 PM Page 650
Give the child

NURSING DIAGNOSES CAUSES
with celiac disease • Imbalanced nutrition: Less than body re- • Congenital defects; in some cases multifac-
small, frequent quirements torial environmental and genetic factors play a
meals to reduce • Delayed growth and development role
fatigue and improve • Deficient fluid volume • Part of another chromosomal or mendelian
nutritional intake. abnormality
TREATMENT • Prenatal exposure to teratogens
• Diet: gluten-free but includes corn and rice
products, soy and potato flour, breast milk or DATA COLLECTION FINDINGS
soy-based formula, and all fresh fruits • Abdominal distention from swallowed air
• Folate • Cleft lip: can range from a simple notch on
• Iron (Feosol) supplements the upper lip to complete cleft from the lip
• Vitamins A and D in water-soluble forms edge to the floor of the nostril, on either side
of the midline, but rarely along the midline it-
INTERVENTIONS AND RATIONALES self
• Give the child small, frequent meals to re- • Cleft palate: may be partial or complete, and
duce fatigue and improve nutritional intake. unilateral or bilateral
• Record the consistency, appearance, and • Difficulty swallowing
number of stools. The disappearance of steat- • Note that cleft lip with or without cleft
orrhea is a good indicator that the child’s abili- palate is obvious at birth; cleft palate without
ty to absorb nutrients is improving. cleft lip may not be detected until a mouth ex-
• Monitor growth and development to de- amination is done or until feeding difficulties
termne growth delay and to detect changes in develop.
level of functioning and, as appropriate, plan
an activity program for the child. DIAGNOSTIC FINDING
• Prenatal ultrasonography may indicate se-
Teaching topics vere defects.
• Providing foods and formula the child can
eat (breads made from rice, corn, soybean, NURSING DIAGNOSES
potato, tapioca, sago, or gluten-free wheat; • Imbalanced nutrition: Less than body re-
dry cereals made only with rice or corn; corn- quirements
meal or hominy) • Impaired swallowing
• Risk for aspiration
Cleft lip and palate TREATMENT

• Cheiloplasty performed between 2 and
With cleft lip and palate, the bone and tissue 3 months of age to unite the lip and gum
of the upper jaw and palate fail to fuse com- edges in anticipation of teeth eruption, provid-
pletely at the midline. The defects may be par- ing a route for adequate nutrition and sucking
tial or complete, unilateral or bilateral, and • Cleft palate repair surgery (staphylorrha-
may involve just the lip, just the palate, or phy); scheduled at about age 18 months to al-
both. low for growth of the palate and to be done
Cleft lip and palate also increase the risk of: before the infant develops speech patterns; in-
• aspiration because increased open space in fant must be free from ear and respiratory in-
the mouth may cause formula or breast milk fections
to enter the respiratory tract • Long-term, team-oriented care to address
• upper respiratory infection and otitis media speech defects, dental and orthodontic prob-
because the increased open space decreases lems, nasal defects, and possible alterations in
natural defenses against bacterial invasion. hearing
• If cleft lip is detected on sonogram while
the infant is in utero, possible fetal repair
920132.qxd 8/7/08 3:59 PM Page 651
INTERVENTIONS AND RATIONALES • Clean the suture line after each feeding by
• Monitor vital signs and intake and output to dabbing it with half-strength hydrogen perox-
determine fluid volume status. ide or normal saline solution to prevent crusts
• Monitor respiratory status to detect signs of and scarring.
aspiration. • Monitor for pain and administer pain med-
• Evaluate the quality of the infant’s suck by ication as prescribed; note effectiveness of
determining if he can form an airtight seal pain medication to promote comfort.
around a finger or nipple placed in his mouth
to determine an effective feeding method. Preoperative interventions for cleft palate
• Monitor for respiratory distress when feed- repair
ing to avoid aspiration. • Feed the infant with a cleft palate nipple or a
• As the child grows older, explore his feel- Teflon implant to enhance nutritional intake.
ings to evaluate actual and potential coping • Wean the infant from the bottle or breast
problems. before cleft palate surgery; the toddler must be
able to drink from a cup.
Preoperative interventions for cleft lip repair
• Feed the infant slowly and in an upright po- Postoperative interventions for cleft palate
sition to decrease the risk of aspiration. repair
• Burp the infant frequently during feeding to • Position the toddler on the abdomen or side
eliminate swallowed air and decrease the risk to promote a patent airway.
of emesis. • Anticipate edema and a decreased airway
• Use gavage feedings if oral feedings are un- from palate closure, which may make the tod-
successful. dler appear temporarily dyspneic, and ob-
• Administer a small amount of water after serve for signs of altered oxygenation to pro-
feedings to prevent formula from accumulating mote good respiration.
and becoming a medium for bacterial growth. • Keep hard or pointed objects (utensils,
• Give small, frequent feedings to promote ad- straws, frozen dessert sticks) away from the
equate nutrition and prevent tiring the infant. mouth to prevent trauma to the suture line.
• Hold the infant while feeding and promote • Use a cup to feed; don’t use a nipple or paci-
sucking between meals. Sucking is important fier to prevent injury to the suture line.
to speech development. • When feeding the infant with a spoon, place
the spoon into the side of the mouth; touching
Postoperative interventions for cleft lip repair the roof of the mouth may interrupt the suture
• Observe for cyanosis as the infant begins to line.
breathe through the nose to detect signs of res- • Use elbow restraints to keep the toddler’s
piratory compromise. hands out of the mouth.
• Keep the infant’s hands away from the • Provide soft toys to prevent injury.
mouth by using restraints or pinning the • Start the toddler on clear liquids and
sleeves to the shirt; use adhesive strips to progress to a soft diet; rinse the suture line by
hold the suture line in place to prevent tension giving the toddler a sip of water after each
and to maintain an intact suture line. feeding to prevent infection.
• Anticipate the infant’s needs to prevent cry- • Distract or hold the toddler to try to keep the
ing, which may cause tension on the suture tongue away from the roof of the mouth.
line. Don’t position him prone.
• Give extra care and support because the in- Teaching topics
fant can’t meet emotional needs by sucking. • Bonding with the child (because it results
• Use a syringe with tubing to administer in facial disfigurement, the condition may
foods at the side of the mouth to prevent trau- cause shock, guilt, and grief for the parents
ma to the suture line. and may block parental bonding with the
• Place the infant on the right side to prevent child)
aspiration. • Following-up with speech therapy
920132.qxd 8/7/08 3:59 PM Page 652
• Understanding the child’s susceptibility to Tracheoesophageal fistula

otitis media (from the altered position of the • Abdominal distention from air that goes
eustachian tubes) and other infections through the fistula into the stomach
• Choking, coughing, and intermittent cya-
nosis during feeding due to food that goes
Esophageal atresia and through the fistula into the trachea
• Excessive drooling of saliva; possibly the
tracheoesophageal fistula first symptom
• Tracheal irritation from gastric acids that
Esophageal atresia occurs when the proximal reflux across the fistula
end of the esophagus ends in a blind pouch;
Feeding a neonate food can’t enter the stomach via the esopha- Esophageal atresia with tracheoesophageal
a few sips of sterile gus. fistula
water will detect or Tracheoesophageal fistula occurs when a • Excessive salivation and drooling due to in-
rule out esophageal
connection exists between the esophagus and ability to pass food through the esophagus
atresia and
tracheoesophageal the trachea. It may result in the reflux of gas- • Inability to pass an NG tube
fistula. tric juice after feeding; this can allow acidic • Regurgitation of undigested formula imme-
stomach contents to cross the fistula, irritat- diately after feeding; possible respiratory dis-
ing the trachea. tress and cyanosis if secretions are aspirated
Esophageal atresia and tracheoesophageal • Signs of respiratory distress (coughing,
fistula occur in many combinations and may choking, and intermittent cyanosis) because
be associated with other defects. Esophageal the infant has difficulty tolerating oral foods
atresia with tracheoesophageal fistula is the and handling oral secretions or refluxed gas-
most common of these conditions. Esopha- tric contents
geal atresia alone is the second most common
of these conditions. DIAGNOSTIC FINDINGS
Esophageal atresia with tracheoesophageal • Neonates are fed first with a few sips of ster-
fistula occurs when either: ile water to detect these anomalies and to pre-
• the distal end of the esophagus ends in a vent the aspiration of formula or breast milk
blind pouch and the proximal end of the into the lungs.
esophagus is linked to the trachea via a fistula • Ultrasonography or X-ray identifies the ab-
• the proximal end of the esophagus ends in a normality.
blind pouch and the distal portion of the
esophagus is connected to the trachea via a NURSING DIAGNOSES
fistula. • Imbalanced nutrition: Less than body re-
quirements
CAUSES • Risk for infection
• Congenital defect • Risk for impaired parenting
• Maternal history of polyhydramnios
• Prenatal exposure to teratogens TREATMENT
• Gastrostomy tube (PEG tube) inserted
DATA COLLECTION FINDINGS (child not fed orally)
Esophageal atresia • Surgical correction by ligating the tracheo-
• Excessive salivation and drooling due to in- esophageal fistula and reanastomosing the
ability to pass food through the esophagus esophageal ends; in many cases, repair done
• Inability to pass an NG tube in stages
• Regurgitation of undigested formula imme-
diately after feeding; possible respiratory dis- INTERVENTIONS AND RATIONALES
tress and cyanosis if secretions are aspirated • Monitor vital signs to detect tachycardia and
tachypnea, which could indicate hypoxemia.
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• Monitor respiratory status. Poor respiratory CAUSES

status may result in hypoxemia. • Organic: acute or chronic illness (GI reflux,
• Position the infant with his head elevated to malabsorption syndrome, congenital heart de-
30 degrees to decrease reflux at the distal fect, or cystic fibrosis)
esophagus. • Nonorganic: psychological problem be-
• Suction as needed to stimulate cough and tween child and primary caregiver, such as
clear airways. failure to bond
• If feeding the child through a gastrostomy • Mixed: combination of organic and non-
tube after surgery, anticipate abdominal dis- organic
tention from air. Keep the child upright dur-
ing feedings to reduce the chance of refluxed DATA COLLECTION FINDINGS
stomach contents and aspiration pneumonia. • Altered body posture; child is stiff or floppy,
Keep tube open and elevated before and after doesn’t cuddle
feedings to allow release of gas. • Delayed psychosocial behavior; for exam-
• Administer gastrostomy feedings only by ple, reluctance to smile or talk
gravity flow—not a feeding pump—to help • Disparities between chronological age and
meet nutritional and metabolic requirements. height and weight
• History of inadequate feeding techniques,
Postoperative care such as bottle propping or insufficient burp-
• Maintain chest tube and respiratory sup- ing
port to prevent respiratory compromise. • History of insufficient stimulation and inad-
• Keep a suction catheter ready to get rid of equate parental knowledge of child develop-
secretions and prevent aspiration. ment
• Mark the catheter to indicate the distance • History of medical problems
from the infant’s nose to the point just above • History of sleep disturbances
the anastomosis to avoid causing trauma to • Psychosocial family problems
the anastomosis site. • Regurgitation of food after almost every
• Make sure the NG tube is secure and han- feeding, part being vomited and the remain-
dle with extreme caution to avoid displace- der swallowed (rumination of food)
ment.
• Administer antibiotics as prescribed to pre- DIAGNOSTIC FINDINGS
vent infection. • Negative nitrogen balance indicates inade-
• Administer total parenteral nutrition (TPN) quate intake of protein or calories.
to maintain nutritional support. • Associated physiologic causes may be de-
tected.
Teaching topics • Reduced creatinine-height index reflects
• Understanding proper care of child at muscle mass and estimates muscle protein
home, such as feeding and bathing tech- depletion.
niques
NURSING DIAGNOSES
Failure to thrive • Impaired parenting
Failure to thrive is a chronic, potentially life- quirements
threatening condition characterized by failure
to maintain weight and height above the 5th TREATMENT
percentile on age-appropriate growth charts. • High-calorie diet
Most children are diagnosed before age 2. It • Parent counseling
can result from physical, emotional, or psy- • Respite care for the child
chological causes.
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Drug therapy • Understanding formula preparation and

I dig visual and
auditory stimulation. • Vitamin and mineral supplements feeding techniques
Adequate stimulation
helps to prevent INTERVENTIONS AND RATIONALES
failure to thrive. • Weigh the child on admission and daily to Intestinal obstruction
determine fluctuations in weight.
• Properly feed and interact with the child to Intestinal obstruction is the partial or com-
promote nutrition and growth and develop- plete blockage of the lumen in the small or
ment. large bowel. Small-bowel obstruction is far
• Establish specific times for feeding, more common and usually more serious.
bathing, and sleeping to establish and main- Complete obstruction in any part of the bow-
tain a structured routine. el, if untreated, can cause death within hours
• Provide the child with visual and auditory from shock and vascular collapse.
stimulation to promote normal sensory develop- Intestinal obstruction can occur in three
ment. forms:
• Observe the interaction of parent with child
to determine if failure to thrive is due to par- simple: blockage prevents intestinal con-
ent’s inability to form emotional attachment to tents from passing, with no other complica-
child. tions
• When caring for the child in the parent’s
presence, act as a role model for effective par- strangulated: blood supply to part or all of
enting skills. Demonstrate comfort measures the obstructed section is cut off, in addition to
such as rocking the infant, and show the blockage of the lumen
mother how to hold the infant in an en face
position to increase the parent’s knowledge of close-looped: both ends of a bowel sec-
routine child care practices. tion are occluded, isolating it from the rest of
• Teach the mother about normal growth and the intestine.
development, and identify ages at which the
child should be able to master developmental CAUSES
tasks, such as rolling over, crawling, and Mechanical causes
walking. This will assist the parents in monitor- • Adhesions and strangulated hernias (most
ing the child’s growth and development. Also common causes of small-bowel obstruction)
discuss problem behaviors associated with • Carcinomas (most common cause of large-
When caring for specific ages, such as colic, temper tantrums, bowel obstruction)
the child in the and sleeping difficulties, to further enhance • Compression of the bowel wall due to steno-
parents’ presence, the parents’ understanding of developmental sis, intussusception, volvulus of the sigmoid
act as a role model norms. or cecum, tumors, or atresia
for effective • Discuss the child’s need for tactile and sen- • Congenital bowel deformities
parenting skills. sory stimulation. Demonstrate play activities • Ingestion of foreign bodies (such as fruit
that promote developmental skills, such as pits or worms)
shaking a rattle in front of the infant to build • Obstruction after abdominal surgery
eye-and-hand coordination or placing a mobile
above the infant to encourage visual tracking Other causes
and trunk and head control. Sensory experi- • Paralytic ileus
ences promote cognitive development. • Electrolyte imbalances
• Toxicity (uremia, generalized infection)
Teaching topics • Neurogenic abnormalities (spinal cord le-
• Understanding normal parenting skills sions)
• Obtaining counseling for the parents, if nec- • Thrombosis or embolism of mesenteric
essary vessels
920132.qxd 8/7/08 3:59 PM Page 655
DATA COLLECTION FINDINGS • With lower bowel obstruction, ABG analy-

The highs and lows
Partial small-bowel obstruction sis reveals metabolic acidosis caused by slow- of intestinal
• Abdominal distention er dehydration and loss of intestinal alkaline obstruction are
• Colicky pain fluids. simple: high means
• Constipation • X-rays confirm the diagnosis. Abdominal marked vomiting with
• Drowsiness films show the presence and location of in- limited abdominal
• Dry oral mucous membranes and tongue testinal gas or fluid. distention; low means
• Intense thirst little vomiting with
• Malaise NURSING DIAGNOSES marked distention.
• Nausea • Imbalanced nutrition: Less than body re-
• Vomiting (the higher the obstruction, the quirements
earlier and more severe the vomiting) • Acute pain
• Ineffective tissue perfusion: Gastrointesti-
Complete small-bowel obstruction nal
• Persistent epigastric or periumbilical pain
• Bowel contents propelled toward mouth (in- TREATMENT
stead of rectum) by vigorous peristaltic waves • I.V. therapy to correct fluid and electrolyte
imbalances
Partial large-bowel obstruction • NG intubation to decompress the bowel to
With partial large-bowel obstruction, signs relieve vomiting and distention
and symptoms develop slowly because the • Surgical resection with anastomosis,
colon can absorb fluid from its contents and colostomy, or ileostomy, commonly after de-
distend well beyond its normal size. Signs and compression with an NG tube (for large-
symptoms may include the following: bowel obstruction)
• dramatic abdominal distention • TPN for protein deficit from chronic ob-
• colicky abdominal pain; may appear sudden- struction, paralytic ileus, infection, or pro-
ly, producing spasms that last less than 1 longed postoperative recovery time that re-
minute and recur every few minutes quires NPO status
• constipation (may be only clinical effect for
days) Drug therapy
• continuous hypogastric pain and nausea; • Analgesics (usually nonopioid to avoid re-
vomiting usually absent at first duced intestinal motility commonly caused by
• leakage of liquid stools around the obstruc- opioid analgesics)
tion (common) • Antibiotics for peritonitis
• loops of large bowel becoming visible on
the abdomen. INTERVENTIONS AND RATIONALES
• Monitor vital signs frequently. A drop in
Complete large-bowel obstruction blood pressure may indicate reduced circulating
• Continuous pain blood volume due to blood loss from a strangu-
• Fecal vomiting lated hernia.
• Localized peritonitis • Monitor child’s cardiovascular status to ob-
serve for signs of shock, such as pallor, rapid
DIAGNOSTIC FINDINGS pulse, and hypotension.
• With large-bowel obstruction, barium ene- • Stay alert for signs and symptoms of meta-
ma reveals a distended, air-filled colon or, in bolic alkalosis (changes in sensorium; slow,
sigmoid volvulus, a closed loop of sigmoid shallow respirations; hypertonic muscles;
with extreme distention. tetany) or acidosis (dyspnea on exertion; dis-
• With obstruction in the upper intestine, ar- orientation; and later, deep, rapid breathing,
terial blood gas (ABG) analysis reveals meta- weakness, and malaise). This allows for early
bolic alkalosis from dehydration and loss of detection of complications.
gastric hydrochloric acid. • Watch for signs and symptoms of sec-
ondary infection, such as fever and chills. Sus-
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tained temperature elevations after surgery • Symptoms of malnutrition and dehydration

may signal onset of pulmonary complications despite the child’s apparent adequate intake
or wound infection. of food
• Monitor intake and output; monitor urine • Projectile vomiting during or shortly after
output carefully to evaluate renal function, cir- feedings, preceded by reverse peristaltic
culating blood volume, and possible urine re- waves (going left to right) but not by nausea;
tention caused by bladder compression by the child resumes eating after vomiting
distended intestine. • Symptoms appearing at about 4 weeks in
• Catheterize the child for residual urine im- formula-fed infants and about 6 weeks in
mediately after he has voided if you suspect breast-fed infants
bladder compression. Also, measure abdominal • Tetany
girth frequently to detect progressive disten-
tion. DIAGNOSTIC FINDINGS
• Provide fastidious mouth and nose care if • ABG analysis reveals metabolic alkalosis.
the child has vomited or undergone decom- • Blood chemistry tests may reveal hypocal-
pression by intubation to prevent skin break- cemia, hypokalemia, and hypochloremia.
down. Look for signs of dehydration (thick, • Hematest reveals blood in vomitus.
swollen tongue; dry, cracked lips; dry oral • Ultrasound shows hypertrophied sphincter.
mucous membranes). • Endoscopy reveals hypertrophied sphinc-
• Keep the child in Fowler’s position as much ter.
as possible to promote pulmonary ventilation • Upper GI shows narrow pyloric channel.
and ease respiratory distress from abdominal
distention. NURSING DIAGNOSES
• Listen for bowel sounds, and watch for • Imbalanced nutrition: Less than body re-
signs of returning peristalsis (passage of fla- quirements
tus and mucus through the rectum) to pro- • Risk for deficient fluid volume
mote nutritional status. • Risk for infection

• Preparing the child and his family for the • Diet: Maintain NPO status before surgery
possibility of surgery, and providing emotion- • I.V. therapy to correct fluid and electrolyte
al support and positive reinforcement after- imbalances
ward • Possible insertion of an NG tube, kept open
and elevated for gastric decompression
Provide a • Surgical intervention: pyloromyotomy per-
pacifier to the
pyloric stenosis
Pyloric stenosis formed by laparoscopy
post-op patient!
With pyloric stenosis, hyperplasia and hyper- Drug therapy
trophy of the circular muscle at the pylorus • Potassium supplements but only after it’s
narrow the pyloric canal, thereby preventing confirmed that kidneys are functioning prop-
the stomach from emptying normally. The de- erly
fect is most commonly seen in male infants • I.V. calcium administration
between ages 1 and 6 months.
CAUSES • Weigh the infant daily to monitor growth.
• Exact cause unknown • Monitor vital signs and intake and output to
• Family history of pyloric stenosis evaluate renal function and check for signs of
dehydration.
DATA COLLECTION FINDINGS • Monitor for metabolic alkalosis and dehy-
• Olive-size bulge palpated below the right dration from frequent emesis to detect early
costal margin complications.
• Poor weight gain
920132.qxd 8/7/08 3:59 PM Page 657
• Monitor abdominal and cardiovascular sta- DATA COLLECTION FINDINGS Because aspirin
tus to detect early signs of compromise. • Coma inhibits platelet
• Provide small, frequent, thickened feedings • Diarrhea aggregation, look for
with the head of the bed elevated; burp the in- • High fever from the stimulation of petechiae and bleeding
fant frequently (preoperatively) to promote nu- carbohydrate metabolism in salicylate poisoning.
trition and prevent aspiration. • Increased respiratory rate from metabolic
• Position the infant on the right side to pre- acidosis
vent the aspiration of vomitus. • Irritability, restlessness
• Petechiae and bleeding tendency
Postoperative care • Restlessness
• After surgery, feed the infant small amounts • Seizures
of oral electrolyte solution at first; then in- • Stomach ulcer
crease the amount and concentration of food • Stupor
until normal feeding is achieved to meet nutri- • Tachycardia
tional needs and prevent vomiting. • Tinnitus or altered hearing
• Provide a pacifier to meet nonnutritive suck- • Vomiting
ing needs and maintain comfort.
• Provide routine postoperative care to main- DIAGNOSTIC FINDINGS
tain and improve the infant’s condition and to • Blood glucose levels are initially elevated
detect early complications. Position the infant and then decreased.
on his side to decrease the risk of aspiration if • PT is prolonged.
vomiting occurs. Laying the infant on the right • Serum salicylate levels are elevated.
side may aid the flow of fluid through the py-
loric valve by gravity. NURSING DIAGNOSES
• Keep the incision area clean. The infant is at • Imbalanced nutrition: Less than body re-
an increased risk for infection because the inci- quirements
sion is near the diaper area. • Hyperthermia
• Risk for deficient fluid volume
Teaching topics
• Feeding the infant, including specific formu- TREATMENT
la, volume, and technique • Oral or I.V. fluids
• Preventing infection • Gastric lavage or emesis induction with
ipecac syrup
• Hemodialysis
Salicylate poisoning • Hypothermia blanket
• Possible intubation and mechanical ventila-
Salicylate (aspirin) is an analgesic, antipyretic, tion
and anti-inflammatory agent that inhibits
platelet aggregation. Poisoning may result Drug therapy
from an overdose of salicylate. Symptoms be- • Calcium and potassium supplements, if indi-
gin when children ingest 150 to 200 mg of as- cated
pirin per kilogram of body weight. The peak • Sodium bicarbonate
blood level is reached within 2 to 3 hours of • Vitamin K to control bleeding
ingestion. The prognosis of the child with sali-
cylate poisoning depends on the amount of INTERVENTIONS AND RATIONALES
salicylate ingested and how quickly treatment • Administer oral and I.V. fluids to dilute the
begins. poison and prevent dehydration.
• Monitor vital signs and intake and output to
CAUSE detect dehydration and early signs of compro-
• Aspirin overdose mise.
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• Monitor cardiovascular and GI status to Answer: 3. The nurse should position the
evaluate for signs of metabolic acidosis and GI neonate on his right side to prevent aspira-
bleeding. tion. The neonate should be weighed daily,
• Maintain mechanical ventilation, if required, not every 12 hours. Vital signs should be
to ensure adequate oxygenation. monitored every 4 hours, not every 8 hours.
• Monitor urine pH; pH over 8 aids salicylate Client needs category: Physiological
excretion. integrity
• Dress the child lightly and sponge him with Client needs subcategory: Reduction of
tepid water or use a cooling blanket to reduce risk potential
fear and promote comfort. Cognitive level: Application
• Monitor body temperature every 15 to
30 minutes according to policy while hypo- 2. The nurse teaches a mother to position an
thermia blanket is in use to evaluate its effec- infant with a tracheoesophageal fistula with
tiveness and prevent injury. his head elevated to 30 degrees. The nurse
• Monitor blood glucose levels to detect hypo- should recognize that teaching was effective
glycemia. when the mother makes which statement?
1. “Positioning him with his head elevated
Teaching topics to 30 degrees helps with eating.”
• Storing medication safely and taking steps 2. “Positioning him with his head elevated
to prevent poisoning to 30 degrees helps his breathing.”
• Monitoring child’s temperature and encour- 3. “Positioning him with his head elevated
aging a high fluid intake to 30 degrees keeps gastric juices from
backing up.”
4. “Positioning him with his head elevated
to 30 degrees makes him comfortable.”
Answer: 3. Placing the infant with his head el-
evated to 30 degrees helps decrease gastric
reflux into the trachea. The child won’t be tak-
ing food by mouth until after the fistula is sur-
gically repaired. The infant will also breathe
easier and be more comfortable with his head
elevated, but they aren’t the primary reasons
for elevating the infant’s head to 30 degrees.
integrity
Pump up on practice risk potential
questions 3. A child with an NG tube in place complains
1. A 3-week-old neonate diagnosed with py- of nausea. Which action by the nurse is most
loric stenosis is admitted to the hospital dur- appropriate?
ing a vomiting episode. Which action by the 1. Administer an antiemetic.
nurse is most appropriate? 2. Irrigate the NG tube.
1. Placing the neonate on his back to 3. Notify the physician about the nausea.
sleep 4. Reposition the NG tube.
2. Weighing the neonate every 12 hours Answer: 2. The nurse should first check NG
3. Positioning the neonate on his right tube placement, then irrigate the tube to
side check for patency. If nausea continues, the
4. Taking vital signs every 8 hours NG tube may be repositioned, depending on
the child’s condition. If the child continues to
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complain of nausea after these measures, the 6. The nurse is caring for a child with a com-
physician should be notified and an antiemet- plete intestinal obstruction. Which is a key
ic given as ordered. finding in this client?
Client needs category: Physiological 1. Vomiting
integrity 2. Intense thirst
Client needs subcategory: Reduction of 3. Visible peristaltic waves
risk potential 4. Nausea
Cognitive level: Application Answer: 3. Visible peristaltic waves propel
bowel contents toward the mouth instead of
4. The mother of a child diagnosed with celi- the rectum. Vomiting, intense thirst, and nau-
ac disease asks the nurse which foods should sea are symptoms of a small-bowel obstruc-
be eliminated from her child’s diet. The nurse tion and aren’t the key findings in complete
should advise the mother to eliminate: intestinal obstruction.
1. malted milk, wheat bread, and spaghet- Client needs category: Physiological
ti. integrity
2. rice cereals, milk, and corn bread. Client needs subcategory: Reduction of
3. tapioca, potato bread, and peanut risk potential
butter. Cognitive level: Comprehension
4. corn cereals, milk, and honey.
Answer: 1. The mother should provide her
child with a gluten-free diet, eliminating such
foods as malted milk, wheat bread, and
spaghetti. Rice and corn cereals, milk, corn
and potato breads, tapioca, peanut butter, and
honey are all appropriate for a gluten-free
diet.
integrity
and comfort
7. The nurse is caring for an infant with a
5. The nurse is caring for a toddler after sur- cleft lip and palate. This condition places the
gical repair of a cleft palate. The nurse should infant at increased risk for:
position the child: 1. upper respiratory infections and otitis
1. on his back. media.
2. on his stomach. 2. otitis media and diarrhea.
3. on his back with his head slightly 3. upper respiratory infections and diar-
elevated. rhea.
4. for comfort. 4. diarrhea and vomiting.
Answer: 2. After surgical repair of a cleft Answer: 1. The infant with a cleft lip and
palate, the child should be positioned on his palate is at increased risk for upper respirato-
stomach to prevent pooling of secretions in ry infections and otitis media because the in-
the oropharynx. The child shouldn’t be posi- creased open space decreases natural defens-
tioned on his back. The nurse shouldn’t es against bacteria. It doesn’t increase the
choose a position based on comfort. risk of vomiting and diarrhea.
integrity integrity
Client needs subcategory: Reduction of Client needs subcategory: Reduction of
risk potential risk potential
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8. The nurse is teaching the mother of an in- with constipation, colicky abdominal pain,
fant with a cleft palate. Which teaching point nausea, and dramatic abdominal distention.
should the nurse tell the mother? Intussusception causes sudden onset of se-
1. Surgical repair is delayed until the child vere abdominal pain; the infant is usually in-
is 6 months old. consolable. Tracheoesophageal fistula causes
2. Surgical repair is delayed until the child abdominal distention and coughing, choking,
is 18 months old. and intermittent cyanosis during feeding.
3. Surgical repair is done between birth Client needs category: Physiological
and age 3 months. integrity
4. Surgical repair is done as soon as Client needs subcategory: Reduction of
arrangements can be made. risk potential
Answer: 2. Surgical repair of a cleft palate Cognitive level: Application
(staphylorrhaphy) is scheduled at about age
18 months to allow for growth of the palate 10. The nurse is caring for a neonate. What
and to be done before the infant develops intervention is routinely performed for all
speech patterns. Surgical repair of a cleft lip neonates to rule out the possibility of tracheo-
(cheiloplasty) takes place between birth and esophageal fistula and esophageal atresia?
age 3 months. 1. Feeding the neonate a few sips of ster-
Client needs category: Physiological ile water before introducing breast milk or
integrity formula
Client needs subcategory: Reduction of 2. Feeding the neonate a few sips of for-
risk potential mula before introducing breast milk
Cognitive level: Knowledge 3. Feeding the neonate a few sips of for-
mula in an upright position
9. A 4-week-old neonate is brought to the 4. Feeding the neonate sterile water for
pediatrician’s office. The neonate has been the first two feedings
experiencing projectile vomiting shortly after Answer: 1. All neonates should be fed first
feedings. The neonate most likely has: with a few sips of sterile water to rule out
1. an intestinal obstruction. these anomalies and to prevent the aspiration
2. intussusception. of formula into the lungs. Feeding the neo-
3. a tracheoesophageal fistula. nate formula, breast milk, or sterile water for
4. pyloric stenosis. the first two feedings could put the neonate at
Answer: 4. Symptoms of pyloric stenosis gen- risk for aspiration pneumonia if either anom-
erally develop between ages 4 and 6 weeks. aly is present.
They include a palpable bulge below the right Client needs category: Health promo-
costal margin, projectile vomiting during or tion and maintenance
shortly after feeding, resuming feeding after Client needs subcategory: None
vomiting, poor weight gain, malnutrition, and Cognitive level: Knowledge
dehydration. Intestinal obstruction presents
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33 Endocrine
system
Male secondary sexual development con-
In this chapter,
you’ll review:
Brush up on key sists of genital growth and the appearance of
pubic and body hair.
✐ endocrine function in concepts A place to integrate
childhood
✐ tests used to diag- Together with the nervous system, the endo- The endocrine system meets the nervous sys-
crine system regulates and integrates the tem at the hypothalamus. The hypothala-
nose endocrine
body’s metabolic activities. A disorder of the mus, the main integrative center for the endo-
disorders
endocrine system involves a hyposecretion or crine and autonomic nervous systems, con-
✐ common endocrine hypersecretion of hormones, which affect the trols the function of endocrine organs by
disorders. body’s metabolic processes and function. neural and hormonal stimulation.
At any time, you can review the major points Neural pathways connect the hypothalamus
of this chapter by consulting the Cheat sheet to the posterior pituitary, or neurohypophysis.
on page 662. Neural stimulation of the posterior pituitary
provokes the secretion of hormones (chemi-
Endocrine junior cal transmitters released from specialized
Here are key points about endocrine function cells into the bloodstream). Hormones are
in childhood: then carried to specialized organ-receptor
• The pituitar y gland controls the release of cells that respond to them.
seven different hormones and is the master
gland for all age-groups. Negative feedback
• The adrenal cortex begins secreting glu- In addition to hormonal and neural controls, a
cocorticoids and mineralocorticoids early in negative feedback system regulates the en-
embryonic life. docrine system. The mechanism of feedback
may be simple or complex:
Ch..ch..changes • Simple feedback occurs when the level of
The pituitary gland is stimulated at puberty to a substance regulates secretion of a hormone.
produce androgen steroids responsible for For example, a low serum calcium level stim-
secondar y sex characteristics. ulates parathyroid hormone secretion; a high
Female secondary sexual development dur- serum calcium level inhibits it.
ing puberty involves an increase in the size of • Complex feedback occurs through an axis
the ovaries, uterus, vagina, labia, and breasts. established between the hypothalamus, pitu-
The first visible sign of sexual maturity is the itary gland, and target organ. For example,
appearance of breast buds. Body hair then ap- secretion of the hypothalamic corticotropin-
pears in the pubic area and under the arms releasing hormone stimulates release of pitu-
and menarche begins. The ovaries, present at itary corticotropin, which, in turn, stimulates
birth, remain inactive until puberty. cortisol secretion by the adrenal gland (the
target organ). A rise in the serum cortisol lev-
el inhibits corticotropin secretion by decreas-
ing corticotropin-releasing hormone.
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et
heat she
C
Pediatric endocrine refresher
DIABETES MELLITUS HYPOTHYROIDISM
• Polydipsia Untreated hypothyroidism in infants
• Polyphagia • Hoarse crying
• Polyuria • Persistent jaundice
Key test results • Puffy face and swollen tongue
• Fasting plasma glucose level (no calorie intake Untreated hypothyroidism in older children
for at least 8 hours) is greater than or equal to • Stunted growth (dwarfism)
126 mg/dl. • Cognitive impairment
• Plasma glucose value in the 2-hour sample of • Weight gain
the oral glucose tolerance test is greater than or Key test result
equal to 200 mg/dl. This test should be performed • Radioimmunoassay confirms hypothyroidism
after a loading dose of 75 g of anhydrous glucose. with low triiodothyronine and thyroxine levels.
• A random plasma glucose value (obtained with- Key treatments
out regard to the time of the child’s last food in- • Oral thyroid hormone (thyroxine)
take) greater than or equal to 200 mg/dl accom- • Supplemental vitamin D to prevent rickets from
panied by symptoms of diabetes indicates dia- rapid bone growth
betes mellitus.
Key interventions
Key treatments • During early management of infantile hypothy-
• Exercise roidism, monitor blood pressure and pulse rate
• Insulin replacement and report hypertension and tachycardia imme-
• Strict diet planned to meet nutritional needs, diately (normal infant heart rate is approximately
control blood glucose levels, and reach and 120 beats/minute).
maintain appropriate body weight • Check axillary temperature every 2 to 4 hours.
Key interventions Keep the infant warm and his skin moist.
• Monitor vital signs and intake and output. • If the infant’s tongue is unusually large, position
• Provide appropriate treatment for hypo- him on his side and observe him frequently.
Remember to glycemia. • Teach the child and his parents to recognize
tailor your teaching • Teach the child and his parents about complying signs of supplemental thyroid hormone overdose
to the child’s needs, with the prescribed treatment program; monitor- (rapid pulse rate, irritability, insomnia, fever,
abilities, and ing blood glucose levels at home; rotating injec- sweating, weight loss).
developmental stage. tion sites; and preventing, recognizing, and treat-
ing hypoglycemia and hyperglycemia at home.
mon nursing interventions associated with

Keep abreast of each test.
diagnostic tests Function studies

An endocrine function study focuses on
Here are some important tests used to diag- measuring the level or effect of a hormone,
nose endocrine disorders, along with com-
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such as the effect of insulin on blood glucose Early diagnosis and treatment offer the best
levels. hope. Infants with congenital hypothyroidism Balance is better.
Too many hormones
Sophisticated techniques of hormone mea- who are treated before age 3 months usually
or not enough
surement have improved the diagnosis of grow and develop normally. Children with hormones can cause
endocrine disorders. For example, the human congenital hypothyroidism who remain un- an endocrine
growth hormone (GH) stimulation test mea- treated beyond age 3 months and children disorder.
sures human GH levels after I.V. administra- with acquired hypothyroidism who remain
tion of arginine, an amino acid that, under untreated beyond age 2 suffer irreversible
normal circumstances, stimulates human GH. cognitive impairment. Skeletal abnor-
This test is used to diagnose GH deficiency. malities, however, may be re-
versible with treatment.
Nursing actions
• Explain the test to the child and his parents. CAUSES
• Check with the laboratory and consult facili- • Antithyroid drugs taken
ty protocol to determine specific actions to during pregnancy (in infants)
take before the test (for example, nothing-by- • Chromosomal abnormalities
mouth for blood glucose test). • Chronic autoimmune thyroiditis
(in children older than age 2)
Minute measurements • Defective embryonic
A radioimmunoassay is used to measure development that causes
minute quantities of hormones. congenital absence or
underdevelopment of the
Nursing actions thyroid gland (most common cause in infants)
• Explain the test to the child and his parents. • Inherited enzymatic defect in the synthesis
of thyroxine (T4) caused by an autosomal re- Timing is
cessive gene (in infants) everything.
Polish up on patient DATA COLLECTION FINDINGS

General findings
If treated before
age 3 months, the
prognosis for
care • Delayed dentition
• Enlarged tongue
congenital
hypothyroidism is
Two major endocrine disorders in pediatric • Hypotonia excellent. Left
patients are hypothyroidism and diabetes mel- • Legs short in relation to trunk size untreated, it leads to
cognitive impairment
litus. • Cognitive impairment (develops as the dis-
and skeletal
order progresses) abnormalities.
• Short stature with the persistence of infant
Hypothyroidism proportions
• Short, thick neck
Hypothyroidism occurs when the body
doesn’t produce enough thyroid gland hor- With slow basal metabolic rate
mone, the hormone necessary for normal • Cool body and skin temperature
growth and development. (See Thyroid gland • Decreased perspiration
hormones, page 664.) • Dry, scaly skin
Two types of hypothyroidism exist. Congen- • Easy weight gain
ital hypothyroidism is present at birth. Ac- • Slow pulse
quired hypothyroidism is commonly due to
thyroiditis, an inflammation of the thyroid Untreated hypothyroidism in infants
gland that results in injury or damage to thy- • Hoarse crying
roid tissue. Hypothyroidism is three times • Persistent jaundice
more common in girls than in boys. • Puffy face and swollen tongue
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Thyroid gland hormones

• The thyroid gland secretes the iodinated hormones thyroxine and triiodothyronine.
• Thyroid hormones, necessary for normal growth and development, act on many tissues to increase
metabolic activity and protein synthesis.
• Deficiency of thyroid hormone causes varying degrees of hypothyroidism, from a mild, clinically in-
significant form to life-threatening myxedema coma.
Untreated hypothyroidism in older children TREATMENT

• Stunted growth (dwarfism) • Routine monitoring of T4 and TSH levels
• Cognitive impairment • Periodic evaluation of growth to ensure that
• Weight gain thyroid replacement is adequate
DIAGNOSTIC FINDINGS Drug therapy

• Electrocardiogram shows bradycardia and • Oral thyroid hormone: levothyroxine (Syn-
flat or inverted T waves in untreated infants. throid)
• Hip, knee, and thigh X-rays reveal absence • Supplemental vitamin D to prevent rickets
of the femoral or tibial epiphyseal line and de- resulting from rapid bone growth
layed skeletal development that’s markedly in-
appropriate for the child’s chronological age. INTERVENTIONS AND RATIONALES
• With myxedema coma, laboratory tests may • During early management of infantile hy-
also show a low serum sodium level, de- pothyroidism, monitor blood pressure and
creased pH, and increased partial pressure of pulse rate; report hypertension and tachycar-
arterial carbon dioxide, indicating respiratory dia immediately (normal infant heart rate is
A key test for acidosis. approximately 120 beats/minute) to detect
detecting
• Increased gonadotropin levels accompany signs of hyperthyroidism, which indicate that
hypothyroidism,
radioimmunoassay precocious puberty in older children and may the dose of thyroid replacement medication is
results show low coexist with hypothyroidism. too high.
T3 and T4 • Serum cholesterol, alkaline phosphatase, • Check axillary temperature every 2 to
hormone levels. and triglyceride levels are elevated. 4 hours. Keep the infant warm and his skin
• Normocytic normochromic anemia is moist to promote normothermia and reduce
present. metabolic demands.
• Radioimmunoassay confirms hypothyroidism • If the infant’s tongue is unusually large, po-
with low triiodothyronine (T3) and T4 levels. sition him on his side and observe him fre-
• Thyroid scan and 131I uptake tests show de- quently to prevent airway obstruction.
creased uptake levels and confirm the ab- • Provide the parents with support, referrals,
sence of thyroid tissue in athyroid children. and counseling as necessary to help them cope
• Thyroid-stimulating hormone (TSH) level is with the possibility of caring for a physically
decreased when hypothyroidism is due to hy- and cognitively impaired child.
pothalamic or pituitary insufficiency. • Recommend that adolescent girls seek
• TSH level is increased when hypothyroid- future-oriented counseling that stresses the
ism is due to thyroid insufficiency. importance of adequate thyroid replacement
during pregnancy. Ideally, women should
NURSING DIAGNOSES have excellent control before conception to
• Delayed growth and development prevent pregnancy complications.
• Interrupted family processes
• Deficient knowledge (treatment regimen)
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Teaching topics Hypoglycemia

• Recognizing signs of supplemental thyroid • Increased insulin use
hormone overdose (rapid pulse rate, irritabili- • Excessive exercise
ty, insomnia, fever, sweating, weight loss) • Failure to eat Memory
• Understanding that the child requires life- jogger
long treatment with thyroid supplements DATA COLLECTION FINDINGS
• Complying with the treatment regimen to • Polydipsia To remem-
prevent further mental impairment • Polyphagia ber the
• Adopting a positive but realistic attitude and • Polyuria
key assessment
findings in diabetes
focusing on the child’s strengths rather than mellitus, think
weaknesses Hyperglycemia “tri-poly” (sounds
• Providing stimulating activities to help the • Abdominal cramping like Tripoli):
child reach maximum potential (referring par- • Dry, flushed skin
ents to appropriate community resources for • Fatigue
• Polydipsia
support) • Fruity breath odor • Polyphagia
• Preventing infantile hypothyroidism (Em- • Headache • Polyuria.
phasize the importance of adequate nutrition • Mental status changes
during pregnancy, including iodine-rich foods • Nausea
and the use of iodized salt or, in the case of • Thin appearance and possible malnourish-
sodium restriction, an iodine supplement.) ment
• Vomiting
• Weakness
Diabetes mellitus
Hypoglycemia in conjunction with diabetes
The diabetes that commonly occurs in child- • Behavior changes (belligerence, confusion,
hood is known as type 1 diabetes. However, slurred speech)
recently, type 2 diabetes, which was previous- • Diaphoresis
ly thought to be a disease of adults, has in- • Palpitations
creased in incidence among children. Chil- • Tachycardia
dren with type 1 diabetes must take insulin to • Tremors
replace what their pancreas can no longer
produce. (See Understanding type 1 diabetes, DIAGNOSTIC FINDINGS
page 666.) Type 2 diabetes can sometimes be • Fasting plasma glucose level (no calorie in-
controlled with weight loss, dietary changes, take for at least 8 hours) is greater than or
and exercise. equal to 126 mg/dl.
• Plasma glucose value in the 2-hour sample
CAUSES of the oral glucose tolerance test is greater
• Genetic predisposition than or equal to 200 mg/dl. This test should
• Viral infection be performed after a loading dose of 75 g of
• Obesity (type 2 diabetes) anhydrous glucose.
• A random plasma glucose value (obtained
Hyperglycemia without regard to the time of the child’s last
• Cortisone use food intake) greater than or equal to 200 mg/dl
• Decreased exercise with no decrease in and accompanied by symptoms of diabetes in-
food intake dicates diabetes mellitus.
• Decreased use of insulin • Test for glycosuria and ketonuria using dip-
• Increased sugar intake stick, Clinitest, Acetest, Keto-Diastix, or glu-
• Increased stressors cose enzymatic test strip is positive.
• Infection
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Now I get it!
Understanding type 1 diabetes

Here are important points to help you understand how type 1 diabetes develops.
THE KEY PLAYERS
• The endocrine part of the pancreas produces glucagon from the alpha cells and insulin from the
beta cells.
• Glucagon, the hormone of the fasting state, releases stored glucose to raise the blood glucose
level.
• Insulin, the hormone of the nourished state, facilitates glucose transport, promotes glucose stor-
age, stimulates protein synthesis, and enhances free fatty acid uptake and storage.
WHAT HAPPENS
Absolute or relative insulin deficiency causes diabetes mellitus. Here’s what happens:
• Pancreatic beta cells are destroyed, no insulin is produced, and the cells can’t utilize glucose.
• Excess glucose in the blood spills into the urine.
• The increased level of blood glucose can act as an osmotic diuretic, resulting in dehydration,
hypotension, and renal shutdown.
• The body attempts to compensate for lost energy by breaking down fatty acids to form ketones,
which results in metabolic acidosis.
NURSING DIAGNOSES • Provide appropriate treatment for hypo-

Monitor the child’s • Disturbed body image glycemia to stabilize the child’s condition and
blood glucose and • Risk for deficient fluid volume prevent complications.
electrolyte levels for • Deficient knowledge (treatment regimen) • Evaluate the child’s understanding of dia-
early signs of betes and his attitude about the need to man-
electrolyte TREATMENT age it. This will help you plan teaching.
imbalances. • Exercise • Correct misconceptions the child may have
• Strict diet planned to meet nutritional needs, regarding diabetes and the therapeutic regi-
control blood glucose levels, and reach and men. Use age-appropriate teaching materials
maintain appropriate body weight to increase his knowledge of his condition and
instill confidence in his ability to manage it.
Drug therapy • Provide an opportunity for the child to inter-
• Insulin replacement act with peers who have experienced diabetes
to decrease the child’s feelings of isolation and
INTERVENTIONS AND RATIONALES sense of being different from others.
• Monitor vital signs and fluid intake and out- • Explore ways of dealing with peer pressure.
put to detect high urine output, which may sig- Ask the adolescent if he feels that social pres-
nify hyperglycemia, or weak, thready pulse, sure causes him to ignore his diet or avoid self-
which may indicate hypoglycemia. administering insulin. Ask if he feels embar-
• Monitor blood glucose and electrolyte lev- rassed by his disorder. Peer pressure is a reality
els to detect early signs of electrolyte imbalance. that each adolescent must learn to deal with.
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Hyperglycemia
• Administer regular insulin for fast action to
promote an euglycemic state and prevent com-
plications.
• Maintain I.V. fluids without dextrose to flush
out acetone and maintain hydration.
• Monitor blood glucose level to detect early
changes and prevent complications such as dia-
betic ketoacidosis.
Hypoglycemia
• Give a fast-acting carbohydrate, such as
honey, orange juice, or sugar cubes, followed
later by a protein source to establish normal
glucose levels, thereby preventing complications
Pump up on practice
of hypoglycemia. questions
Teaching topics
• Complying with the prescribed treatment 1. The nurse is teaching the mother of a
program, including diet, exercise, and insulin child diagnosed with type 1 diabetes. The
administration mother asks why her child must inject insulin
• Monitoring blood glucose levels and can’t take pills as her uncle does. Which
• Importance of rotating injection sites reply is most appropriate?
• Understanding the importance of good hy- 1. “Because a child’s pancreas is less de-
giene veloped than an adult’s, antidiabetic pills
• Preventing, recognizing, and treating hypo- aren’t recommended for children.”
glycemia and hyperglycemia 2. “Pills only affect fat and protein me-
• Understanding the effect of blood glucose tabolism, not sugar.”
control on long-term health 3. “The only way to replace insulin is by
• Managing diabetes during minor illness, injection.”
such as a cold, the flu, and an upset stomach 4. “Your child may be able to take pills
• Providing the child and his parents with when he’s older.”
written materials that cover the teaching topic Answer: 3. With type 1 diabetes, the pancreas
• Providing the child and his parents with in- doesn’t produce insulin, so the child must re-
formation about the Juvenile Diabetes Foun- ceive insulin replacement by injection. Oral
dation antidiabetic agents stimulate the pancreas to
produce more insulin, delay the release of
glucose from the liver, or decrease absorption
of glucose and are only effective in treating
type 2 diabetes. Because the pancreas in the
child with type 1 diabetes doesn’t produce in-
sulin, the child will never be a candidate for
oral antidiabetic agents.
integrity
logical therapies
920133.qxd 8/7/08 3:59 PM Page 668
2. The nurse is teaching the mother of a dia- Client needs category: Health promo-
betic child how to recognize the signs and tion and maintenance
symptoms of hypoglycemia. Which signs and Client needs subcategory: None
symptoms should the nurse discuss? Cognitive level: Comprehension
1. Behavioral changes, increased heart
rate, sweating, and tremors 4. The nurse is caring for a child with type 1
2. Nausea, fruity breath odor, headache, diabetes. The nurse enters the child’s room,
and fatigue finds him diaphoretic, and can’t waken him.
3. Polydipsia, polyuria, polyphagia, and The nurse should anticipate which emer-
weight loss gency intervention?
4. Enlarged tongue, hypotonia, easy 1. Administering honey followed by a
weight gain, and cool skin temperature protein source
Answer: 1. The signs and symptoms of hypo- 2. Administering orange juice followed
glycemia include behavioral changes, in- by a protein source
creased heart rate, sweating, and tremors. 3. Administering I.V. dextrose
Nausea, fruity breath odor, headache, and fa- 4. Administering insulin
tigue are present in hyperglycemia. Polydip- Answer: 3. The child is unconscious and may
sia, polyuria, polyphagia, and weight loss are be experiencing a hypoglycemic reaction;
classic signs of diabetes. Enlarged tongue, hy- therefore, the nurse should make sure that
potonia, easy weight gain, and cool skin tem- I.V. dextrose is available for administration. A
perature are associated with hypothyroidism. conscious child experiencing a hypoglycemic
Client needs category: Physiological episode should be given a fast-acting carbohy-
integrity drate, such as honey, orange juice, or sugar
Client needs subcategory: Reduction of cubes, followed by a protein source. Insulin
risk potential administration would further worsen the
Cognitive level: Comprehension child’s condition.
3. The nurse is collecting data on a child integrity
who may have diabetes. Which laboratory val- Client needs subcategory: Pharmaco-
ue would help confirm a diagnosis of type 1 logical therapies
diabetes? Cognitive level: Application
1. A fasting plasma glucose level of
110 mg/dl 5. The nurse is teaching the parents of a
2. A fasting plasma glucose level of child with diabetes. Which agent should the
126 mg/dl nurse teach the parents to administer if their
3. A random plasma glucose level of child suffers a severe hypoglycemic reaction?
180 mg/dl 1. Subcutaneous insulin
4. A 2-hour oral glucose tolerance test 2. I.V. dextrose
result of 140 mg/dl 3. Subcutaneous glucagon
Answer: 2. According to the American Dia- 4. Oral fast-acting carbohydrate
betes Association, diabetes is present when Answer: 3. The nurse should instruct the par-
any of the following criteria exist: symptoms of ents of a child with diabetes about proper ad-
diabetes plus a random plasma glucose level ministration of subcutaneous glucagon if their
greater than or equal to 200 mg/dl, a fasting child suffers a severe hypoglycemic episode.
plasma glucose level greater than or equal to Subcutaneous insulin would further worsen
126 mg/dl, or a 2-hour oral glucose tolerance the child’s condition. I.V. dextrose is reserved
test result greater than or equal to 200 mg/dl. for health care professionals specially trained
in I.V. drug administration. Oral administra-
920133.qxd 8/7/08 3:59 PM Page 669
tion of fast-acting carbohydrates is reserved cream, not skipping meals when using in-
for a conscious child who isn’t suffering from sulin, and the need to adjust insulin doses
a severe hypoglycemic reaction. during times of illness.
integrity integrity
risk potential risk potential Remember that
Cognitive level: Knowledge Cognitive level: Analysis regular study habits
do more good than
cramming. Plan a
6. The nurse is teaching a child with dia- 8. A 10-year-old boy with type 1 diabetes realistic, regular
betes about occurrences that can alter insulin comes to the pediatrician’s office to learn how schedule and
requirements. Which should be emphasized? to administer insulin. Which technique is best stick to it.
1. Illness, stress, growth, food intake, to ensure responsible insulin administration?
and exercise 1. The child observes his parents
2. Water intake, illness, stress, and exer- as they administer his injections.
cise 2. The child learns to adminis-
3. Exposure to ultraviolet light, illness, ter his insulin with supervision.
stress, and exercise 3. The child manages his insulin
4. Sodium intake, exercise, stress, and administration independently.
illness 4. The child learns to draw up
Answer: 1. Illness, stress, growth, food intake, his own insulin and his parents
and exercise can alter insulin requirements. inject it.
Water intake, ultraviolet light exposure, and Answer: 2. School-age children should
sodium intake don’t alter insulin requirements. be encouraged to administer their
Client needs category: Physiological own insulin with adult supervision to
integrity ensure that the correct procedure is
Client needs subcategory: Reduction of followed and that the correct dose is adminis-
risk potential tered. Having the child observe the parents
Cognitive level: Knowledge or draw up his insulin and not inject it doesn’t
allow the child to take sufficient responsibility
7. The nurse is teaching a child with dia- for his care. Allowing the child to administer
betes. Which statement by the child indicates his insulin without adult supervision gives
that teaching was effective? him too much responsibility.
1. “If I want to eat ice cream, I’ll just give Client needs category: Physiological
myself more insulin.” integrity
2. “I’m so busy, I’m glad I can still skip Client needs subcategory: Reduction of
meals if I need to.” risk potential
3. “I will remember to take my regular Cognitive level: Application
dose of insulin even if I’m sick.”
4. “I will monitor my blood glucose level 9. A 9-year-old boy with type 1 diabetes
to determine how much insulin I need.” takes a mixture of regular and neutral prota-
Answer: 4. Diabetic teaching is effective when mine Hagedorn (NPH) insulin. He’s sched-
the child verbalizes the importance of moni- uled to go on a camping trip, and his mother
toring his blood glucose level to determine asks the nurse whether it’s safe for him to
his insulin needs. Teaching should stress the participate in this activity. What’s the most
importance of maintaining a diabetic diet and appropriate response?
avoiding inappropriate items such as ice
920133.qxd 8/7/08 3:59 PM Page 670
1. “He needs to understand the physical 10. The nurse administers oral thyroid hor-
limitations placed on a client with dia- mone to an infant with hypothyroidism. For
betes.” which signs of overdose should the nurse ob-
2. “He should have a light snack before serve the infant?
doing any hiking.” 1. Tachycardia, fever, irritability, and
3. “He shouldn’t go on this trip because sweating
it’s potentially dangerous.” 2. Bradycardia, cool skin temperature,
4. “Have him increase his morning NPH and dry, scaly skin
insulin to compensate for higher metabo- 3. Bradycardia, fever, hypotension, and
lism while hiking.” irritability
Answer: 2. A light meal before rigorous exer- 4. Tachycardia, cool skin temperature,
cise gives the child adequate blood glucose and irritability
levels during the peak action of his morning Answer: 1. The infant experiencing an over-
NPH insulin. Restricting the child’s physical dose of thyroid replacement hormone exhibits
activity discourages a normal lifestyle and tachycardia, fever, irritability, and sweating.
isn’t necessary. The child’s diagnosis alone Bradycardia, cool skin temperature, and dry,
shouldn’t be used to evaluate the danger of scaly skin are signs of hypothyroidism.
the trip. Increasing the child’s insulin would Client needs category: Physiological
increase the likelihood of a hypoglycemic re- integrity
action. Client needs subcategory: Pharmaco-
Client needs category: Physiological logical therapies
risk potential
Treat yourself right while
studying for the NCLEX. Don’t
skip meals, miss sleep, or neglect
exercise. Stay healthy and, in
the long run, you’ll stay ahead.
920134.qxd 8/7/08 3:17 PM Page 671
34 Genitourinary
system
An infant’s renal system can maintain a
In this chapter,
you’ll review:
Brush up on key healthy fluid and electrolyte status. However,
it doesn’t function as efficiently during stress
✐ pediatric genitouri- concepts as an adult’s renal system. For example, if a
child doesn’t receive enough fluid to meet his
nary system
✐ tests used to diag- The genitourinary system includes the geni- needs, his kidneys can’t adequately concen-
talia and urinary structures. The focus of this trate urine to prevent dehydration. Conversely,
nose genitourinary
chapter is the kidneys, ureters, and bladder, if the child receives too much fluid, he may be
disorders
which are involved in renal and urinary func- unable to dilute urine appropriately to get rid
✐ common pediatric tion. The chapter also discusses a sexually of the increased volume.
genitourinary disor- transmitted disease (STD) that affects pedi-
ders. atric patients. Concentration change
You can review the major points of this An infant’s kidneys don’t concentrate urine at
chapter by consulting the Cheat sheet on an adult level (average specific gravity is less
pages 672 and 673. than 1.010 for an infant, compared with 1.010
to 1.030 for an adult).
High turnover Although the number of daily voidings de-
Water, which is controlled by the genitouri- creases with increasing age (because of in-
nary system, is the body’s primary fluid. An creased urine concentration), the total amount
infant has a much greater percentage of total of urine produced daily may not vary signifi-
body water in extracellular fluid (42% to 45%) cantly.
than an adult does (20%). Because of the in- An infant usually voids 5 to 10 ml/hour, a
creased percentage of water in a child’s extra- 10-year-old child usually voids 10 to 25 ml/
cellular fluid, a child’s water turnover rate is hour, and an adult usually voids 35 ml/hour.
two to three times greater than an adult’s.
Uh-oh!
Every day, 50% of an infant’s extracellular Short path to the bladder
Under stress, fluid is exchanged, compared with only 20% of A child has a short urethra; therefore, organ-
my renal system an adult’s; a child is, therefore, more suscepti- isms can travel easily to the bladder, increas-
doesn’t function as ble than an adult to dehydration. ing the risk of bladder infection.
well as an adult’s.
Sweating it out
A neonate also has a greater ratio of body
surface area to body weight than an adult;
this results in greater fluid loss through
Keep abreast of
the skin. diagnostic tests
Less efficient during stress Here are some important tests used to diag-
A child’s kidneys attain the adult number of nose genitourinary disorders, along with com-
nephrons (about 1 million in each kidney) mon nursing interventions associated with
shortly after birth. The nephrons, which form each test.
urine, continue to mature throughout early
childhood.
920134.qxd 8/7/08 3:17 PM Page 672
et
heat she
C
Pediatric genitourinary refresher
CHLAMYDIA Key treatments
Key signs and symptoms • Avoiding circumcision (the foreskin may be
In a child with conjunctivitis needed later during surgical repair)
• Edematous eyelids • Analgesics: morphine or acetaminophen
• Fiery red conjunctivae with a thick pus (Tylenol) for postoperative pain relief
In a child with pneumonia • Antispasmodic agent: propantheline (Pro-
• Crackles and wheezing on auscultation of lungs Banthine) prescribed postoperatively
• Failure to gain weight Surgery
• Nasal congestion • Meatotomy (surgical procedure in which the
• Sharp cough urethra is extended into a normal position); may
• Tachypnea initially be performed to restore normal urinary
Key test results function
• When the child is age 12 to 18 months, surgery
• Cultures reveal Chlamydia trachomatis.
to release the adherent chordee (fibrous band
Key treatments that causes the penis to curve downward)
• Antibiotic: erythromycin (Ilotycin) • Surgery possibly delayed until age 4 if repair is
• Chest physiotherapy to mobilize secretions in a to be extensive
child with pneumonia • Indwelling urinary catheter or suprapubic uri-
• Humidified oxygen to alleviate labored breath- nary catheter postoperatively
ing and prevent hypoxemia in a child with pneu-
Key interventions
monia
• Keep the area clean.
• Irrigation of eyes with sterile saline solution to
• Encourage parents to express feelings and
clear copious discharge
concerns about changes in the child’s body ap-
Key interventions pearance or function. Provide accurate informa-
• Check the neonate of an infected mother for tion and answer questions thoroughly.
signs of chlamydial infection. • Instruct parents in hygiene of uncircumcised
• Administer medication as prescribed, and mon- penis.
itor its effectiveness. Postoperative care
• Auscultate breath sounds and monitor oxy- • Monitor for signs of infection.
genation. • Leave the dressing in place for several days.
HYPOSPADIAS • Take care to avoid pressure on the child’s
catheter and avoid kinking the catheter.
• Altered angle of urination NEPHRITIS
• Meatus terminating at some point along lateral Key signs and symptoms
fusion line, ranging from the perineum to the dis- • Anorexia
tal penile shaft • Burning during urination
Key test results • Flank pain
• Observation confirms aberrant placement of • Shaking chills
the meatus; therefore, diagnostic testing isn’t • Temperature of 102° F (38.9° C) or higher
necessary. • Urinary frequency
• Urinary urgency
920134.qxd 8/7/08 3:17 PM Page 673
Pediatric genitourinary refresher (continued)

NEPHRITIS (continued) Key interventions
Key test results • Monitor vital signs and intake and output.
• Pyuria (pus in urine) is present. Urine sediment reveals the • Don’t palpate the abdomen, and prevent others from doing
presence of leukocytes singly, in clumps, and in casts and, pos- so.
sibly, a few red blood cells. • Handle and bathe the child carefully, and loosen clothing
• Urine culture reveals significant bacteriuria: more than around the abdomen.
100,000/µl of urine. Proteinuria, glycosuria, and ketonuria are less • Prepare the child and family members for a nephrectomy with-
common. in 24 to 48 hours of diagnosis.
Key treatments After nephrectomy
• Antibiotic therapy appropriate to the specific infecting organ- • Monitor urine output and report output less than 30 ml/hour.
ism over a 10- to 14-day course • Assist with turning, coughing, and deep breathing.
• Urinary analgesics such as phenazopyridine (Pyridium) • Encourage early ambulation.
• Provide pain medications, as necessary.
Key interventions
• Monitor postoperative dressings for signs of bleeding.
• Force fluids to achieve urine output of more than 2 L/day. How-
• Use aseptic technique for dressing changes.
ever, discourage intake greater than 3 L/day.
• Teach the child and parents about: URINARY TRACT INFECTION
– refrigerating or culturing a urine specimen within 30 minutes of Key signs and symptoms
collection to prevent overgrowth of bacteria • Frequent urge to void with pain or burning on urination
– completing the prescribed antibiotic therapy, even after symp- • Lethargy
toms subside • Low-grade fever
– long-term follow-up care for high-risk children. • Urine that’s cloudy and foul-smelling
NEPHROBLASTOMA Key test results
Key signs and symptoms • Clean-catch urine culture yields large amounts of bacteria.
• Associated congenital anomalies — microcephaly, mental re- Key treatments
tardation, genitourinary tract problems • Cranberry juice to acidify urine
• Nontender mass, usually midline near the liver; usually • Forced fluids to flush infection from the urinary tract
detected by the parent while bathing or dressing the child • Antibiotics: co-trimoxazole (Bactrim) or ampicillin to prevent
Key test results glomerulonephritis
• Excretory urography reveals a mass displacing the normal kid- Key interventions
ney structure. • Monitor intake and output.
• Computed tomography scan or sonography will reveal metas- • Evaluate toileting habits for proper front-to-back wiping and
tasis. proper hand washing.
Key treatments • Encourage increased intake of fluids and cranberry juice.
• Nephrectomy within 24 to 48 hours of diagnosis because these • Assist the child when necessary to ensure that the perineal
tumors metastasize quickly area is clean after elimination.
• Radiation therapy (following surgery)
• Chemotherapy (following surgery) with dactinomycin, doxoru-
bicin, or vincristine
Blood analysis Nursing actions

Blood tests are used to analyze serum levels • Explain to the parent and child that the test
of chemical substances, such as uric acid, cre- requires a blood sample and may cause some
atinine, and blood urea nitrogen, and elec- discomfort from the needle stick.
trolytes, such as sodium, potassium, chloride,
calcium, magnesium, and phosphorus.
920134.qxd 8/7/08 3:17 PM Page 674
Infant specimen collection

Use the clean-catch method to collect urine from an infant, as follows:
• After properly cleaning the skin and genitals, apply a pediatric urine collector to dry skin (powders
or creams shouldn’t be used).
• If the child doesn’t void within 45 minutes, remove the bag and repeat the procedure.
• Allow the child to hold a comfort object, • use calibrated containers

such as a stuffed animal or blanket, to help di- • validate intake and output measurements by
minish his anxiety. checking the child’s weight daily
• monitor all fluid losses daily, including
Urine testing blood, vomitus, diarrhea, and wound and
Urinalysis is used to determine urine charac- stoma drainage.
teristics, such as:
• presence of red blood cells (RBCs) Kidney pictures
• presence of white blood cells Kidney-ureter-bladder (KUB) radiogra-
• presence of casts or bacteria phy is used to assess the size, shape, position,
• specific gravity and pH and possible areas of calcification of the renal
• physical properties, such as clarity, color, organs.
and odor.
Nursing actions
Nursing actions • Explain the procedure to the parents and
• Before specimen collection, explain the im- the child.
portance of cleaning the meatal area thor- • Tell the child that the X-ray takes only a few
Holding a comfort oughly. minutes and remind him to remain still.
object, such as a • Explain that the culture specimen should be • Shield the genitals of a male child to pre-
stuffed animal, may
caught midstream, in a sterile container. (See vent irradiation of the testes.
help decrease
anxiety. I wonder if Infant specimen collection.)
I can take him • Explain that the specimen for urinalysis I.V. action
to the NCLEX. should be caught in a clean container, prefer- Excretor y urography aids in checking renal
ably at the first voiding of the day. pelvic structures. A contrast medium is intro-
• Begin a 24-hour specimen collection after dis- duced into the renal pelvis, allowing visualiza-
carding the first voiding; such specimens com- tion of the collecting system and ureters.
monly necessitate special handling or preserva-
tives. Nursing actions
• When obtaining a urine specimen from a • Check the child’s history for allergies to io-
catheterized child, aspirate a sample through dine, shellfish, or contrast media.
the collection port in the catheter, with a ster- • Monitor the child’s intake and output.
ile needle and a syringe. • Explain the purpose of the test to the child
and his parents.
Fluids in and out • Maintain the child on nothing-by-mouth sta-
Intake and output data help determine the tus for 8 hours before the test.
child’s hydration status. • Make sure that written, informed consent
has been obtained.
Nursing actions • Increase hydration after the procedure.
To provide the most useful and accurate infor-
mation, you should:
920134.qxd 8/7/08 3:17 PM Page 675
While the water’s running In a child with pneumonia

Voiding cystourethrography aids in viewing • Crackles and wheezing on auscultation of Picture this.
Several tests help
the bladder and related structures during lungs
picture the renal
voiding. • Failure to gain weight system: KUB
• Nasal congestion radiography,
Nursing actions • Sharp cough excretory urography,
• Check the child’s history for allergies to io- • Tachypnea and voiding
dine, shellfish, and contrast media. cystourethrography.
• Monitor the child’s intake and output. DIAGNOSTIC FINDINGS
• Explain the purpose of the test to the child • Cultures reveal C. trachomatis.
and his parents. • Blood studies show elevated levels of im-
• Make sure that written, informed consent munoglobulin (Ig) G and IgM antibodies.
has been obtained.
• After the procedure, encourage the child to NURSING DIAGNOSES
drink lots of fluid to reduce burning on urina- • Ineffective airway clearance
tion and to flush out residual dye. • Interrupted family processes
TREATMENT
Polish up on patient • Humidified oxygen to alleviate la-
bored breathing and prevent hypoxemia
care in a child with pneumonia
• Chest physiotherapy to mobilize se-
Common genitourinary disorders in pediatric cretions in a child with pneumonia
patients include chlamydia, hypospadias, • Irrigation of the eyes with sterile
nephritis, nephroblastoma (Wilms’ tumor), saline solution to clear copious discharge
and urinary tract infections (UTIs).
Drug therapy
• Antibiotic: erythromycin (Ilotycin)
Chlamydia
Chlamydial infections are the most common • Check the neonate of an infected mother for
STDs in the United States. In infants, the in- signs of chlamydial infection to identify infec-
fecting organism is passed from the infected tion early and initiate treatment.
mother to the fetus during passage through • Administer medication as prescribed and
the birth canal. monitor its effectiveness to improve the child’s
Chlamydia is the most common cause of condition.
ophthalmia neonatorum (eye infection at • Obtain appropriate specimens for diagnostic
birth or during the 1st month) and a major testing to aid in diagnosis of infection.
cause of pneumonia in infants in the first 3 • Auscultate breath sounds and monitor oxy-
months of life. With antibiotic therapy, the genation to determine oxygen status and respi-
chance of cure is good. ratory function.
• Suction as needed to provide airway clear-
CAUSE ance.
• Chlamydia trachomatis infection
Teaching topics
DATA COLLECTION FINDINGS • Completing the entire course of drug therapy
In a child with conjunctivitis • Taking proper care of the eyes
• Edematous eyelids
• Fiery red conjunctivae with a thick, puslike
discharge
920134.qxd 8/7/08 3:17 PM Page 676
Hypospadias Drug therapy

• Analgesics: morphine or acetaminophen
Hypospadias is a congenital anomaly of the (Tylenol) for postoperative pain relief
penis. With this condition, the urethral open- • Antispasmodic agent: propantheline (Pro-
ing may be anywhere along the ventral side of Banthine) prescribed postoperatively
the penis. The condition shortens the dis-
tance to the bladder, offering easier access for INTERVENTIONS AND RATIONALES
bacteria. • Monitor urine output to ensure that the in-
fant maintains a normal urine output of 5 to
CAUSES 10 ml/hour.
• Genetic factors • Keep the area clean to prevent bacteria inva-
sion and infection.
DATA COLLECTION FINDINGS • Encourage the parents to express feelings
• Altered angle of urination and concerns about changes in the child’s
• Meatus terminating at some point along lat- body appearance or function. Provide accu-
eral fusion line, ranging from the perineum to rate information and answer questions thor-
the distal penile shaft oughly. Encouraging open discussion enables
• Normal urination (with penis elevated) im- the nurse to provide emotional support and
possible may help ease the parents’ anxiety.
DIAGNOSTIC FINDINGS Postoperative care

• Observation confirms aberrant placement • Monitor for signs of infection to identify
of the opening; therefore, diagnostic testing complications.
isn’t necessary. • Leave the dressing in place for several days
to encourage healing of the grafted skin flap.
NURSING DIAGNOSES • Take care to avoid pressure on the child’s
•Disturbed body image catheter to prevent trauma to the incision site
The key • Deficient knowledge (disease process and and avoid kinking of the catheter to ensure
intervention in treatment regimen) urine flow.
hypospadias is • Risk for infection (urinary tract) • Encourage early ambulation to prevent com-
scrupulous cleaning
plications of immobility.
to deter bacteria.
TREATMENT
• Avoiding circumcision (the foreskin may be Teaching topics
needed later during surgical repair) • Practicing hygiene of uncircumcised penis
• No treatment (in mild disorder) • Caring for the catheter
• Understanding signs and symptoms of UTI
Surgery or incisional infection
• Meatotomy (procedure in which the ure-
thra is extended into a normal position); may
initially be performed to restore normal uri- Nephritis
nary function
• When the child is age 12 to 18 months, Also known as acute infective tubulointerstitial
surgery to release the adherent chordee (fi- nephritis, pyelonephritis, or glomerulonephritis,
brous band that causes the penis to curve this disorder is a sudden inflammation that
downward) primarily affects the interstitial area and the
• Surgery possibly delayed until age 4 if re- renal pelvis or, less typically, the renal
pair is to be extensive tubules. One of the most common renal dis-
• Indwelling urinary catheter or suprapubic eases, nephritis occurs more often in females,
urinary catheter postoperatively probably because of their shorter urethra and
the proximity of the urinary meatus to the
vagina and rectum.
920134.qxd 8/7/08 3:17 PM Page 677
With treatment and continued follow-up • Urine specific gravity and osmolality are
care, the prognosis is good and extensive per- low, resulting from a temporarily decreased Antibiotic therapy
for nephritis targets
manent damage is rare. ability to concentrate urine.
the specific infecting
• Urine pH is slightly alkaline. organism.
CAUSES • KUB radiography may reveal calculi, tumors,
• Infection of the kidneys (the most common or cysts in the kidneys and urinary tract.
cause) by bacteria, which usually are normal
intestinal and fecal flora that grow readily in NURSING DIAGNOSES
urine (The most common causative organism • Impaired urinary elimination
is Escherichia coli, but Proteus, Pseudomonas, • Risk for infection
Staphylococcus aureus, and Enterococcus fae- • Acute pain
calis [formerly Streptococcus faecalis] may
also cause such infections.) TREATMENT
• Hematogenic infection (as in septicemia or • Follow-up treatment for an-
endocarditis) tibiotic therapy: reculturing
• Inability to empty the bladder (for example, urine 1 week after drug therapy
in patients with neurogenic bladder), urinary stops and then periodically for
stasis, or urinary obstruction due to tumors the next year to detect residual
or strictures or recurring infection
• Contamination from instruments used in di- • Surgery to relieve obstruc-
agnostic testing, surgery, and routine patient tion or correct the anomaly re-
care (such as catheterization, cystoscopy, or sponsible for obstruction or vesicoureteral
urologic surgery) reflux; antibiotics aren’t always effective
• Lymphatic infection
Antibiotic therapy
DATA COLLECTION FINDINGS Antibiotic therapy is targeted to the specific
• Anorexia infecting organism; the course of therapy is
• Burning during urination 10 to 14 days. Therapy for specific organisms
• Dysuria is described below:
• Flank pain • Enterococcus — ampicillin (Principen), peni-
• General fatigue cillin G (Pfizerpen), or vancomycin (Vancocin)
• Hematuria (usually microscopic but may be • E. coli — nalidixic acid (NegGram), and ni-
gross) trofurantoin (Macrobid)
• Nocturia • Proteus — ampicillin, sulfisoxazole, nalidixic
• Shaking chills acid, and a cephalosporin
• Temperature of 102° F (38.9° C) or higher • Pseudomonas — gentamicin, and carbeni-
• Urinary frequency cillin (Geocillin)
• Urinary urgency • Staphylococcus — penicillin G; if resistance
• Urine that’s cloudy and has an ammonia-like develops, a semisynthetic penicillin, such as
or fishy odor nafcillin (Unipen) or a cephalosporin
When the infecting organism can’t be iden-
DIAGNOSTIC FINDINGS tified, therapy usually consists of a broad-
• Excretory urography may show asymmetri- spectrum antibiotic, such as ampicillin or
cal kidneys. cephalexin (Keflex).
• Pyuria (pus in urine) is present. Urine sedi-
ment reveals the presence of leukocytes Other drug therapy
singly, in clumps, and in casts and, possibly, a • Urinary analgesics: phenazopyridine (Pyrid-
few RBCs. ium)
• Urine culture reveals significant bacteriuria:
more than 100,000/µl of urine. Proteinuria,
glycosuria, and ketonuria are less common.
920134.qxd 8/7/08 3:17 PM Page 678
INTERVENTIONS AND RATIONALES • Associated congenital anomalies, such as

It ain’t over till the • Monitor urine specific gravity to detect dehy- microcephaly, mental retardation, and geni-
pill bottle is empty.
dration. tourinary tract problems
Emphasize the need
to complete the • Monitor vital signs to detect fever and hyper- • Constipation
prescribed antibiotic tension. • Hematuria
therapy, even after • Administer antipyretics to reduce fever. • Hypertension
symptoms subside. • Force fluids to achieve urine output of more • Nontender mass, usually midline near the
than 2 L/day. However, discourage intake liver; commonly detected by the parent while
greater than 3 L/day. Excessive fluid intake bathing or dressing the child
may decrease the effectiveness of the antibiotics.
• Provide a diet that contains 500 mg of calci- DIAGNOSTIC FINDINGS
um for children up to age 3, 800 mg for chil- • Excretory urography reveals a mass dis-
dren over age 3, and 1,300 mg for adoles- placing the normal kidney structure.
cents; moderate sodium restriction; moderate • Computed tomography scan or sonography
animal protein intake; and avoidance of high reveals metastasis.
doses of vitamin C. These measures help to pre- • Serum blood studies show anemia.
vent renal calculi formation.
NURSING DIAGNOSES
Teaching topics • Fear
• Collecting a clean-catch urine specimen • Chronic and acute pain
• Refrigerating or culturing a urine specimen • Anxiety
within 30 minutes of collection to prevent
overgrowth of bacteria TREATMENT
• Completing prescribed antibiotic therapy, • Nephrectomy within 48 hours of diagnosis
even after symptoms subside • Radiation therapy (following surgery)
• Understanding long-term follow-up care for
high-risk children Drug therapy
• Analgesics (postoperatively): morphine
• Chemotherapy (following surgery) with
Nephroblastoma dactinomycin (Cosmegen), doxorubicin
(Adriamycin), or vincristine (Oncovin)
Nephroblastoma, also known as Wilms’ tumor,
is an embryonal cancer of the kidney. The av- INTERVENTIONS AND RATIONALES
Don’t palpate the erage age at diagnosis is 2 to 4 years. The • Monitor vital signs and intake and output to
child’s abdomen. prognosis is excellent if there’s no metastasis. determine fluid volume status.
Doing so might cause Nephroblastoma is measured in four stages: • Don’t palpate the abdomen and prevent oth-
cancer cells to • In stage I, the tumor is limited to the kidney. ers from doing so to prevent the dissemination
spread.
• In stage II, the tumor extends beyond the of cancer cells to other sites.
kidney but can be completely excised. • Handle and bathe the child carefully and
• In stage III, the tumor spreads but is con- loosen clothing around the abdomen to pre-
fined to the abdomen and lymph nodes. vent pressure on the abdomen, which may
• In stage IV, the tumor metastasizes to the cause dissemination of cancer cells.
lung, liver, bone, and brain. • Prepare the child and family members for a
nephrectomy within 24 to 48 hours of diagno-
CAUSE sis. Surgery must be performed quickly after di-
• Genetic predisposition agnosis because these tumors metastasize quickly.
After nephrectomy
DATA COLLECTION FINDINGS • Monitor urine output and report output less
• Abdominal pain than 30 ml/hour.
• Assist with turning, coughing, and deep
breathing.
920134.qxd 8/7/08 3:17 PM Page 679
• Encourage early ambulation. • Lethargy

• Provide pain medications, as necessary. • Low-grade fever
• Monitor postoperative dressings for signs of • Poor feeding patterns
bleeding. • Urine that’s cloudy and foul-smelling
• Use aseptic technique for dressing changes.
These measures will help prevent postopera- DIAGNOSTIC FINDINGS
tive complications, such as pneumonia, wound • Clean-catch urine culture yields large
infection, and kidney failure. amounts of bacteria.
• Urine pH is increased.
Teaching topics
• Providing adequate nutrition and hydration NURSING DIAGNOSES
• Dealing with adverse reactions to chemo- • Impaired urinary elimination
therapy • Acute pain
• Contacting support groups • Risk for infection
TREATMENT
Urinary tract infection • Cranberry juice to acidify urine
• Forced fluids to flush infection from the uri-
A UTI is a microbial invasion of the kidneys, nary tract
ureters, bladder, or urethra.
The risk of UTI varies, depending on the Drug therapy
child’s age and the presence of obstructive • Antibiotics: co-trimoxazole (Bactrim) or
uropathy or voiding dysfunction. In the neo- ampicillin to prevent glomerulonephritis
natal period, UTIs occur most commonly in
males, possibly because of the higher incidence INTERVENTIONS AND RATIONALES
of congenital abnormalities in male neonates. • Monitor input and output to determine if flu-
By age 4 months, UTIs are more common in id replacement therapy is adequate.
girls than in boys. The increased incidence in • Evaluate toileting habits for proper front-to-
girls continues throughout childhood. back wiping and proper hand washing to pre-
After infancy, nearly all UTIs occur when vent recurrent infection.
bacteria enter the urethra and ascend the uri- • Encourage increased intake of fluids and
nary tract. Females are especially at risk for cranberry juice to flush the infection from the
infection because the female urethra is much urinary tract and acidify the urine.
Memory
shorter than the male urethra. The female • Assist the child when necessary to ensure
jogger
urethra is subject to more direct contamina- that the perineal area is clean after elimina- To remem-
tion because of its proximity to the anal open- tion. Cleaning the perineal area by wiping from ber the
ing. E. coli causes approximately 75% to 90% the area of least contamination (urinary mea- clinical findings as-
of all UTIs in females. tus) to the area of greatest contamination sociated with uri-
(anus) helps prevent UTIs.
nary tract infec-
tion, think, “The uri-
CAUSES nary tract is FULL
• Incomplete bladder emptying Teaching topics of infection.” Look
• Irritation by bubble baths • Avoiding tub baths or bubble baths for:
• Poor hygiene • Encouraging the child to use the toilet
• Reflux every 2 hours
Frequent urge to
void
• Performing proper toilet hygiene; wiping
DATA COLLECTION FINDINGS from front to back Urine that’s foul-
• Abdominal pain • Proper hand washing smelling and cloudy
• Enuresis Low-grade fever
• Frequent urge to void with pain or burning
Lethargy.
on urination
• Hematuria
920134.qxd 8/7/08 3:17 PM Page 680
2. The nurse is collecting data on a young

girl who may have a UTI. A girl is more sus-
ceptible to UTIs than a boy because she has:
1. smaller kidneys.
2. a smaller bladder.
3. a shorter urethra.
4. no pubic hair.
Answer: 3. A girl is more susceptible to UTIs
than a boy because she has a shorter urethra,
making it easier for organisms to travel to the
bladder. An infant’s smaller, immature kid-
neys cause a low glomerular filtration rate but
don’t make the infant prone to a UTI. A small
Pump up on practice child voids more frequently because of a
small bladder, but this doesn’t make the child
questions prone to UTI. Pubic hair growth signals the
onset of puberty and its absence is normal in
young children.
1. A school-age child is diagnosed with Client needs category: Health promo-
acute glomerulonephritis (nephritis). Which tion and maintenance
nursing action takes priority when caring for Client needs subcategory: None
this child? Cognitive level: Application
1. Monitoring blood pressure every 4
hours 3. An infant is admitted to the pediatric unit
2. Checking urine specific gravity every for surgical repair of hypospadias. The in-
8 hours fant’s urine output is 7 ml/hour. What nursing
3. Offering the child fluids every hour action is most appropriate?
4. Providing the child with a regular diet 1. Notify the physician immediately.
and snacks 2. Prepare to administer I.V. fluids.
Answer: 1. Hypertension is a major complica- 3. Offer the infant formula every hour.
tion that can occur during the acute phase of 4. Continue to monitor urine output.
glomerulonephritis; therefore, blood pressure Answer: 4. Normal urine output for an infant
should be monitored at least every 4 hours. is 5 to 10 ml/hour. If urine output falls within
Specific gravity should also be monitored, but it the normal range, the nurse should continue
doesn’t take priority over blood pressure moni- monitoring. It isn’t necessary to notify the
toring. Fluids may be limited and a low-sodium physician, administer I.V. fluids, or increase
diet initiated if the child is hypertensive. the infant’s intake of formula.
integrity integrity
920134.qxd 8/7/08 3:17 PM Page 681
4. The nurse must obtain a urine specimen 6. A child is admitted to the pediatric unit
from an infant. The nurse can best obtain a with a fever of 102.5º F (39.2º C), shaking I think I can. I think
I can. Setting goals,
clean-catch specimen by: chills, and flank pain. From these data collec-
having an organized
1. applying a pediatric urine collector to tion findings, the nurse would most likely sus- plan of action, and
dry skin. pect which diagnosis? maintaining a strong
2. placing the infant on a pediatric bed- 1. UTI belief in yourself can
pan. 2. Nephritis help you survive the
3. inserting an indwelling urinary 3. Nephroblastoma NCLEX.
catheter. 4. Urolithiasis
4. wringing out a cloth diaper after the Answer: 2. With nephritis, the child exhibits
infant voids. fever of 102º F (38.9º C) or higher, shaking
Answer: 1. The nurse should properly clean chills, flank pain, urinary urgency
the infant’s skin and genitals and apply a pedi- and frequency, and burning during
atric urine collector to dry skin (powders or urination. The child experiencing a
creams shouldn’t be used). If the infant doesn’t UTI may exhibit low-grade fever,
void within 45 minutes, the bag should be re- dysuria, urinary frequency and ur-
moved and the procedure repeated. This is the gency, lethargy, and cloudy, foul-
least invasive method, making it the best way smelling urine. The child with a
to obtain a specimen. Placing the infant on a nephroblastoma typically exhibits a
pediatric bedpan, inserting an indwelling uri- nontender mass, usually midline
nary catheter, and wringing out a urine-filled near the liver; abdominal pain; hy-
cloth diaper aren’t the best methods for col- pertension; hematuria; and constipa-
lecting urine specimens from an infant. tion. The child with urolithiasis ex-
Client needs category: Safe, effective hibits colicky flank pain, nausea,
care environment vomiting, hematuria, and dysuria.
Client needs subcategory: Safety and Client needs category:
infection control Physiological integrity
Cognitive level: Knowledge Client needs subcategory: Reduction of
risk potential
5. The nurse is assisting with the creation of Cognitive level: Analysis
a teaching plan for a school-age child with a
UTI. Which should be evaluated first? 7. The nurse is teaching parents of an infant
1. The child’s dietary intake with hypospadias. The nurse should tell the
2. The child’s toileting habits parents to avoid:
3. The child’s calcium intake 1. using disposable diapers.
4. The child’s activity level 2. positioning the infant on his back to
Answer: 2. The nurse should evaluate the sleep.
child’s toileting habits before creating a teach- 3. bathing the infant in an infant bath-
ing plan for the school-age child with a UTI. tub.
Based on her findings, the nurse should in- 4. having the infant circumcised.
struct the child in proper front-to-back wiping, Answer: 4. The parents should be instructed
hand washing, and using the toilet every 2 to avoid having the infant circumcised be-
hours. It isn’t necessary to inquire about the cause the foreskin may be needed for surgical
child’s dietary intake, calcium intake, or activ- repair. The parents would be permitted to use
ity level at this time. disposable diapers for their infant and bathe
Client needs category: Physiological him in an infant tub. The parents should be in-
integrity structed to place their child on his back to
Client needs subcategory: Reduction of sleep to decrease the risk of sudden infant
risk potential death syndrome.
920134.qxd 8/7/08 3:17 PM Page 682

integrity integrity
Cognitive level: Knowledge Cognitive level: Knowledge
8. A toddler is admitted to the pediatric unit 10. A neonate is suspected of having a

with a diagnosis of nephroblastoma. When chlamydial infection. The neonate most likely
providing routine care for this toddler, the contracted this infection:
nurse should avoid: 1. transplacentally.
1. palpating the toddler’s abdomen. 2. during passage through the birth
2. positioning the toddler on his side. canal.
3. bathing the toddler. 3. through sexual abuse.
4. loosening the toddler’s clothing. 4. in the nursery because of improper
Answer: 1. The nurse shouldn’t palpate the infection-control measures.
toddler’s abdomen and should prevent others Answer: 2. Chlamydia is transmitted to the
from doing so to avoid disseminating cancer neonate during passage through the birth
cells to other sites. The toddler may be care- canal, not transplacentally or by improper in-
fully positioned on his side and may be fection-control measures. Transmission from
bathed but must be handled carefully. The sexual abuse in neonates is less common than
toddler’s clothes should be loosened around transmission through the birth canal.
the abdomen. Client needs category: Safe, effective
Client needs category: Physiological care environment
integrity Client needs subcategory: Safety and
Client needs subcategory: Reduction of infection control
risk potential Cognitive level: Knowledge
9. A parent reports finding a mass in her

child’s abdomen. After the diagnosis of
nephroblastoma is confirmed, the nurse
should prepare the child and family for:
1. immediate chemotherapy.
2. immediate radiation therapy. One more
3. nephrectomy within 24 to 48 hours of pediatric
diagnosis. chapter to go!
4. discharge to home with hospice care.
Answer: 3. The nurse should prepare the
child and his family for a nephrectomy, which
is usually performed within 24 to 48 hours of
diagnosis. Chemotherapy and radiation are
used as follow-up treatment after nephrecto-
my is completed. Because the prognosis is
excellent if there’s no metastasis, hospice isn’t
necessary.
920135.qxd 8/7/08 4:00 PM Page 683
35 Integumentary
system
tic body odor. The sebaceous glands begin
In this chapter,
you’ll review:
Brush up on key to produce sebum in response to hormone ac-
tivity, which predisposes the adolescent to
✐ characteristics of the concepts acne. Along with the skin glands becoming
active, coarse terminal hair grows in the axil-
pediatric integumen-
tary system The skin, the primary component of the integ- lae and pubic areas of both sexes and on the
umentary system, forms a protective barrier faces of males.
between internal structures and the external
nose integumentary
environment. Tough and resilient, the skin is Here’s the skinny
disorders virtually impermeable to aqueous solutions, Skin performs many vital functions, including:
✐ common integumen- bacteria, and toxic compounds. • protecting against trauma
tary disorders. At any time, you can review the major points • regulating body temperature
of this chapter by consulting the Cheat Sheet • serving as an organ of excretion and sensa-
on pages 684 and 685. tion
• synthesizing vitamin D in the presence of
Thin-skinned at birth ultraviolet light.
Like most body systems, the integumentary
system isn’t mature at birth. Therefore, it pro- Wearing layers
vides a less effective barrier to physical ele- Skin has three primary layers:
ments and microorganisms during birth and
infancy than during childhood. This helps to The epidermis (the outermost layer)
explain why infants and young children are produces keratin as its primary function. It
more prone to infection. contains two sublayers: the stratum corneum,
an outer, horny layer of keratin that protects
Untouched the body against harmful environmental sub-
The skin of infants and young children ap- stances and restricts water loss, and the cellu-
pears smoother than that of adults. A child’s lar stratum, where keratin cells are synthe-
skin has less terminal hair and hasn’t been sized. The epidermis contains melanocytes
subjected to long-term exposure to environ- that produce melanin, which gives the skin its
mental elements. color. It also contains Langerhans’ cells,
which are involved in several immunologic re-
I’m chilly actions.
Infants have poorly developed subcutaneous
The dermis (the middle layer) contains
fat, predisposing them to hypothermia. Ec-
collagen, which strengthens the skin to pre-
crine sweat glands don’t begin to function
vent it from tearing, and elastin to give it re-
until the first month of life, which also inhibits
silience.
the infant’s ability to control body tempera-
ture. Subcutaneous tissue (the innermost
layer) consists mainly of fat (containing most-
Is it hot in here? ly triglycerides), which provides heat, insula-
With the onset of adolescence, apocrine tion, shock absorption, and a reserve of calo-
glands enlarge and become active. This activ- ries.
ity leads to axillary sweating and characteris-
920135.qxd 8/7/08 4:00 PM Page 684
et
heat she
C
Pediatric integumentary refresher
ACNE VULGARIS • Instruct the patient to take tetracycline on an
Key signs and symptoms empty stomach and not to take it with antacids
• Closed comedo, or whitehead (acne plug not or milk.
protruding from the follicle and covered by the • Tell the patient who’s taking isotretinoin to avoid
epidermis) vitamin A supplements. Also discuss how to deal
• Inflammation and characteristic acne pustules, with the dry skin and mucous membranes that
papules or, in severe forms, acne cysts or ab- usually occur during treatment. Warn the female
scesses (caused by rupture or leakage of an en- patient about the severe risk of teratogenesis.
larged plug into the dermis) • Offer emotional support to the patient who’s in-
• Open comedo, or blackhead (acne plug pro- secure about his appearance.
truding from the follicle and not covered by the BURNS
epidermis)
Key treatments For first-degree burn (partial thickness of skin)
• Exposure to ultraviolet light (but never when a • Dry, painful, red skin with edema
photosensitizing agent, such as tretinoin, is being • Sunburn appearance
used) For second-degree burn (partial thickness of
• Oral isotretinoin (Accutane) limited to those skin)
with nodulocystic or recalcitrant acne who don’t • Moist, weeping blisters with edema
respond to conventional therapy • Severe pain
• Systemic therapy: usually tetracycline (Su- For third-degree burn (full thickness of skin)
mycin) to decrease bacterial growth; alternative- • Avascular site without blanching or pain
ly, erythromycin (E-mycin; tetracycline con- • Dry, pale, leathery skin
traindicated during pregnancy and childhood be-
Key test results
cause it discolors developing teeth)
• To determine the extent of injury, many burn fa-
You can read the • Topical medications: benzoyl peroxide (Ben-
cilities use the Lund-Browder chart, which is a
whole chapter, or you zac), clindamycin (Cleocin), or erythromycin and
body surface area chart that accounts for age.
can just go skin deep benzoyl peroxide (Benzamycin) antibacterial
and study the agents, alone or in combination with tretinoin Key treatments
Cheat sheet. (retinoic acid), or a keratolytic • I.V. fluids to prevent and treat shock; urine out-
Key interventions put maintained at 1 to 2 ml/kg
• Protective isolation, depending on burn severity
• Identify predisposing factors.
• Instruct the patient using tretinoin to apply it at Key interventions
least 30 minutes after washing the face and at • Stop the burning in an emergency situation.
least 1 hour before bedtime. Warn against using • Maintain a patent airway in the immediate post-
it around the eyes or lips. After treatments, the burn phase.
skin should look pink and dry. • Monitor vital signs and intake and output.
• Advise the patient to avoid exposure to sunlight • Prevent heat loss.
or to use a sunblock. If the prescribed regimen CONTACT DERMATITIS
includes tretinoin and benzoyl peroxide, tell the
patient to use one preparation in the morning and
the other at night. • Characteristic bright red, maculopapular rash
in the diaper area
920135.qxd 8/7/08 4:00 PM Page 685
Pediatric integumentary refresher (continued)

CONTACT DERMATITIS (continued) • Pustular rash: vesicles and bullae that fill with purulent exu-
Key treatments date
• Cleaning affected area with mild soap and water • Vesicular rash: small, raised, circumscribed lesions filled with
• Leaving affected area open to air clear fluid
Key interventions Key test results
• Keep the diaper area clean and dry. • Aspirate from lesions may reveal cause.
• Patch test may identify cause.
HEAD LICE
Key treatments
• Antibacterial, antifungal, or antiviral agent (depending on
• Pruritus of the scalp cause)
• White flecks attached to the hair shafts • Antihistamines if the rash is the result of an allergy
Key test results Key interventions
• Examination reveals lice eggs, which look like white flecks, • Maintain standard precautions to prevent the spread of infec-
firmly attached to hair shafts near the base. tion.
Key treatments • Teach sanitary techniques.
• Pyrethrins (Rid) or permethrin (Nix) shampoos or lindane (GBH) • Cover weeping lesions.
in resistant cases
SCABIES
Key interventions
• Explain the need to wash bed linens, hats, combs, brushes, and
anything else that comes in contact with the hair. • Linear black burrows between fingers and toes and in palms,
axillae, and groin
IMPETIGO Key test results
Key signs and symptoms • Drop of mineral oil placed over the burrow, followed by superfi-
• Macular rash progressing to a papular and vesicular rash, cial scraping and examination of expressed material under a mi-
which oozes and forms a moist, honey-colored crust croscope may reveal ova or mite feces.
• Washing affected area with disinfectant soap • Application of permethrin (Elimite)
• Apply antibiotic ointment. • Teach the child and parents to apply permethrin from the neck
• Wash the area three times daily with antiseptic soap. down covering the entire body, wait 15 minutes before dressing,
and avoid bathing for 8 to 12 hours.
RASHES
• Explain the need to change bed linens, towels, and clothing af-
Key signs and symptoms ter bathing and lotion application.
• Papular rash: raised solid lesions with color changes in cir-
cumscribed areas
Thinner, more sensitive

A child’s skin differs from an adult’s in two
important ways:
Keep abreast of
• A child has thinner and more sensitive skin
than an adult.
diagnostic tests
• Birthmarks in a neonate can result from the Here are some tests used to diagnose
sensitivity of the infant’s skin, the incomplete skin disorders, along with common nursing
migration of skin cells, or clogged pores. interventions associated with each test.
920135.qxd 8/7/08 4:00 PM Page 686
Slide show Tissue test

With diascopy, a lesion is covered with a A skin biopsy determines the histology of
microscope slide or piece of clear plastic. The cells. It can be used to diagnose or confirm a
area is observed to determine whether dilat- disorder.
ed capillaries or extravasated blood is causing
the lesion’s redness. Nursing actions
Nursing actions • Explain the procedure to the child and his
• Explain the procedure to the child and his parents.
parents. • Make sure written, informed consent has
been obtained.
Light up and down After the procedure
Sidelighting shows minor elevations or de- • Prevent secondary infections by cutting the
pressions in lesions; it also helps determine child’s nails and applying mittens and elbow
the configuration and degree of eruption. restraints.
Subdued lighting, another test, highlights • Suggest that the child wear light, loose,
the difference between normal skin and cir- nonirritating clothing over the procedure site.
cumscribed lesions that are hypopigmented
or hyperpigmented.
Nursing actions
• Explain the procedure to the child and his
parents. care
Spotlight on disease Major skin disorders in pediatric patients in-
Microscopic immunofluorescence identi- clude acne vulgaris, burns, contact dermatitis
fies immunoglobulins and elastic tissue, skin (diaper rash), head lice, impetigo, rashes, and
manifestations of immunologically mediated scabies.
disease.
Important nursing
Nursing actions Acne vulgaris
actions after skin
parents. An inflammatory disease of the sebaceous fol-
biopsy include
preventing infection, licles, acne vulgaris primarily affects adoles-
injury, and irritation. Organism info cents, although lesions can appear as early as
Gram stains and exudate cultures help age 8. Although acne strikes boys more often
identify organisms responsible for underlying and more severely, it usually occurs in girls at
infections. an earlier age and tends to last longer, some-
times into adulthood. The prognosis is good
Nursing actions with treatment.
parents. CAUSES
• Obtain cultures as directed by facility policy. • Androgen-stimulated sebum production
• Follicle occlusion
Patching it together • Propionibacterium acnes, a normal skin flora
Patch tests identify contact sensitivity (usual-
ly in dermatitis). Predisposing factors
• Androgen stimulation
Nursing actions • Certain drugs, including corticosteroids,
• Explain the procedure to the child and his corticotropin, androgens, iodides, bromides,
parents. trimethadione, phenytoin, isoniazid, lithium,
920135.qxd 8/7/08 4:00 PM Page 687
and halothane; cobalt irradiation; or total par- ing pregnancy and childhood because it dis-
enteral nutrition (TPN) colors developing teeth)
• Cosmetics • Topical medications: benzoyl peroxide
• Exposure to heavy oils, greases, or tars (Benzac), clindamycin (Cleocin), or erythro-
• Heredity mycin and benzoyl peroxide (Benzamycin)
• Hormonal contraceptives (many females ex- antibacterial agents, alone or in combination
perience an acne flare-up during their first few with tretinoin (retinoic acid, Retin-A), or a
menses after starting or discontinuing hor- keratolytic Acne vulgaris?
monal contraceptives) • Antiandrogenic agents: estrogens or In other words, ZITS!
• Trauma or rubbing from tight clothing spironolactone (Aldactazide)
• Unfavorable climate
DATA COLLECTION FINDINGS • Check the patient’s drug history because
• Acne scars from chronic, recurring lesions certain medications, such as some hormonal
• Closed comedo, or whitehead (acne plug contraceptives, may cause an acne flare-up.
not protruding from the follicle and covered • Try to identify predisposing factors to deter-
by the epidermis) mine if any may be eliminated or modified.
• Open comedo, or blackhead (acne plug pro- • Explain the causes of acne to the patient
truding from the follicle and not covered by and his family. Make sure they understand
the epidermis) that the prescribed treatment is more likely to
• Inflammation and characteristic acne pus- improve acne than a strict diet and fanatic
tules, papules or, in severe forms, acne cysts scrubbing with soap and water. Provide writ-
or abscesses (caused by rupture or leakage of ten instructions regarding treatment to elimi-
an enlarged plug into the dermis) nate misconceptions.
• Instruct the patient using tretinoin to apply
DIAGNOSTIC FINDINGS it at least 30 minutes after washing the face
• Diagnostic testing isn’t necessary. The ap- and at least 1 hour before bedtime. Warn
pearance of characteristic acne lesions, espe- against using it around the eyes or lips to pre-
cially in an adolescent patient, confirms the vent damage. After treatments, the skin
presence of acne vulgaris. should look pink and dry. If it appears red or
starts to peel, the preparation may have to be
NURSING DIAGNOSES weakened or applied less often.
• Impaired skin integrity • Advise the patient to avoid exposure to sun-
• Disturbed body image light or to use a sunscreen to prevent a photo-
• Risk for infection sensitivity reaction. If the prescribed regimen
includes tretinoin and benzoyl peroxide, tell
TREATMENT the patient to use one preparation in the
• Exposure to ultraviolet light (but never morning and the other at night to avoid skin
when a photosensitizing agent, such as irritation.
tretinoin, is being used) • Instruct the patient to take tetracycline on
an empty stomach and not to take it with
Drug therapy antacids or milk because it interacts with their
• Intralesional corticosteroid injection metallic ions and is then poorly absorbed.
• Oral isotretinoin (Accutane) — limited to • Tell the patient who’s taking isotretinoin to
those with nodulocystic or recalcitrant acne avoid vitamin A supplements, which can wors-
who don’t respond to conventional therapy; en adverse effects. Also discuss how to deal
contraindicated during pregnancy with the dry skin and mucous membranes
• Systemic therapy: tetracycline (Sumycin) to that usually occur during treatment. Warn the
decrease bacterial growth; alternatively, ery- female patient about the severe risk of terato-
thromycin (tetracycline contraindicated dur- genesis.
920135.qxd 8/7/08 4:00 PM Page 688
• Inform the patient that acne takes a long • Hypovolemia and symptoms of shock from
time to clear — sometimes years for complete fluid shift
resolution. Encourage continued local skin care • Infection due to altered skin integrity
even after acne clears. Explain the adverse
effects of all drugs to promote compliance. DIAGNOSTIC FINDINGS
• Pay special attention to the patient’s percep- • To determine the extent of injury, many
tion of his physical appearance, and offer burn facilities use the Lund-Browder chart,
emotional support to help the patient cope with which is a body surface area (BSA) chart that
the effects of his condition. accounts for age. (The Rule of Nines is inac-
curate for children because the head can ac-
Teaching topics count for 13% to 19% of the BSA and the legs
• Understanding the treatment regimen account for 10% to 16%, depending on the
• Avoiding prolonged exposure to sunlight child’s age and size.)
• Eliminating misconceptions
• Eliminating predisposing factors, such as NURSING DIAGNOSES
cosmetic use and emotional stress • Ineffective airway clearance
Burns
TREATMENT
Most pediatric burns occur in children under • Debridement
age 5. Overall, burns are the third leading • Diet: adequate nutritional support to avoid
cause of accidental death in children (after negative nitrogen balance and prevent over-
motor vehicle accidents and drowning). feeding
Burns are classified as first-, second-, or third- • Escharotomy
degree, depending on severity. • I.V. fluids to prevent and treat shock; urine
Remember that output maintained at 1 to 2 ml/kg
the Rule of Nines, CAUSES • Oxygen therapy (may require intubation)
generally used to • Contact with hot liquid or electricity (most • Protective isolation, depending on burn
determine the extent common cause of burns in children under severity
of a burn, is age 3) • Skin grafting
inaccurate for • Contact with flames (most common cause • TPN
children. Use the of burns in older children)
Lund-Browder chart • Exposure to ultraviolet light (sunburn) Drug therapy
instead.
• Analgesics: morphine
DATA COLLECTION FINDINGS • Diuretic therapy: mannitol (Osmitrol) to
First-degree burn (partial thickness of skin) flush hemoglobin from the kidneys
• Dry, painful, red skin with edema • Antibiotics: silver sulfadiazine (Silvadene)
• Looks like sunburn or mafenide acetate (Sulfamylon) to limit in-
fection at the site
Second-degree burn (partial thickness of skin)
• Moist, weeping blisters with edema INTERVENTIONS AND RATIONALES
• Severe pain • Stop the burning in an emergency situation
to prevent further injury.
Third-degree burn (full thickness of skin) • Maintain a patent airway in the immediate
• Avascular site without blanching or pain postburn phase; inhalation of smoke may
• Dry, pale, leathery skin cause airway edema.
• Diuresis 2 to 5 days after the burn, as fluid • Monitor vital signs and intake and output to
shifts back detect signs of complications.
• Fluid shift from intravascular to interstitial • Maintain I.V. analgesics to relieve pain;
compartments don’t administer I.M. injections.
920135.qxd 8/7/08 4:00 PM Page 689
• Assist with debridement to promote healing. • Clothing dyes or the soaps used to wash di-
• Elevate the burned body part to promote ve- apers
nous drainage and decrease edema. • Irritation due to acidic urine and stools or
• Apply a thin layer of topical medication, the formation of ammonia in the diaper
such as mafenide acetate, over the burn to • Moist, warm environment found in a plastic
prevent infection. diaper lining
• Prevent heat loss to reduce metabolic de-
mands. DATA COLLECTION FINDINGS
• Explain treatments, pain management, and • Characteristic bright red, maculopapular
the need for the child’s active participation in rash in the diaper area
the treatment plan. Allow the child choices, • Irritability because the rash is painful and
where appropriate, to help the child feel less warm
afraid and anxious.
• Encourage family and friends to participate DIAGNOSTIC FINDINGS
in the child’s care when appropriate to create • Diagnostic testing isn’t necessary. Diagno-
a pleasant, loving, and supportive atmosphere. sis is based on inspection of the diaper area,
• Allow the child to participate in everyday which exhibits the characteristic bright red
activities, such as playing and school activi- maculopapular rash.
ties, to normalize the child’s situation.
• Give the child the opportunity to maintain NURSING DIAGNOSES
the developmental tasks already achieved, • Risk for infection
such as eating in a high chair, not using dia- • Acute pain
pers if the child has been toilet-trained, and al- • Impaired skin integrity
lowing self-feeding if the child is able, to pre-
vent regression. TREATMENT Because contact
• Rock, cuddle, and treat the patient like any • Cleaning affected area with mild soap and dermatitis is
other child to encourage normalcy in his situa- water commonly caused by
tion. • Leaving affected area open to air a moist, warm
• Promote a comfortable atmosphere for the environment, it
child to encourage the child to talk and act out Drug therapy makes sense that
feelings of depression, hostility, and anxiety. • Application of vitamin A and D skin cream an important
or zinc oxide ointment to help the skin heal intervention is keeping
Teaching topics • Antibiotics if secondary infection occurs the area clean, dry,
and open to the air.
• Explaining treatment to the child and his
parents INTERVENTIONS AND RATIONALES
• Coping strategies for dealing with long-term • Keep the diaper area clean and dry to
care maintain skin integrity.
• Preventing burns • Change the diaper immedi-
• Wound care ately after the child voids or
defecates to prevent skin
breakdown.
Contact dermatitis • Wash the area with mild
soap and water to promote
Contact dermatitis, also known as diaper rash, healing.
is a local skin reaction in the areas normally • Avoid plastic bed linings,
covered by a diaper. and keep the area open to the
air, if possible, to promote cir-
CAUSES culation and comfort.
• Body soaps, bubble baths, tight clothes, and • Avoid using commercially
wool or rough clothing prepared diaper wipes on
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broken skin; the chemicals and alcohol in these INTERVENTIONS AND RATIONALES
When applying wipes may be irritating and painful. • Carefully follow the manufacturer’s direc-
insecticidal
tions when applying medicated shampoo to
treatments, carefully
follow the Teaching topics avoid neurotoxicity.
manufacturer’s • Preventing diaper rash • Repeat treatment in 7 to 12 days to ensure
directions to avoid • Administering medication properly that all the eggs have been killed.
neurotoxicity.
Teaching topics
Head lice • Preventing reinfestation by washing bed
linens, hats, combs, brushes, and anything
Head lice (pediculosis capitis) is a contagious else that comes in contact with the hair
infestation of lice eggs, which look like white • Identifying reinfestation
flecks that are firmly attached to hair shafts • Refraining from exchanging combs, brush-
near the base. The cause of this disorder isn’t es, headgear, or clothing with other children
related to the hygiene of a child or family
members; however, head lice is easily trans-
mitted among children and family members. Impetigo
CAUSES Impetigo is a highly contagious superficial in-
• Infestation with Pediculus humanus (usually fection of the skin, marked by patches of tiny
acquired by sharing of clothing and combs or blisters that erupt. It’s common in children
close physical contact with peers) ages 2 to 5. Infection is spread by direct con-
tact after an incubation period of 2 to 10 days.
• Pruritus of the scalp CAUSES
• White flecks attached to the hair shafts • Group A beta-hemolytic streptococci
• Staphylococci
DIAGNOSTIC FINDINGS
• Examination reveals lice eggs, which look DATA COLLECTION FINDINGS
like white flecks, firmly attached to hair shafts • Rash commonly seen on the face and ex-
Insidious, near the base. tremities but may have spread to other parts
infectious itch! of the body by scratching
Impetigo may be NURSING DIAGNOSES • Macular rash progressing to a papular and
spread to other • Disturbed body image vesicular rash, which oozes and forms a
parts of the body by
• Impaired skin integrity moist, honey-colored crust
scratching.
• Social isolation • Pruritus
TREATMENT DIAGNOSTIC FINDINGS

• Removal of lice and eggs using a fine- • Diagnostic testing isn’t necessary. Diagno-
toothed comb sis is based on inspection of the rash.
Drug therapy NURSING DIAGNOSES

• Medicated shampoo: pyrethrins (Rid) or • Bathing or hygiene self-care deficit
permethrin (Nix); lindane (GBH) in resistant • Impaired skin integrity
cases • Risk for infection
• Preventive drug therapy for other family
members and classmates TREATMENT
• Washing area with disinfectant soap
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Drug therapy It may result from infection, inflammation, or

• Systemic antibiotics (in severe cases) allergic reactions. Vesicular rashes in children
• Topical antibiotic ointment may be caused by staphylococcal infections,
varicella, hand-foot-mouth disease, or miliaria.
• Apply antibiotic ointment to eradicate the CAUSES
infection. • Allergic reaction
• Wash the affected area three times daily • Environmental cause
with antiseptic soap to promote skin healing. • Viral, fungal, or bacterial infestation
• Cover the child’s hands, if necessary, and
cut the child’s nails to prevent secondary infec- DATA COLLECTION FINDINGS
tion. • Papular rash: raised solid lesions with color
• Cover the lesions to prevent their spread. changes in circumscribed areas
• Pustular rash: vesicles and bullae that fill
Teaching topics with purulent exudate
• Preventing recurrence • Vesicular rash: small, raised, circumscribed
• Applying medications properly lesions filled with clear fluid
DIAGNOSTIC FINDINGS
Rashes • Aspirate from lesions may reveal cause.
• Patch test may identify cause.
A rash is a temporary skin eruption. Three
types of rashes — papular, pustular, and vesic- NURSING DIAGNOSES
ular — are described here. • Impaired skin integrity
A papular rash may erupt anywhere on the • Risk for infection
body in various configurations and may be • Disturbed body image
acute or chronic. Papular rashes characterize
many cutaneous disorders; they may also re- TREATMENT
sult from allergies or infectious, neoplastic, or • Antibacterial, antifungal, or antiviral agent
systemic disorders. Common causes of papu- (depending on cause)
lar rashes in children are infectious diseases, • Antihistamines if the rash is from an allergy
such as molluscum and scarlet fever; scabies;
insect bites; allergies or drug reactions; and INTERVENTIONS AND RATIONALES
miliaria. • Keep the affected area cool. Heat aggravates
A pustular rash is made up of groups of pus- most skin rashes and increases pruritus; cool-
tules that fill with purulent exudate. These le- ness decreases pruritus.
sions vary greatly in size and shape and can • Keep the affected area clean and dry to pro-
be generalized or localized to the hair follicles mote healing.
or sweat glands. Pustules appear with skin and • Avoid using powder or cornstarch because
systemic disorders, with use of certain drugs, they encourage bacterial growth.
and with exposure to skin irritants. Disorders • Maintain standard precautions to prevent the
that produce a pustular rash in children in- spread of infection.
clude varicella, erythema toxicum neonato- • Cover weeping lesions to prevent transmis-
rum, candidiasis, and impetigo. Pustules typi- sion.
fy the inflammatory lesions of acne vulgaris,
common in adolescents. Teaching topics
A vesicular rash is a scattered or linear dis- • Understanding sanitary techniques
tribution of vesicles. A vesicular rash may be • Avoiding sharing combs or hats
mild or severe and temporary or permanent. • Avoiding scratching
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I like to make
Scabies • Withhold lindane cream if skin is raw or in-
flamed to avoid irritating the skin.
myself at home.
Scabies is a parasitic skin disorder that causes • Explain to the child and parents that if skin
Scabies mites can
live their entire lives severe pruritus. Scabies develops when mi- irritation or an allergic reaction develops,
in human skin, croscopic itch mites enter a child’s skin and they should notify the doctor immediately,
causing chronic provoke a sensitivity reaction. Mites can live stop using the cream, and wash it off thor-
infection. their entire lives inside human skin, causing oughly to avoid the risk of an anaphylactic
chronic infection. The female mite burrows reaction.
into the skin to lay her eggs from which lar-
vae emerge to copulate and then reburrow Teaching topics
under the skin. Scabies is transmitted • Understanding that pruritus may persist for
through the skin or through sexual contact. several weeks after treatment
• Following proper hygiene measures
CAUSES • Changing bed linens, towels, and clothing
• A female mite that burrows into the skin and washing them in hot water and drying
and deposits eggs in areas that are thin and them in a hot dryer after bathing and lotion
moist application
• Understanding the need to treat family
DATA COLLECTION FINDINGS members and close contacts because the par-
• Linear black burrows between fingers and asite is transmitted by close personal contact
toes and in palms, axillae, and groin and through clothes and linens
• Severe pruritus
DIAGNOSTIC FINDINGS
• Drop of mineral oil placed over the burrow,
Severe pruritus
followed by superficial scraping and examina- marks scabies
tion of expressed material under a micro- infestation. Linear
scope may reveal ova or mite feces. black mite burrows
may be visible
NURSING DIAGNOSES between the fingers
• Disturbed body image and toes or on the
• Impaired skin integrity palms, axillae, and
• Social isolation groin.
TREATMENT
• Treatment for all members of the family (as
well as close contacts of the child)
Drug therapy
• Application of permethrin (Elimite)

• Wash area thoroughly with soap and water
to promote healing.
• Teach the child and parents to apply perme-
thrin from the neck down covering the entire
body, wait 15 minutes before dressing, and
avoid bathing for 8 to 12 hours to ensure effec-
tiveness of therapy.
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1. Ineffective airway clearance related to

edema
2. Disturbed body image related to
physical appearance
3. Impaired urinary elimination related
to fluid loss
4. Risk for infection related to epidermal
disruption
Answer: 1. When a client is admitted to the
hospital for burns, the primary focus is on as-
sessing for and managing an effective airway.
Disturbed body image, impaired urinary elim-
ination, and risk for infection are all integral
Pump up on practice parts of burn management but aren’t the first
priority.
questions Client needs category: Physiological
integrity
Client needs subcategory: Physiolog-
1. The clothes of a 16-year-old girl catch fire ical adaptation To keep up your
while she’s lighting the grill for a family pic- Cognitive level: Analysis motivation for
nic. The girl’s mother, a nurse, tells her to studying, remember
drop and roll to extinguish the flames. Which 3. The nurse is caring for a child with second- the big picture.
action should the mother take next? and third-degree burns. Which analgesic Conquering the
1. Move her daughter away from the would most effectively manage the client’s NCLEX is a step
grill. severe pain? toward fulfilling life
goals you’ve chosen
2. Remove her daughter’s clothing. 1. Acetaminophen administered by sup-
for yourself.
3. Use the garden hose to wet her pository
daughter down. 2. Meperidine administered I.M.
4. Call the fire department. 3. Codeine administered by mouth
Answer: 3. In emergency burn care, the priori- 4. Morphine administered I.V.
ty is to stop the burning. The client shouldn’t Answer: 4. A client with severe burns re-
be moved because flames may intensify. After quires strong analgesia. The most effec-
the fire is extinguished, the client’s clothes tive method of administering analgesics
should be removed to prevent further injury. is the I.V. route. Second-degree burns
Emergency medical personnel should be are commonly too painful to be relieved
summoned after the flames are extinguished. by acetaminophen. I.M. medication may
Client needs category: Physiological not be absorbed when the client is phys-
integrity iologically unstable. Codeine may not
Client needs subcategory: Reduction of provide sufficient analgesia, and oral ad-
risk potential ministration isn’t usually the best route
Cognitive level: Application for a client with severe burns.
2. A child has sustained third-degree burns integrity
of the hands, face, and chest. Which nursing Client needs subcategory: Pharma-
diagnosis takes priority? cological therapies
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4. A 14-month-old child is in a private room 6. A child comes into the emergency de-
for treatment of burns. Which intervention partment with a rash that’s raised and has col-
can best meet the developmental needs of the or changes in circumscribed areas. What type
child? of rash should the nurse document?
1. Ask the mother to room with the 1. Macular rash
child. 2. Papular rash
2. Have nursing personnel visit the child 3. Petechial rash
regularly throughout the day. 4. Vesicular rash
3. Set the television to the child’s fa- Answer: 2. A papular rash contains raised sol-
vorite cartoon shows. id lesions with color changes in circum-
4. Attach a brightly colored balloon to scribed areas. A macular rash is flat with color
the child’s crib. changes in circumscribed areas. Petechiae
Answer: 1. The mother can best provide for are pinpoint purple or red spots on the skin
the child’s developmental needs by being pre- caused by minute hemorrhages. A vesicular
sent all of the time. At this age, the child is rash contains small, raised circumscribed le-
most susceptible to separation anxiety. A child sions filled with clear fluid.
of this age is likely to be apprehensive toward Client needs category: Physiological
unfamiliar adults, so regular visits by nursing integrity
personnel wouldn’t help. Television is a poor Client needs subcategory: Reduction of
substitute for human contact. A balloon is risk potential
dangerous for a child this age. Cognitive level: Comprehension
5. A 13-year-old client has sustained third-

degree burns over 20% of his body. When col-
lecting data 72 hours after the burn, which
finding should the nurse expect?
1. Increased urine output
2. Severe peripheral edema
3. Respiratory distress
4. Absent bowel sounds
Answer: 1. During the resuscitative-emergent
phase of a burn, fluid shifts back into the inter- 7. The nurse is developing a teaching plan
stitial space, resulting in diuresis. Edema re- for the mother of a neonate with diaper rash.
solves during the emergent phase, when fluid The nurse should instruct the mother to pre-
shifts back to the intravascular space. Respira- vent the rash by:
tory rate increases during the first hours as a 1. using disposable diapers so she
result of edema. When edema resolves, respi- doesn’t have to change the infant often.
rations return to normal. Absent bowel sounds 2. bathing the infant in a tub with bubble
occur in the initial stage. bath.
Client needs category: Physiological 3. not washing the infant with soap.
integrity 4. keeping the infant’s diaper area clean
Client needs subcategory: Physiolog- and dry.
ical adaptation
920135.qxd 8/7/08 4:00 PM Page 695
Answer: 4. The mother should be instructed 1. Stop treatment because the drug isn’t
to keep the infant’s diaper area clean and dry, safe for children under age 2.
to change the diaper immediately after the in- 2. Pruritus can be present for weeks af-
fant voids or defecates, to avoid bubble baths, ter treatment.
and to wash the diaper area with mild soap 3. Apply the drug every day until the
and water with every diaper change. rash disappears.
Client needs category: Physiological 4. Pruritus is common in children under
integrity age 5 treated with Elimite.
Client needs subcategory: Reduction of Answer: 2. Pruritus may persist for weeks af-
risk potential ter the child is treated with Elimite for sca-
Cognitive level: Application bies. The drug is safe for use in infants as
young as age 2 months. Treatment can safely
8. A mother calls the pediatrician’s office be repeated in 2 weeks. Pruritus is caused by
because there’s an outbreak of scabies at her secondary reactions of mites.
child’s day-care center. The nurse should in- Client needs category: Physiological
struct the mother to check her child for integrity
which findings associated with scabies infes- Client needs subcategory: Pharmaco-
tation? logical therapies
1. Pruritic papules, pustules, and linear Cognitive level: Knowledge
burrows between fingers and toes
2. Oval white dots adhering to the hair 10. The mother of a child diagnosed with
shafts head lice asks how she should get the nits out
3. Diffuse pruritic wheals of her child’s hair. The nurse gives the moth-
4. Pain, erythema, and edema at the site er which instructions about head lice treat-
of the bite ment?
Answer: 1. The mother should be instructed 1. The treatment should be repeated in
to check her child for pruritic papules, vesi- 7 to 12 days.
cles, and linear burrows between the fingers 2. Combing the hair after shampooing is
and toes. Oval flecks on the hair shaft indicate necessary. I’m just itching to
answer more practice
head lice. Diffuse pruritic wheals can indicate 3. Treatment should be repeated every
questions. In addition
an allergic reaction. The mite bites don’t day for 7 days. to the questions
cause pain, erythema, or edema. 4. All children that had contact with the that follow, don’t
Client needs category: Health promo- child should be prophylactically treated. forget to pump up on
tion and maintenance Answer: 1. Treatment should be repeated in 7 practice questions
Client needs subcategory: None to 12 days to ensure that all of the eggs have using the free
Cognitive level: Knowledge been killed. Combing the hair thoroughly CD-ROM.
isn’t necessary to remove lice eggs. People
9. A 16-month-old child is being treated with exposed should be observed for infestation
permethrin (Elimite) for scabies. The child’s before being treated.
mother is concerned that the drug hasn’t Client needs category: Physiological
been effective because her child continues to integrity
scratch. Which response by the nurse is most Client needs subcategory: Reduction
appropriate? of risk potential
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696 Care of the child

1. The nurse is teaching the mother of an 1. Offer the child liquids immediately on
infant with tetralogy of Fallot. The mother awakening.
asks what to do when her infant becomes 2. Allow the child to sleep as much as
very blue and has trouble breathing after cry- possible.
ing. What should the nurse tell the mother to 3. Monitor peripheral pulses for sym-
do? metry.
1. “Leave the infant alone until the cry- 4. Change the dressing over the
ing stops.” catheter site.
2. “Put the infant in the knee-chest posi- Answer: 3. The most important nursing inter-
tion.” vention after cardiac catheterization is to as-
3. “Offer the infant a bottle of formula.” sess peripheral pulses, especially those distal
4. “Take the infant for a ride in the car.” to the catheter site. The pulse may be weaker
Answer: 2. The infant is having a “tet,” or blue initially but typically becomes stronger in a
spell, which is an acute spell of hypoxemia short period. The dressing should be moni-
and cyanosis. This occurs when the infant’s tored, and the child may want liquids after the
oxygen requirements exceed the oxygen sup- procedure; however, these interventions
ply in the blood. Treatment involves placing aren’t as important as monitoring pulses. Al-
the infant in the knee-chest position to reduce lowing the child to sleep as much as possible
venous return from the extremities because may be appropriate but isn’t the most impor-
that blood is desaturated. The knee-chest po- tant intervention.
sition also increases systemic vascular resis- Client needs category: Physiological
tance, which causes more blood to be shunt- integrity
ed to the pulmonary artery. Leaving the infant Client needs subcategory: Reduction of
alone until the crying stops will cause an in- risk potential
crease in cyanosis. An infant who’s crying and Cognitive level: Application
Practice makes having trouble breathing shouldn’t be offered
perfect. So do these a bottle because of the danger of aspiration. 3. The nurse notices that the dressing over
30 pediatric practice Taking the infant for a ride in the car may be a client’s cardiac catheterization site has a
questions. an alternative if the mother can’t quiet the large amount of sanguineous drainage. What
infant. should the nurse do first?
Client needs category: Physiological 1. Notify the on-call physician.
integrity 2. Apply pressure 1 (2.5 cm) above the
Client needs subcategory: Reduction of skin site.
risk potential 3. Check the client’s vital signs, includ-
Cognitive level: Application ing temperature.
4. Check the peripheral pulse distal to
2. The nurse is providing care to a child the site.
who underwent a cardiac catheterization. Answer: 2. If bleeding occurs, it’s important to
Which intervention should the nurse provide? apply direct, continuous pressure above the
percutaneous skin site to localize pressure
over the punctured vessel. All of the other
920135.qxd 8/7/08 4:00 PM Page 697
actions are important, but applying pressure where vaso-occlusive crisis occurs; this crisis
is the priority. is also associated with localized pain at the
Client needs category: Physiological site of infection. It’s important for the child to
integrity receive adequate fluids to help prevent dehy-
Client needs subcategory: Reduction of dration and increase blood volume. A history
risk potential will help determine other coexisting condi-
Cognitive level: Application tions.
4. The nurse is teaching the mother of a integrity
toddler with iron deficiency anemia about di- Client needs subcategory: Basic care
etary modifications. Which statement by the and comfort
mother indicates that she understands the Cognitive level: Application
teaching?
1. “I can let my child have four glasses 6. The nurse is caring for a child with
of milk every day.” leukemia who has an absolute granulocyte
2. “I will feed my child fortified cereal count of 400 ␮l. Which intervention should
and lots of green leafy vegetables.” the nurse implement?
3. “I plan to offer my child juice and ce- 1. Place the child in strict isolation.
real for snacks.” 2. Notify the physician immediately.
4. “I think my child will drink milk and 3. Restrict visitors with active infections.
juice easily.” 4. Begin antibiotics according to proto-
Answer: 2. For the child with iron deficiency col.
anemia, iron-rich foods, such as fortified cere- Answer: 3. When the absolute granulocyte
al, green leafy vegetables, and red meat, need count is low, a child has difficulty fighting an
to be offered in larger amounts. Foods that infection. Visitors with active infections
contain less iron, such as milk, juice, yellow should be restricted to prevent the child from
vegetables, and nonfortified cereals, should developing an infection. The child should be
be offered in smaller amounts. placed in protective isolation, not strict isola-
Client needs category: Health promotion. Antibiotics shouldn’t be started without a
tion and maintenance septic workup first. The physician must also
Client needs subcategory: None be notified of the client’s condition so that ap-
Cognitive level: Knowledge propriate medical management is initiated.
5. A 10-year-old child is admitted to the pe- care environment
diatric unit in sickle cell crisis. What should Client needs subcategory: Safety and
the nurse do first? infection control
1. Obtain vital signs, including tempera- Cognitive level: Application
ture.
2. Determine the degree of pain using a
pain scale.
3. Determine the rate of the I.V. fluids.
4. Obtain pertinent history information
from the parents.
Answer: 1. All of the options are important,
but the nurse should obtain vital signs first to
determine the client’s baseline. Children with
sickle cell disease are prone to developing in-
fections as a result of necrosis of body areas
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7. A client is receiving cyclophosphamide Client needs category: Physiological

(Cytoxan) as part of a chemotherapy regi- integrity
men. Which adverse reaction should the Client needs subcategory: Reduction of
nurse teach the family to report right away? risk potential
1. Stomatitis Cognitive level: Application
2. Flulike syndrome
3. Ototoxicity 9. A 6-year-old child with a history of asth-
4. Hematuria ma is brought to the clinic in respiratory dis-
Answer: 4. Hematuria, an indication of hemor- tress. The nurse notes the following: respira-
rhagic cystitis, is an adverse effect of cyclo- tory rate, 36 breaths/minute; heart rate,
phosphamide. Stomatitis is a rare complica- 150 beats/minute; and anxiety. The nurse
tion with this medication. Flulike syndrome should be most concerned about the:
occurs with dacarbazine. Ototoxicity occurs 1. child’s loose cough.
more commonly with cisplatin. 2. prolonged expiratory phase.
Client needs category: Physiological 3. absence of wheezing.
integrity 4. whistling sound on inspiration.
Client needs subcategory: Pharmaco- Answer: 3. The most likely explanation for the
logical therapies respiratory distress is an acute asthma attack.
Cognitive level: Comprehension These episodes usually begin with a cough,
expiratory wheezing, and a prolonged expira-
tory phase and then may progress to more ob-
vious symptoms, such as wheezing on inspira-
tion, shortness of breath, and tight cough. The
absence of wheezing during an attack indi-
cates that the child is probably hypoxic and
needs medical attention immediately.
integrity
risk potential
8. A 15-month-old child has been admitted 10. An adolescent with cystic fibrosis comes
to the pediatric unit with the diagnosis of to the clinic for a follow-up appointment after
croup. The nurse collects the following data: discharge from the hospital for pneumonia.
respiratory rate, 36 breaths/minute; heart Which question should the nurse ask?
rate, 120 beats/minute; temperature, 100.7° F 1. “How has your appetite been this past
(38.2° C); pulse oximetry, 93%; and restless- week?”
ness. From these findings, the nurse should 2. “How many doses of antibiotics have
infer that the: you missed?”
1. toddler is in respiratory failure. 3. “Have you been sleeping well?”
2. toddler’s condition is improving. 4. “Have you gone back to school yet?”
3. mother should stay at the bedside. Answer: 1. An important indication of how
4. parents can calm the toddler. clients with cystic fibrosis are doing is their
Answer: 1. Recognizing subtle signs of respi- appetite. Poor appetite and weight loss are in-
ratory failure is an extremely important skill dications that an infectious process may be
for nurses to develop. Subtle signs include occurring. To ask how many doses of antibi-
restlessness, increase in respiratory effort, otics the client has missed implies that the
tachypnea, tachycardia, and an inability of the client isn’t trustworthy, which doesn’t help
family to calm the child. establish a therapeutic relationship. Asking
920135.qxd 8/7/08 4:00 PM Page 699
about sleep and returning to school would be 1. “When my child comes home from
important because they might provide helpful school, I have him do homework first.”
information about the client’s overall health, 2. “I take my child to play in the park as
but they aren’t the most important questions. soon as school is over.”
Client needs category: Physiological 3. “My child loves to sit and watch tele-
integrity vision after the bus ride home.”
Client needs subcategory: Reduction of 4. “As soon as I arrive home, my child
risk potential begins to read his favorite book.”
Cognitive level: Application Answer: 2. Children with ADHD are impul-
sive, have high energy levels, and don’t follow
directions well. An appropriate plan after the
child has been in school all day would be to
allow the child to run and play to burn up en-
ergy. This enables the child to concentrate
better later.
integrity
ical adaptation
11. A 5-month-old boy is brought to the clinic
by his mother, who reports that the infant has 13. An infant is to receive amoxicillin 90 mg
nasal congestion, symptoms of a cold, fever, three times per day for 10 days to treat otitis
and difficulty breathing. The nurse should media in the left ear. Amoxicillin suspension
first: is supplied as 125 mg/5 ml. How much of the
1. ask for more history information. medication should the mother administer at
2. evaluate the respiratory status. each dosing time?
3. notify the available physician. 1. 1.8 ml
4. take vital signs, including tempera- 2. 3.6 ml
ture. 3. 13.45 ml
Answer: 2. Anytime a relative reports that a 4. 26.90 ml
child has difficulty breathing, it’s imperative Answer: 2. Calculate the dose as follows:
for the nurse evaluate the respiratory status 125 mg : 5 ml :: 90 mg : X ml ⫽
immediately. History information and vital (90 mg ⫻ 5 ml) ⫼ (125 mg ⫻ X ml) ⫽
signs can be obtained later. After the nurse 450 ⫼ 125 ⫽ 3.6
determines the respiratory status, she can Client needs category: Physiological
contact the physician if warranted. integrity
Client needs category: Safe, effective Client needs subcategory: Pharmaco-
care environment logical therapies
Client needs subcategory: Safety and Cognitive level: Application
infection control
Cognitive level: Application 14. A school-age child with hydrocephalus is
admitted for a revision of his ventriculoperi-
12. The nurse is counseling the mother of a toneal shunt. When he returns from surgery,
child with attention deficit hyperactivity disor- how should the nurse position him?
der (ADHD). The nurse should conclude that
the mother understood the teaching when the
mother responds with:
920135.qxd 8/7/08 4:00 PM Page 700
1. On his abdomen where he’s comfort- Client needs category: Safe, effective
able care environment
2. In semi-Fowler’s position to prevent Client needs subcategory: Safety and
aspiration infection control
3. With the bed flat to prevent a subdur- Cognitive level: Application
al hematoma
4. On the same side as the shunt repair 16. Parents bring a 4-year-old child to the
Answer: 3. The child should be kept flat to de- clinic for a checkup. The child has been diag-
crease complications that might occur from nosed with Duchenne’s muscular dystrophy.
too rapid a reduction in intracranial fluid. What early signs would the nurse expect the
When the fluid is drained too rapidly, a sub- child to exhibit?
dural hematoma may result. In children with 1. Contracture deformities
increased intracranial pressure, the position 2. Loss of independent ambulation
of choice is with the head of the bed elevated 3. Difficulty climbing stairs
and the child lying on the side opposite the 4. Small and weak muscles
shunt to keep pressure off the shunt valve. Answer: 3. Muscular dystrophy has an early
Client needs category: Physiological onset; signs are seen by age 5. Difficulty
integrity climbing stairs and riding a tricycle are early
Client needs subcategory: Physiolog- signs. Contractures are progressive and begin
ical adaptation to develop later, and loss of independent am-
Cognitive level: Application bulation usually occurs by age 11. Small,
weak muscles are a later sign.
integrity
ical adaptation
17. The nurse is caring for an infant with bi-

lateral plaster leg casts for congenital club-
foot. Which statement by the parents would
indicate understanding of the nurse’s teach-
ing?
15. A 10-month-old infant is admitted to the 1. “When the casts get dirty, I will just
hospital from the clinic with a history of 2 wash them with soap and warm water.”
days of fever, anorexia, crying, and poor 2. “I will need to frequently check the
sleeping. The infant is diagnosed with possi- temperature and color of my child’s
ble meningitis. In which situation should the toes.”
nurse place the infant? 3. “I can dry the casts faster with a
1. In strict isolation hair dryer so we can go meet my
2. In respiratory isolation mother.”
3. With other older infants 4. “When the casts are partly dry, I can
4. With another infant with meningitis coat them with a clear acrylic spray.”
Answer: 2. The organisms that cause meningi- Answer: 2. Frequently checking the extremity
tis are transmitted by the spread of droplets. distal to the cast is important. If the cast is too
To protect the nursing staff and the family, an tight, neurovascular compromise can result.
infant with the probable diagnosis of meningi- This may manifest as coolness, pale digits,
tis is placed in a private room in respiratory pain, decreased sensation, and absence of
isolation until appropriate I.V. antibiotics have pulse. Putting water on a plaster cast can
been administered for 24 hours. soften it and cause it to become misshapen.
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External heat shouldn’t be used to dry the syringe and attached tubing. This prevents
cast because the inside of the cast wouldn’t be stress to the suture line from sucking. Paci-
adequately dried. The cast shouldn’t be fiers wouldn’t be used during the healing
sprayed with anything that would inhibit the process. The infant would be put down for
loss of moisture from the plaster. sleep on his back or side so the surgery site
Client needs category: Physiological wouldn’t be traumatized. Arm restraints
integrity would usually be loosened every 2 hours.
Cognitive level: Analysis Client needs subcategory: Reduction of
risk potential
20. A nurse is collecting data on an infant

with persistent emesis. Which acid-base im-
balance may occur based on the provisional
diagnosis of pyloric stenosis?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Answer: 4. Persistent emesis may cause meta-
18. The nurse in a clinic is counseling an ado- bolic alkalosis from an excessive loss of potas-
lescent who’s wearing a Milwaukee brace for sium, hydrogen, and chloride. A compensato-
scoliosis. The nurse would consider the teach- ry increase in bicarbonate ions is caused by
ing successful when the adolescent states that chloride loss. Metabolic acidosis occurs as a
the brace must be worn: result of excessive diarrhea or malnutrition.
1. at night when sleeping. Respiratory acidosis results from excessive
2. during school hours. retention of partial pressure of arterial carbon
3. 23 hours per day. dioxide (PaCO2). Respiratory alkalosis results
4. when eating meals and snacks. from a loss of PaCO2.
Answer: 3. Routinely, the Milwaukee brace is Client needs category: Physiological
worn about 23 hours per day to decrease the integrity
thoracic curvature as the adolescent grows. Client needs subcategory: Reduction of
The adolescent can be out of the brace for risk potential
about 1 hour when showering or exercising. Cognitive level: Comprehension
tion and maintenance 21. The nurse is caring for an infant with
Client needs subcategory: None esophageal atresia and tracheoesophageal fis-
Cognitive level: Application tula. Which statement indicates that the in-
fant’s parents understand the diagnosis?
19. The nurse is teaching the parents of an 1. “The esophagus ends in a blind
infant undergoing cleft lip repair. Which in- pouch so eating can’t occur.”
struction should the nurse give? 2. “There’s a connection between the
1. Offer the pacifier as needed. esophagus and the trachea.”
2. Lay the infant on his abdomen for 3. “The esophagus ends in a blind
sleep. pouch and there’s a tube between the tra-
3. Sit the infant up for each feeding. chea and esophagus.”
4. Loosen the arm restraints every hour. 4. “Stomach acids come back up into the
Answer: 3. An infant who has undergone cleft trachea, causing heartburn.”
lip repair is fed in the upright position with a
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Answer: 3. This statement correctly describes 23. The nurse is teaching a child with dia-
the most common type of esophageal atresia betes. Which statement by the child indicates
and tracheoesophageal fistula. that the teaching was successful?
Client needs category: Physiological 1. “Intermediate insulin begins to work
integrity about 2 to 4 hours after the injection.”
Client needs subcategory: Basic care 2. “I should take regular insulin early in
and comfort the morning, long before breakfast.”
Cognitive level: Application 3. “Hunger, headache, shakiness, and
sweating are all signs of hyperglycemia.”
4. “Because exercise increases the
blood glucose level, I shouldn’t eat snacks
before I exercise.”
Answer: 1. Intermediate insulin begins to act 2
to 4 hours after injection and peaks about 6 to
8 hours after injection. Regular insulin begins
to act within 30 minutes and is usually admin-
istered right before breakfast. Hunger,
headache, shakiness, and sweating are signs
22. The mother of a 6-week-old breast-fed in- of hypoglycemia. Strenuous exercise decreas-
fant asks the nurse why her infant wasn’t diag- es the blood glucose level, so children with di-
nosed earlier with congenital hypothyroidism. abetes usually need a snack before engaging
Which response would the nurse give? in exercise.
1. “Breast-fed infants may not display Client needs category: Physiological
symptoms until they’re weaned.” integrity
2. “If you had brought your infant in for Client needs subcategory: Pharmaco-
a 2-week checkup, you would have been logical therapies
told.” Cognitive level: Application
3. “The diagnosis was made earlier, but
replacement medication won’t start yet.” 24. The nurse is teaching the mother of a
4. “The public health nurse couldn’t lo- child who’s newly diagnosed with diabetes
cate your home.” mellitus. As part of the teaching, the nurse re-
Answer: 1. Frequently, a neonate doesn’t ex- views diet and snacks. Which statement indi-
hibit signs of congenital hypothyroidism be- cates that the mother understands why her
cause of the exogenous thyroid hormone sup- child needs snacks?
plied by the maternal circulation. It may not 1. “Snacks will help my child not want to
be obvious in infants because they have a eat candy with friends.”
functional remnant of the thyroid hormone. 2. “Snacks are given at the time insulin
Breast-fed babies may not manifest symptoms peaks to prevent hypoglycemia.”
until they’re weaned. Telling the mother she 3. “Children can’t eat all the calories
missed her 2-week checkup puts the blame they need in just three meals a day.”
on the mother, which isn’t necessary. The oth- 4. “The insulin shots make my child
er responses aren’t appropriate because the hungry, so snacks help prevent cheating
infant was breast-fed — preventing earlier di- on the diet.”
agnosis. Answer: 2. The diabetic diet for children in-
Client needs category: Health promo- cludes at least two snacks per day at mid-
tion and maintenance afternoon and before bed. Snacks are given
Client needs subcategory: None at the time insulin peaks to help prevent
Cognitive level: Application hypoglycemia. Snacks aren’t given to help
control the desire for sweets, to ensure suffi-
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cient calorie intake, or to prevent the child 26. A child with a UTI is being treated with
from cheating on this diet. co-trimoxazole (Bactrim) for 10 days. What
Client needs category: Physiological would the nurse teach the mother?
integrity 1. “With this medication, it’s important
Client needs subcategory: Reduction of that your child drink lots of water.”
risk potential 2. “When your child has taken this med-
Cognitive level: Application ication for 5 days, call the clinic.”
3. “While taking this medication, it’s im-
25. A 24-month-old toddler is seen in the clin- portant for your child to stay out of the
ic for a well-child checkup. The mother re- sun.”
ports that she’s in the process of toilet train- 4. “If your child won’t take this medica-
ing her child but it isn’t going well. The tod- tion, mix it in 3 ounces of fruit juice.”
dler has many accidents during the day. Answer: 1. Co-trimoxazole can cause crystals
Which question should the nurse ask the to form in the kidneys if the child doesn’t
mother? drink enough water. It isn’t necessary for the
1. “Does your child understand what’s mother to call the clinic halfway through the
expected?” course of treatment. There’s no reason for the
2. “How many accidents a day does your child to stay out of the sun while on this med-
child have?” ication. Three ounces of fruit juice is too
3. “Does your child seem to be in pain much liquid in which to mix the medication.
right before the accident?” Client needs category: Physiological
4. “What does your child’s urine smell integrity
like?” Client needs subcategory: Pharmaco-
Answer: 4. This question would yield the most logical therapies
helpful information. When a child has a uri- Cognitive level: Application
nary tract infection (UTI), the urine common-
ly has a strong, foul smell. Many 24-month-old 27. A child has just returned from surgery
children are ready to be toilet trained and, at for removal of a kidney for Wilms’ tumor.
this age, they usually understand what’s Which would be an appropriate nursing ac-
asked of them. It may be extremely difficult tion?
for the mother to ascertain whether the child 1. Offer the child ice chips when awake.
has pain before an accident, but it’s worth 2. Administer pain medication when the
asking. child requests it.
Client needs category: Physiological 3. Monitor the child’s vital signs.
integrity 4. Provide games at the child’s develop-
Client needs subcategory: Basic care mental level.
and comfort Answer: 3. The child’s vital signs should be
Cognitive level: Analysis taken immediately upon arrival from surgery
to determine the baseline and to detect early
changes from previous recordings. Following
nephrectomy, the child will most likely have a
nasogastric tube and won’t be allowed ice or
fluids by mouth. Pain medication should be
administered on a routine schedule to keep
the child comfortable. The child should be
provided diversions only after sufficient recu-
peration from surgery.
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Client needs category: Physiological Answer: 3. When a child has a scalding type of
integrity burn, it’s important to immediately flush the
Client needs subcategory: Basic care area with tepid water to cool the skin and
and comfort prevent the burn from progressing. Soap
Cognitive level: Application shouldn’t be used until the area has been
flushed well. Spraying the area with pain re-
28. The mother of a 3-month-old infant calls liever won’t stop the burning process. The
the clinic and states that her child has a dia- child shouldn’t be taken to the clinic until the
per rash. What should the nurse advise her to area has been flushed.
do? Client needs category: Physiological
1. Switch to cloth diapers until the rash integrity
is gone. Client needs subcategory: Basic care
2. Use baby wipes with each diaper and comfort
change. Cognitive level: Application
3. Leave the diaper open while the infant
sleeps. 30. A school-age child asks the school nurse
4. Offer extra fluids to the infant until how a person gets lice. The nurse should re-
the rash improves. spond that lice are:
Answer: 3. The mother should leave the dia- 1. passed to other children because they
per open or off while the child sleeps to pro- don’t wash their hands often.
mote air circulation to the area, improving the 2. spread easily among children be-
condition. There’s no need to switch to cloth cause they share hats and combs.
diapers; in fact, that may make the rash 3. only spread between children; adults
worse. Extra fluids won’t make the rash bet- don’t have them.
ter, and baby wipes contain alcohol, which 4. hard to spread unless your immune
may worsen the condition. system is depressed.
Client needs category: Physiological Answer: 2. Lice are spread easily between chil-
integrity dren because they share possessions more
Client needs subcategory: Basic care readily than adults do. Also, children tend to
and comfort be in closer proximity to each other than
Cognitive level: Application adults are. The other options don’t apply.
29. The nurse is speaking to the mother of a care environment
5-year-old child with a burn on his arm from Client needs subcategory: Safety and
hot soup. What advice should the nurse give infection control
to the child’s mother? Cognitive level: Application
1. Wash the area with soap and water.
2. Spray the area with a pain reliever.
3. Flush the area with tepid water.
4. Bring the child immediately to the
clinic.
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Part VI Coordinating care

36 Management concepts 707
37 Law and ethics 717

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36 Management
concepts
• providing adequate staffing for safe, effec-
In this chapter,
you’ll review:
Brush up on key tive patient care
• evaluating patient care and documentation
✐ management con- concepts • providing patient-education activities
• coordinating nursing services with other
cepts
✐ nursing care delivery Management is a process used to make sure patient-care services
the objectives of a facility are met. In nursing, • supervising and guiding staff members
systems
this involves coordinating staff to accomplish • evaluating staff performance
✐ resource manage-
the objectives of the facility in the most effi- • participating in staff recruitment and reten-
ment cient, cost-effective manner. You can review tion
✐ quality management. the major points of this chapter by consulting • providing new staff members with an ade-
the Cheat sheet on page 708. quate, individualized orientation
• ensuring that staff members participate in
continuing education and maintain required
Role of the nurse-manager competencies
• making sure that staff education is appropri-
A nurse-manager assumes 24-hour account- ate for each member’s assigned responsibili-
ability for the nursing care delivered in a spe- ties
cific nursing area. The licensed practical • planning and implementing budgets
nurse should be aware of the role of the • encouraging staff participation in policy and
nurse-manager. procedure development and quality monitor-
ing.
Getting the job done
The nurse-manager’s responsibilities typically MANAGEMENT STYLES
include: The nurse-manager’s job description defines
• policy and decision making her authority over a specified group of em-
ployees and describes her job responsibilities.
What style!
Accountability is a Each manager directs her staff using a differ-
round-the-clock ent management style. An effective manager
concern for the commonly uses more than one style. At times,
nurse-manager. Her staff should participate in decision making; at
responsibilities are other times, staff participation isn’t appropri-
many and varied. ate. The most commonly used management
styles include:
• autocratic — Decisions are made with little or
no staff input. The manager doesn’t delegate
responsibility. Staff dependence is fostered.
The autocratic leader excels in times of crisis.
• laissez-faire — Little direction, structure, or
support is provided by the manager. The man-
ager abdicates responsibility and decision
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708 Management concepts
et
heat she
C
Management refresher
NURSE-MANAGER ROLE • Prepares staff member for career advance-
• Assumes 24-hour accountability for the nursing ment
care delivered in a specific nursing area
DISCHARGE PLANNING AND PATIENT
Management styles TEACHING
• Autocratic — Decisions made with little or no • Should be initiated on admission
staff input. Manager doesn’t delegate responsi- • For patients with planned admissions, should
bility. Staff dependence is fostered. The autocrat- begin before hospitalization
ic leader excels in times of crisis. • Should take into account cultural and develop-
• Laissez-faire — Little direction, structure, or mental needs
support provided by manager. Manager abdi-
Clinical pathways
cates responsibility and decision making when
• Multidisciplinary guidelines for patient care
possible. Staff development isn’t facilitated.
• Documentation tool for nurses and other health
There’s little interest in achieving the goals nec-
care providers
essary for adequate patient care.
• Provides sequences of multidisciplinary inter-
• Democratic — Staff members are encouraged
ventions that incorporate education, consulta-
to participate in decision making when possible.
tion, discharge planning, medications, nutrition,
Most decisions are made by the group. Staff de-
diagnostic testing, activities, treatments, and
velopment is encouraged. Responsibilities are
therapeutic modalities
carefully delegated and feedback is given to staff
members to encourage professional growth. QUALITY MANAGEMENT
• Participative — Problems are identified by the • A system used to continually assess and evalu-
manager and presented to the staff with possible ate the effectiveness of patient care
solutions. Staff members are encouraged to pro-
vide input but the manager makes the decision. DISASTER MANAGEMENT PLAN
Negotiation is key. Manager encourages staff • Must be able to be implemented quickly
advancement. • Must include measures to control resources,
establish and maintain communication within the
DELEGATION facility and with neighboring responders, protect
• Involves entrusting a task to another staff as many lives as possible, protect property, pro-
member vide resources for the community, help the facili-
• Helps free the nurse of tasks that can be com- ty and staff recover after the disaster
pleted successfully by someone else
making whenever possible. Staff development is given to staff members to encourage pro-
isn’t facilitated. There’s little interest in achiev- fessional growth.
ing the goals necessary for adequate patient • participative — Problems are identified by
care. the manager and presented to the staff with
• democratic — Staff members are encour- several solutions. Staff members are encour-
aged to participate in the decision-making aged to provide input, but the manager makes
process whenever possible. Most decisions the final decision. Negotiation is a key ele-
are made by the group, not the manager. Staff ment of this management style. The manager
development is encouraged. Responsibilities encourages staff advancement.
are carefully delegated to staff to encourage
growth and accountability. Positive feedback
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Come to an understanding prepares the staff member for career ad- An effective
An effective nurse-manager has a good under- vancement. (See How to delegate safely.) nurse-manager
standing of each management style. A manag- Although it may be difficult to delegate at delegates tasks to
er who adopts the autocratic or laissez-faire first, fostering a working environment that staff members. This
takes pressure off
management style rarely produces effective supports autonomy, independence, and pro-
the manager and
outcomes. One who adopts the democratic or fessional growth helps with recruitment and
helps advance the
participative style is typically successful be- retention of staff. staff members’
cause these styles foster staff input, goal careers.
achievement, and professional growth of staff
members. For example, an effective nurse- Discharge planning and
manager recognizes and fosters the role of
the nursing leaders on her staff. (See Leaders patient teaching
aren’t always managers.)
Discharge planning and patient teach-
ing go hand-in-hand; one can’t be ac-
Delegation complished without the other.
One of the most important tasks of the nurse Beginning with admission
is effective delegation. Delegation involves Discharge planning and patient teach-
entrusting a task to another staff member. It’s ing should be initiated on admission
necessary because it helps free the nurse of to the hospital. For patients with
tasks that can be completed successfully by planned admissions, discharge plan-
someone else. In addition, when a nurse- ning should begin before hospitaliza-
manager delegates to a staff member, it also tion. For example, if a patient requires a
Leaders aren’t
always
How to delegate safely managers
An effective nurse-
Nurses must have a clear understanding of their caregiver training) must be appropriate for dele-
manager recognizes
responsibilities to ensure that delegating is done gation. the valuable role
safely and successfully. Nurses must remember
played by a nursing
that although responsibility for a task has been Right person — The individual receiving the
leader. A nursing
delegated, accountability hasn’t. Nurses should responsibility must have the legal authority to
leader can be any
receive regular updates from the person as- perform the task. Institutional policies regarding member of the nursing
signed the task, ask specific questions, and delegation must be consistent with the law. team who encourages
evaluate the outcome.
her colleagues to
Right direction and communication — In-
FIVE “RIGHTS” achieve the unit goals.
structions and expectations must be clear and Most leaders are ex-
The National Council of State Boards of Nursing
identifies five “rights” of delegation that must be understood. cellent role models.
satisfied by the delegating nurse: They help other staff
Right supervision and follow-up — The del-
members develop and
Right task — The task being assigned or egating nurse must supervise, guide, and evalu- improve their nursing
transferred must be within the scope of abilities ate the performance of individuals to whom she skills. They solve prob-
and practice of the individual receiving the re- delegates. In addition to ensuring that a particu- lems and work to im-
sponsibility. lar task has been successfully carried out, the prove both patient
delegating nurse must also provide additional care and working con-
Right circumstance — The individual vari- training and feedback to coworkers who func- ditions at the health
ables involved (patient condition, environment, tion under her direction. care facility.
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Cultural dimensions of care

A critical aspect of the nursing process involves Jehovah’s Witness client, be aware that blood
the assessment of cultural needs, followed by transfusions are forbidden because they’re con-
appropriate planning and implementation. Too sidered against God’s will. What alternative
often this vital component of patient care is ne- treatments are available and acceptable? What
glected because of the urgent need to address legal ramifications need to be considered?
the patient’s physical needs. • Intervene as an advocate for the patient and
• Culture, including religion, helps to determine a family. Ensure that cultural and religious views
person’s role and status in the family and com- are taken into account as physical care is ren-
munity. It influences the availability of social and dered. For example, when caring for a Latter-day
material supports, how illness and health are Saint (Mormon) patient, allowing the retention of
viewed, and how individuals who are sick are special undergarments whenever possible will
expected to behave. be appreciated.
• Involve the patient and his family in planning to • Evaluate the effectiveness of the care plan.
meet cultural needs. Identify institutional and Does the patient feel supported and validated?
home care barriers, which may need to be ad- Are there areas of concern or conflict? Can
dressed. Identify alternate means of meeting these be mitigated or can the difficulties be dis-
cultural or spiritual needs when in conflict with cussed sufficiently with the patient and family so
these barriers. For example, when caring for a that they feel their concerns are understood?
Discharge planning nonemergency surgical procedure, the pa- Follow the clinical pathway
and patient teaching tient should be taught about the procedure Clinical pathways are multidisciplinary guide-
are initiated as early and his postoperative care in the doctor’s of- lines for patient care. A clinical pathway is a
in the care process fice before admission to the hospital. Pa- documentation tool for nurses as well as other
as possible. For tients planning outpatient or same-day treat- health care providers. It provides the se-
patients with
ment should also be taught before admis- quences of multidisciplinary interventions
scheduled admission
dates, teaching sion to the facility for the procedure. that incorporate education, consultation, dis-
begins before Discharge planning and patient teaching charge planning, medication, nutrition, diag-
hospitalization. should take into account the patient’s cultur- nostic testing, activities, treatments, and ther-
al and developmental needs. (See Cultural apeutic modalities.
dimensions of care.) The goal of a clinical pathway is to achieve
realistic expected outcomes for the patient
and family members. It promotes a profes-
sional and collaborative goal for care and
practice and assures continuity of care. It
should also guarantee appropriate use of re-
sources, which reduces costs and hospital
length of stay while also providing the frame-
work for quality management.
Clinical pathways are also used to guide the
use of patient-teaching tools, such as:
• videos
• audiotapes
• printed materials.
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The nurse-manager is responsible for moni- performance and promote professional

toring the effectiveness of discharge planning growth. Performance evaluations provide re-
and patient teaching. She must collaborate cognition, structured feedback, and recom-
with all members of the interdisciplinary mendations for improvement. They also pro-
health care team to evaluate if patients attain vide an opportunity for both the nurse-manager
their maximum state of wellness. and staff member to clarify performance ex-
pectations.
Quality management
Disaster management
The quality of patient care must be continual-
ly evaluated in order to search for methods of Each facility must devise a plan that can be
improvement. Because change is constant in implemented quickly in the event of a disas-
health care, changes must occur before prob- ter. A disaster can include severe weather and
lems arise. natural disasters, such as earthquakes and
tsunamis; release of bioterrorism agents;
Assess and evaluate chemical and radiation emergencies; mass
Continuous quality improvement, based on trauma; or outbreak of infectious disease.
principles from the business world, is a sys- Whatever the disaster, health care facilities
tem used to assess and evaluate the effective- and their neighboring communities must be
ness of patient care on a continual basis. Risk prepared when disaster strikes.
management assesses and evaluates care and
identifies areas that need improvement by re- Be prepared!
viewing such incidents or events as: Health care teams respond better to a disaster
• medication errors when they’re properly prepared. Managers
• patient falls and leaders must work together to develop a
• treatment errors plan. After the plan is developed, each staff
• treatment omissions. member must be adequately trained. To guar-
Incidents or events are investigated and a antee the highest level of preparedness, facili-
plan is devised to minimize or eliminate the ties must conduct disaster drills to ensure
risk of recurrence. Continuous quality im- that their plan can be implemented in an effi-
provement calls for constant evaluation of the cient manner. Moreover, staff members must
system for delivering services and the people also be trained to properly utilize and main-
performing the tasks. tain equipment so that it’s readily available
should disaster strike. After the leadership
Nothing but the best and management team devises a hospital-
Another method for evaluating patient care is wide plan, they must work with the communi-
benchmarking. The best practices from the ty to make sure they’re prepared and in-
top hospitals are compared with the practices formed in the event of a disaster. They must
in a comparable unit. That unit’s practices also coordinate their plan with local, state,
may then be adapted based on how they com- and federal agencies.
pare with the best hospitals’ practices or To be effective, the disaster plan must in-
benchmarks. clude:
• measures to control and direct all of the ap-
Improving performance and propriate resources
promoting professionalism • ways to establish and maintain communica-
Performance improvement, another compo- tion within the facility and with neighboring
nent of continuous quality improvement, es- responders and agencies
tablishes a formal system of job performance • interventions to protect as many lives as
evaluation and recommends ways to improve possible
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• methods to protect property

• resources for the community
• road map for recovery of the facility and
staff after the disaster.
If a disaster actually occurs, nursing leaders
must be available to implement the plan. They
must provide direction for mobilizing staff
and equipment while ensuring that the needs
of hospitalized patients are met. They must
also plan with neighboring facilities to trans-
fer patients to those facilities so that re-
sources can be made available for the disaster
victims.
Take the lead

Leaders also play a key role in the recovery
Pump up on practice
phase that follows the activation of the disas-
ter plan. Tasks include:
questions
• calculating damages
• prioritizing the replenishment of supplies 1. A nurse-manager of an inpatient pediatric
• preparing for future disasters unit is at home one evening when she re-
• assessing staffing needs ceives a call from a staff nurse informing her
• devising plans to relieve front-line person- of a serious medication error that occurred
nel on her unit. The nurse-manager was notified
• preparing for staff debriefing because she assumes accountability for what
• preparing for leadership debriefing happens on the unit:
• evaluating the effectiveness of the disaster 1. 5 days per week.
plan and response 2. 24 hours per day, 7 days per week.
There’s always
• identifying measures to improve the disas- 3. 8 hours per day, 7 days per week.
room for
improvement when it ter plan. 4. 24 hours per day, 5 days per week.
comes to nursing Disaster management plans must be inte- Answer: 2. Nurse-managers are accountable
care. Benchmarking grated into the facility’s culture to ensure for nursing care in the unit 24 hours per day,
and performance safe, effective care before, during, and after a 7 days per week.
evaluations are two disaster. Client needs category: Safe, effective
methods used to care environment
improve nursing Client needs subcategory: Coordinated
practices. care
2. A staff nurse influences the behaviors of

colleagues by guiding and encouraging them.
The nurse is an excellent role model but has
no formal authority over any peers. This
nurse is demonstrating characteristics of
which roles?
1. Manager
2. Autocrat
3. Leader
4. Authority
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Answer: 3. A leader doesn’t always need or 4. In the recovery phase after a disaster,
have formal power and authority. The leader which action should the management team
guides, directs, and enhances the activities of take?
peers and colleagues and is an effective role 1. Preparing for future disasters
model. A manager has a formal position of 2. Planning with neighboring facilities to
power in an organization and should be an ef- transfer clients
fective leader. An autocrat doesn’t seek staff 3. Making resources available for those
input and doesn’t encourage peers or subordi- involved in the disaster
nates to grow professionally. Authority is a 4. Providing staff training
characteristic of managers and is part of the Answer: 1. During the recovery phase, the
formal position of power granted to someone management team prepares for future disas-
as a result of her job description. ters. Planning with neighboring facilities to
Client needs category: Safe, effective transfer clients and making resources avail-
care environment able for those involved in the disaster occur Learn the roles of
Client needs subcategory: Coordinated during the response phase. Providing staff nursing leaders and
care training occurs during the planning phase. nurse-managers. This
Cognitive level: Application Client needs category: Safe, effective knowledge will help
you pass the NCLEX
care environment
and will also come
3. A nurse-manager is concerned after re- Client needs subcategory: Coordinated in handy when
ceiving many time-off requests from staff care you become a
members for the upcoming holiday season. Cognitive level: Knowledge staff nurse.
She has come up with several possible solu-
tions to the staffing dilemma and has sched-
uled a staff meeting to present ideas to the
staff. Which management style is this manag-
er demonstrating?
1. Participative
2. Democratic
3. Autocratic
4. Laissez-faire
Answer: 1. A participative manager identifies
problems and presents staff with several pos-
sible solutions for discussion. A democratic
manager usually allows many decisions to be
made by the group. She also solicits the
group’s ideas about problem solving. An auto-
cratic manager makes decisions without input
from staff. A laissez-faire manager provides
no direction and abdicates decision making
whenever possible.
Client needs category: Safe, effective 5. A nurse has a client scheduled for a par-
care environment tial mastectomy and axillary lymph node re-
Client needs subcategory: Coordinated moval the following week. The nurse should
care make sure that the client is well educated
Cognitive level: Application about the surgical procedure by:
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1. talking with the nursing staff at the states, “I have misplaced my license.” Based
physician’s office to find out what the on her knowledge of her supervisory respon-
client has been taught and her level of un- sibilities, the nurse-manager should:
derstanding. 1. contact the state licensing agency and
2. making sure that the postanesthesia confirm the nurse’s license.
recovery unit nurses know what to teach 2. hire the nurse but tell her that she
the client before discharge. must provide proof of license upon com-
3. providing all of the preoperative pleting orientation.
teaching before surgery. 3. avoid hiring the nurse because she
4. having the postoperative nurses teach can’t provide proof of license.
the client because she’ll be too anxious be- 4. trust that the nurse is telling the truth
fore surgery. because she has excellent references.
Answer: 1. The nurse who’s caring for a client Answer: 1. The nurse-manager must make
scheduled for surgery should talk to the nurs- sure that the nurse is licensed as a practical
es in the physician’s office to find out what nurse. She can do this by contacting the state
the client has been taught. She should then licensing agency. In the case of a new hire,
reinforce the teaching and answer any ques- the nurse-manager must make sure that the
tions the client has. The client will most likely nurse is representing herself truthfully before
be anxious before her surgery, but the nurse offering her the position.
can proceed with teaching. The client will Client needs category: Safe, effective
most likely be too sedated to learn about her care environment
postoperative care immediately after surgery. Client needs subcategory: Coordinated
Client needs category: Safe, effective care
care environment Cognitive level: Application
care 7. The nurse-manager of an outpatient sur-
Cognitive level: Application gery department helps groom department
staff members for career advancement. Which
task can be safely delegated to a licensed prac-
tical nurse?
1. Termination of a patient-care assistant
2. Development of the staffing schedule
for the next 2 months
3. 24-hour responsibility of patient-care
assistants for 2 months
4. Selection of a new nursing care deliv-
ery system for use in the department
Answer: 2. A nurse-manager can only delegate
tasks that are within the scope of practice and
skill of her subordinates. Termination of em-
ployees and 24-hour accountability can’t be
delegated. The selection of a new nursing
care delivery system affects the functioning
6. A nurse-manager of a medical-surgical of an entire department and shouldn’t be dele-
unit is interviewing a licensed practical nurse gated. It should be determined by input from
for a staff position. The nurse appears to be all staff members.
qualified and has excellent references. She
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Client needs category: Safe, effective Client needs category: Safe, effective
care environment care environment
Client needs subcategory: Coordinated Client needs subcategory: Coordinated
care care
8. A new nurse-manager is trying to deter-

mine the best way to implement client teaching
in an outpatient surgical center. She decides
to gather data from other surgical centers and
compare their teaching methods to this cen-
ter’s methods. Which quality improvement
process is she using?
1. Benchmarking
2. Risk management
3. Performance improvement
4. Quality management
Answer: 1. Benchmarking is the process of 9. Which health care team member is re-
comparing your organization’s practices with sponsible for monitoring the effectiveness of
those of organizations formally recognized as discharge planning and client teaching?
some of the best in the business. Risk man- 1. Physician
agement is the process of monitoring the or- 2. Nurse-manager
ganization’s adverse occurrences or potential 3. Social worker
for such occurrences and taking steps to re- 4. Staff nurse
duce or eliminate these incidents. Perfor- Answer: 2. The nurse-manager is responsible
mance improvement is the process of evaluat- for monitoring the effectiveness of discharge
ing the effectiveness of job performance and planning and client teaching. It isn’t the re-
taking steps to improve it. Quality manage- sponsibility of the physician, social worker, or
ment is the overall process of evaluating and staff nurse; however, they all play a collabora-
improving the quality of client services. tive role in discharge planning and client
teaching.
care environment
care
920136.qxd 8/7/08 4:01 PM Page 716
10. When providing a performance evalua- dressed as they occur during the review peri-
tion, a nurse-manager should perform which od. The evaluation should provide recognition
activity? and structured feedback as well as recom-
1. Compare the staff member’s perfor- mendations for improvement. It should also
mance to the performance of other staff provide the opportunity for clarifying perfor-
members. mance expectations. The performance of oth-
2. Clarify performance expectations. er staff members shouldn’t be discussed. A
3. Reprimand the staff member for past performance evaluation shouldn’t be used to
errors. reprimand a staff member.
4. Provide an informal evaluation of the Client needs category: Safe, effective
job performance. care environment
Answer: 2. A performance evaluation provides Client needs subcategory: Coordinated
a formal evaluation of the staff member’s job care
performance. Practice issues should be ad- Cognitive level: Comprehension
Yes!
One more chapter
down and only one
left to go!
920137.qxd 8/7/08 4:01 PM Page 717
37 Law
and ethics
Nurse practice acts also outline the condi-
In this chapter,
you’ll review:
Brush up on key tions and requirements for licensure. To be-
come licensed as a practical nurse, for in-
✐ importance of nurse
concepts stance, you must meet certain qualifications,
such as passing the NCLEX-PN. All states re-
practice acts Safe, effective nursing practice requires be- quire completion of a board of nursing–ap-
✐ importance of coming fully aware of the legal and ethical proved education program. Your state may
obtaining informed issues surrounding professional practice. have additional requirements, including:
consent These issues range from understanding your • good moral character
state’s nurse practice act to upholding pa- • good physical and mental health
✐ patient’s right to tients’ rights and fulfilling the many legal • minimum age
refuse treatment responsibilities you have as a nurse. • fluency in English
✐ issues surrounding At any time, you can review the major points • absence of drug or alcohol addiction.
living wills, of this chapter by consulting the Cheat sheet
malpractice, and
on pages 718 and 719. Get on board
In every U.S. state and Canadian province,
abuse.
the nurse practice act creates a state or
Nurse practice acts provincial board of nursing. The nurse prac-
tice act authorizes this board to administer
Each state has a nurse practice act. It’s de- and enforce rules and regulations about the
signed to protect the nurse and the public by: nursing profession. The board is bound by
• defining the legal scope of nursing practice the provisions of the nurse practice act that
• excluding untrained or unlicensed people created it.
from practicing nursing.
Your state’s nurse practice act is the most Moving violations
important law affecting your nursing practice. The nurse practice act also lists violations that
You’re expected to care for patients within can result in disciplinary action against a
defined practice limits; if you give care be- nurse. Depending on the nature of the viola-
yond those limits, you become vulnerable to tion, a nurse may face state board disciplinary
charges of violating your state’s nurse prac- action and liability for her actions.
tice act.
Get it?
Scope it out Understanding your nurse practice act’s gen-
Most nurse practice acts define important eral provisions helps you to stay within the le-
concepts, including the scope of nursing prac- gal limits of nursing practice. Interpreting the
tice. In other words, they broadly outline what nurse practice act isn’t always easy, however.
nurses can and can’t do on the job. Make sure Nurse practice acts are laws, after all, so they
that you’re familiar with the legally permissi- tend to be worded in broad, vague terms, and
ble scope of your nursing practice, as defined contain wording that varies from state to
in your state’s nurse practice act, and that you state.
never exceed its limits. Otherwise, you’re The key point to remember is this: Your
inviting legal problems. state’s nurse practice act isn’t a word-for-word
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718 Law and ethics
et
heat she
C
Law and ethics refresher
NURSE PRACTICE ACTS • Discussion of possible consequences of not
• Most important law affecting your nursing undergoing the treatment or procedure
practice Witnessing informed consent
• One for each state • The patient voluntarily consented.
• Designed to protect nurse and public by defin- • The patient’s signature is authentic.
ing legal scope of practice and excluding un- • The patient appears to be competent to give
trained or unlicensed people from practicing consent.
nursing
• Outline conditions and requirements for licen- RIGHT TO REFUSE TREATMENT
sure, such as passing NCLEX-PN • Any mentally competent adult may legally
• All states require completion of a board of refuse treatment if he’s fully informed about his
nursing–approved education program; your state medical condition and about the likely conse-
may have additional requirements, including: quences of his refusal.
– good moral character • Some patients may refuse treatment on the
– good physical and mental health grounds of freedom of religion.
– minimum age Advance directives
– fluency in English • Living will — an advance care document that
– absence of drug or alcohol addiction. specifies a person’s wishes about medical care if
he’s unable to make the decision for himself (in
INFORMED CONSENT
some states, living wills don’t address the issue
• Your patient’s right to be adequately informed
of discontinuing artificial nutrition and hydration)
about a proposed treatment or procedure
• Durable power of attorney for health care — a
• Responsibility for obtaining informed consent
document in which the patient designates a per-
rests with the person who will perform the treat-
son to make medical decisions for him if he be-
ment or procedure (usually the doctor).
comes incompetent (differs from the usual power
• The patient should be told that he has a right to
of attorney, which requires the patient’s ongoing
refuse the treatment or procedure without having
consent and deals only with financial issues)
other care or support withdrawn and that he can
withdraw consent after giving it. Grounds for challenging a patient’s right to
refuse treatment
Elements
• Patient is incompetent
• Description of the treatment or procedure
• Compelling reasons exist to overrule patient’s
• Description of inherent risks and benefits that
wishes
occur with frequency or regularity (or specific
consequences significant to the given patient or LIVING WILLS
his designated decision-maker) • Living will laws generally include such provi-
• Explanation of the potential for death or serious sions as:
harm (such as brain damage, stroke, paralysis, or – who may execute a living will
disfiguring scars) or for discomforting adverse ef- – witness and testator requirements
fects during or after the treatment or procedure – immunity from liability for following a living will’s
• Explanation and description of alternative treat- directives
ments or procedures – documentation requirements
• Name and qualifications of the person who will
perform the treatment or procedure
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Law and ethics refresher (continued)

LIVING WILLS (continued) Functions of well-documented record
– instructions on when and how the living will should be • Reflects patient care given
executed • Demonstrates results of treatment
– under what circumstances the living will takes effect. • Helps plan and coordinate care contributed by each profes-
sional
RIGHT TO PRIVACY
• Allows interdisciplinary exchange of information about patient
• Right to make personal choices without outside interference
• Provides evidence of nurse’s legal responsibilities toward pa-
MEDICATION ADMINISTRATION tient
• One of the most important and, legally, one of the riskiest tasks • Demonstrates standards, rules, regulations, and laws of nurs-
a nurse performs ing practice
Five rights • Supplies information for analysis of cost-to-benefit reduction
• Right drug • Reflects professional and ethical conduct and responsibility
• Right patient • Furnishes information for continuing education, risk manage-
• Right time ment, diagnosis-related group assignment and reimbursement,
• Right dosage continuous quality improvement, case management monitoring,
• Right route and research
Common documentation errors
NEGLIGENCE
1. Omissions
• Failure to exercise the degree of care that a person of ordinary
2. Personal opinions
prudence would exercise under the same circumstances
3. Vague entries
Four criteria for negligence claim 4. Late entries
1. A person owed a duty to the person making the claim. 5. Improper corrections
2. The duty was breached. 6. Unauthorized entries
3. The breach resulted in injury to the person making the claim. 7. Erroneous or vague abbreviations
4. Damages were a direct result of the negligence of the health 8. Illegibility and lack of clarity
care provider. ABUSE
Malpractice • The nurse plays a crucial role in recognizing and reporting inci-
• Specific type of negligence: a violation of professional duty or dents of suspected abuse.
a failure to meet a standard of care or use the skills and knowl- • If you detect evidence of apparent abuse, you must pass the
edge of other professionals in similar circumstances information along to appropriate authorities.
• In many states, failure to report actual or suspected abuse
DOCUMENTATION ERRORS
constitutes a crime.
• Complete, accurate, and timely documentation is crucial to the
continuity of each patient’s care.
checklist of how you should do your work. Ul- ment when providing patient care. When such
timately, you must rely on your own education conflicts arise, don’t hesitate to act indepen-
and knowledge of your facility’s policies and dently. Follow these guidelines:
procedures. • When you think an order is wrong, tell the
doctor.
Declare independence • If you’re confused about an order, ask the
Most nurse practice acts pose another prob- doctor to clarify it.
lem: They state that you have a legal duty to • If the doctor fails to correct the error or an-
carry out a doctor’s or a dentist’s orders. Yet, swer your questions, inform your immediate
as a licensed professional, you also have an supervisor or nurse-manager of your doubts.
ethical and legal duty to use your own judg-
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720 Law and ethics
Know your limits Informed consent involves providing the pa-

Nurse practice Conflicts of duty can also arise if your state’s tient (or someone acting on his behalf) with
acts are laws; they
nurse practice act disagrees with your facili- enough information to know:
tend to be worded in
broad, vague terms, ty’s policies. The nursing service department • what the patient is getting into if he decides
and contain wording in each facility develops detailed policies and to undergo the treatment or procedure
that varies from procedures for staff nurses. These policies • the anticipated consequences if consent is
state to state. and procedures usually specify the allowable refused or withdrawn.
scope of nursing practice within the facility. Nurses may provide patients and their fami-
The scope may be narrower than the scope lies with information that’s within a nurse’s
described in your nurse practice act, but it scope of practice and knowledge base. How-
couldn’t be broader. ever, a nurse can’t substitute her knowledge
In other words, your employer can’t legally for the doctor’s input.
expand the scope of your practice to include
tasks prohibited by your nurse practice act. Straight talk
You have a legal obligation to practice within What should the doctor tell the patient? First,
the act’s limits. Except in a life-threatening the patient has a right to reasonable disclo-
emergency, you can’t exceed those limits sure of risks associated with the medical diag-
without risking disciplinary action. To protect nosis and treatment. He also must be given an
yourself, compare your facility’s policies with opportunity to evaluate options, alternatives,
your nurse practice act. and risks before exercising his choice.
The basics of informed consent should in-
Change is good clude:
With every new medical discovery or techno- • description of the treatment or procedure
logical innovation, the world of nursing under- • description of inherent risks and benefits
goes revision. To align nurse practice acts that occur with frequency or regularity (or
with current nursing practice, professional specific consequences significant to the given
nursing organizations and state boards of patient or his designated decision-maker)
Tell it straight.
Reasonable nursing generally propose revisions to regula- • explanation of the potential for death or se-
disclosure means the tions. There’s a catch: Nurse practice acts are rious harm (such as brain damage, stroke,
patient has a right statutory laws subject to the inevitably slow paralysis, or disfiguring scars) or for discom-
to know about the legislative process, so the law sometimes has forting adverse effects during or after the
risks associated with trouble keeping pace with medicine. treatment or procedure
his diagnosis and What does all of this mean for you? To help • explanation and description of alternative
treatment. protect yourself legally, you need to stay cur- treatments or procedures
rent with your state’s nurse practice act while • name and qualifications of the person who
you keep up with innovations in health care will perform the treatment or procedure
practice. • discussion of the possible consequences of
not undergoing the treatment or procedure.
The patient should also be told that he has a
Informed consent right to refuse the treatment or procedure
without having other care or support with-
Your patient has a legal right to be adequately drawn and that he can withdraw consent after
informed about a proposed treatment or pro- giving it.
cedure. Responsibility for obtaining a patient’s
informed consent rests with the person who Can I get a witness?
must carry out the treatment or procedure If you witness a patient’s signature on a con-
(usually the doctor). Carrying out a proce- sent form, you attest to three things:
dure without informed consent can be • The patient voluntarily consented.
grounds for charges of assault and battery. • The patient’s signature is authentic.
920137.qxd 8/7/08 4:01 PM Page 721
• The patient is competent to give consent. ment. Definitions of emancipation vary from
state to state, however. Most states allow
What they don’t know can hurt you teenagers to consent to treatment in cases in-
Another potential legal pitfall for nurses is volving pregnancy or sexually transmitted dis-
called negligent nondisclosure. Let us say, for ease, even if they aren’t emancipated.
example, that you believe a patient is incom-
petent to participate in giving consent be-
cause of medication or sedation given to him. Right to refuse treatment
Perhaps you learn that the practitioner has
discussed consent issues with the patient Any mentally competent adult may legally
when the patient was heavily sedated or med- refuse treatment if he’s fully informed about
icated. Under either of these scenarios, you his medical condition and about the likely
have an obligation to bring it to the practition- consequences of his refusal. As a profession-
er’s attention immediately. If the practitioner al, you must respect that decision.
isn’t available, discuss your concerns with Most court cases related to the right to
your supervisor. refuse treatment have involved patients with a
Always document attempts to reach the terminal illness (or their families) who want
practitioner and attending doctor in the med- to discontinue life support.
ical record before allowing the patient to pro-
ceed with the treatment or procedure. Be- Quality time
sides discussing this with the practitioner and Health care providers consider quality end-
your supervisor, you must also assess your of-life care as an ethical obligation. But what
patient’s understanding of the information does end-of-life mean, and how do you mea-
provided by the practitioner. sure it? Some researchers point to five “do-
mains,” or focal points, that patients view as
When a patient is incompetent end-of-life issues. By understanding these
A patient is deemed mentally incompetent if domains from the patients’ perspectives,
he can’t understand the explanations or can’t nurses can improve the quality of end-of-life Listen up.
comprehend the results of his decisions. care. Whenever a
When a patient is incompetent, the practi- • Pain and other symptoms are of concern for competent patient
tioner has two alternatives: many patients. expresses his wishes
• seek consent from the patient’s next of kin • Many patients fear “being kept alive” after concerning
(usually the spouse) they can no longer enjoy life; they want to extraordinary
• petition the court to appoint a legal guard- “die with dignity.” treatment, health
ian for the patient. • Sense of control is also critical; some pa- care providers should
attempt to follow
Remember, however, that mental illness tients are adamant about controlling their
them.
isn’t the same as incompetence. Persons suf- end-of-life care decisions.
fering from mental illness have been found • Many patients are concerned about the bur-
competent to give consent because they’re den their dying would impose on loved ones
alert and, above all, able to understand the such as the need to provide physical care or
proposed treatment, risks, benefits, alterna- witnessing the patient’s death.
tives, and consequences of refusing treat- • Many patients express an overwhelming
ment. need to communicate with loved ones at this
stage of their life. Dying offers important op-
A minor problem portunities for growth, intimacy, reconcilia-
Every state allows an emancipated minor to tion, and closure.
consent to his own medical care and treat-
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722 Law and ethics
A religious experience the usual power of attorney, which requires

Never ignore a Some patients may refuse treatment on the the patient’s ongoing consent and deals only
patient’s request to
grounds of freedom of religion. Jehovah’s with financial issues).
refuse treatment.
Instead, stop Witnesses, for instance, oppose blood transfu- Most states recognize living wills as legally
preparations for any sions, based on their interpretation of a bibli- valid and have laws authorizing durable pow-
treatment and notify cal passage that forbids “drinking” blood. ers of attorney for initiating or terminating
the doctor and your Some sect members believe that even a life- life-sustaining medical treatment.
supervisor according saving transfusion given against their will de-
to your facility’s prives them of everlasting life. The courts Up to the challenge
protocol. usually uphold their right to refuse treatment There are two grounds for challenging a pa-
because of the constitutionally protected right tient’s right to refuse treatment: You can
to religious freedom. However, if the patient claim that the patient is incompetent, or you
is a critically ill minor, the court may deny the can claim that compelling reasons exist to
parents’ request to refuse treatment. overrule his wishes.
Most other religious freedom court cases The courts consider a patient incompetent
involve Christian Scientists, who oppose when he lacks the mental ability to make a
many medical interventions, including medi- reasoned decision, such as when he’s deliri-
cines. ous. The courts also recognize several com-
pelling circumstances that justify overruling a
Planning in advance patient’s refusal of treatment. These include:
Most states have enacted right-to-die laws • when refusal endangers the life of another
(also called natural death laws or living will • when a parent’s decision to withhold treat-
laws). These laws recognize the patient’s right ment threatens a child’s life
to choose death by refusing life-sustaining • when, despite refusing treatment, the pa-
treatment when he has no hope of recovery. tient makes statements indicating that he
Whenever a competent patient expresses wants to live
his wishes concerning life-sustaining treat- • when the public interest outweighs the pa-
ment, health care providers should attempt to tient’s right.
follow them. If the patient is incompetent or
unconscious, the decision becomes more dif- If your patient refuses treatment
ficult. Never ignore a patient’s request to refuse
In some cases, the next of kin may express treatment. If your patient tells you he’s going
the patient’s desires for him, but whether this to refuse treatment or he simply refuses to
is an honest interpretation of the patient’s give consent, follow these guidelines:
wishes is sometimes uncertain. • Stop preparations for any treatment at once.
Written evidence of the patient’s wishes pro- • Notify the doctor immediately.
vides the best indication of what treatment • Report your patient’s decision to your su-
he’d consent to if he were still able to commu- pervisor promptly.
nicate. This information may be provided Never delay informing your supervisor, es-
through advance directives, such as: pecially if a delay in treatment could be life-
• living will — an advance care document that threatening. Any delay that you’re responsible
specifies a person’s wishes about medical for greatly increases your legal risk.
care if he’s unable to make the decision for
himself (in some states, living wills don’t ad-
dress the issue of discontinuing artificial nu- Living wills
trition and hydration)
• durable power of attorney for health care — When a legally competent person draws up a
a document in which the patient designates a living will, also known as an advanced direc-
person to make medical decisions for him if tive, he declares the steps he wants or doesn’t
he becomes incompetent (this differs from want taken if he becomes incompetent and no
920137.qxd 8/7/08 4:01 PM Page 723
longer able to express his wishes. The will ap- If your patient has a living will, take the fol-
plies to decisions to be made after a patient is lowing steps to safeguard his rights and pro-
incompetent and unable to make health care tect yourself from liability:
decisions. Generally, a living will authorizes • Review your nursing or facility manual for
the attending doctor to withhold or discontin- specific directions on what to do. For in-
ue certain lifesaving procedures under specif- stance, you may need to inform the patient’s
ic circumstances. doctor about it, or you may need to ask your
A patient may also choose to execute a nursing supervisor to inform the facility’s ad-
durable power of attorney for health care. If ministration and legal affairs department.
the patient becomes incompetent, this docu- • With the patient’s permission, make sure
ment designates a surrogate decision maker the family knows about the will.
with authority to carry out the patient’s wish- • If the patient can talk, discuss the will with
es regarding health care decisions. Most him, especially if it contains terms that need
states have laws authorizing durable power of further definition. As always, objectively docu-
attorney for health care only for the purpose ment your actions and findings in the patient’s
of initiating or terminating life-sustaining record.
medical treatment. • If the patient drafts a living will while under
your care, document this in your nurses’
Living will laws: The main ingredients notes, describing the circumstances under
Although living will laws vary from state to which the will was drawn up and signed.
state, they generally include such provisions • Encourage the patient to review the living
as: will with his family and doctor so that unclear
• who may execute a living will passages can be discussed. Living wills
• witness and testator requirements should also be reviewed periodically to keep
• immunity from liability for following a living pace with changes in technology.
will’s directives
• documentation requirements
• instructions on when and how the living will Right to privacy
should be executed
• under what circumstances the living will Obtaining highly personal information from a Respecting your
takes effect. patient can be uncomfortable and embarrass- patient’s right to
ing. Reassuring the patient that you’ll keep all privacy helps to
Immunity information confidential may help put you develop trust, a
cornerstone of the
Nurses and other health care providers who both at ease. But stop to think about the legal
nurse-patient
follow the wishes expressed in a living will au- complexities of this responsibility. What do relationship.
thorized by law are generally immune from you do when your patient’s spouse, other
civil and criminal liability. No matter which health care professionals, the media, or public
state you work in, check your facility’s policy health agencies ask you to disclose confiden-
and procedures manual, and seek advice from tial information?
your facility’s legal department if needed.
It’s in the Constitution! (…or is
General guidelines it?)
The Patient Self-Determination Act of 1990 The right to privacy essentially is the right
requires facilities to provide patients with to make personal choices without outside
written information about their rights regard- interference. Although the U.S. Constitution
ing advance directives as well as about the doesn’t explicitly sanction a right to privacy,
facility’s procedure for implementing them. the U.S. Supreme Court has cited several
The law also requires the institution to docu- constitutional amendments that imply such
ment whether the patient has a an advance a right.
directive.
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724 Law and ethics
The right to privacy has received even more Confidentially speaking

attention at the state level. All states recog- Under certain circumstances, you may lawful-
nize the right to privacy through statutory or ly disclose confidential information about
common law. your patient. For example, the courts general-
ly allow disclosure when:
Making your patient feel privileged • the welfare of a person or a group of people
The state courts have strongly protected a pa- is at stake
tient’s right to have information kept confi- • disclosure is necessary for the patient’s con-
dential. Even in court, your patient is protect- tinued care
ed by the privilege doctrine. People who have • patient consent is obtained for the disclo-
a protected relationship, such as a doctor and sure
patient, can’t be forced, even during legal pro- • the public’s right to know outweighs the pa-
ceedings, to reveal communication between tient’s right to keep his condition private (for
them unless the person who benefits from the example, media reports on the first kidney
protection agrees to it. transplant or the President’s annual physical
Unfortunately, only a handful of states (in- examination).
cluding New York, Arkansas, Oregon, and In some situations, the law not only permits
Vermont) recognize the nurse-patient rela- you to disclose confidential information, it re-
tionship as protected. Some courts have held quires you to do so. These situations include:
that the privilege exists when a nurse is fol- • instances of actual or suspected child abuse
lowing doctor’s orders. (All 50 states and the District of Columbia
The Health Insurance Portability and Ac- have disclosure laws for child abuse cases.
countability Act (HIPAA) of 2003 protects the Except for Maine and Montana, all states also
privacy, confidentiality, and security of med- grant immunity from legal action for a good-
ical information. Under HIPAA, only those faith report on suspected child abuse. In fact,
All 50 states and who have a need to know patient information there may be a criminal penalty for failure to
the District of for the care of the patient and those autho- disclose such information.)
Columbia have rized by the patient to have access to his med- • instances of actual or suspected elder abuse
disclosure laws for ical information can lawfully enter a patient’s (Some states have disclosure laws regarding
child abuse cases. In medical record. elder abuse cases.)
fact, there may be a • criminal cases (Some laws create an exemp-
criminal penalty for Can I get a little privacy here? tion to the privilege doctrine in criminal cases
failure to disclose
Despite legal uncertainties regarding your re- so that courts can have access to all essential
such information.
sponsibilities under the privilege doctrine, information.)
you have a professional and ethical responsi- • government requests. (For example, most
bility to protect your patient’s privacy. This re- states’ public health departments require re-
sponsibility requires more than keeping se- ports of all communicable diseases, births
crets. You may have to educate your patients and deaths, and gunshot wounds.)
about their privacy rights. Some of them may
be unaware of what the right to privacy
means, or even that they have such a right. Medication administration
Explain to the patient that he can refuse to al-
low pictures to be taken of his disorder and Administering drugs to patients continues to
its treatment, for example. Tell him that he be one of the most important — and, legally,
can choose to have information about his con- one of the riskiest — tasks you perform.
dition withheld from others, including family
members. Make every effort to ensure that Getting it right
the patient’s wishes are carried out. When administering drugs, one easy way to
guard against malpractice liability is to remem-
ber the long-standing “five rights” formula:
920137.qxd 8/7/08 4:01 PM Page 725
• the patient’s physical condition contraindi-

the right drug cates using the drug.
In limited circumstances, you may also
to the right patient
legally refuse to administer a drug on
at the right time grounds of conscience. Some U.S. states and
Canadian provinces have enacted right-of-
in the right dosage conscience laws. These laws excuse medical
personnel from the requirement to participate
by the right route. in any abortion or sterilization procedure. Un-
der such laws, you may, for example, refuse to
Just say “know” give any drug you believe is intended to in-
When you have your nursing license, the law duce abortion.
expects you to know about any drug you ad- When you refuse to carry out a drug order,
minister. More specifically, the law expects make sure that you:
you to: • notify your immediate supervisor so she
• know a drug’s safe dosage limits, toxicity, can make alternate arrangements (assigning
potential adverse reactions, and indications a new nurse, clarifying the order)
and contraindications for use • notify the prescribing doctor (if your super-
• refuse to accept an illegible, confusing, or visor hasn’t done so already)
otherwise unclear drug order • document that the drug wasn’t given and
• seek clarification of a confusing order from explain why (if your employer requires it).
the doctor rather than trying to interpret it
yourself. Protecting yourself
If you make an error in giving a drug, or if
Are there any questions? your patient reacts negatively to a properly
If you question a drug order, follow your facil- administered drug, immediately inform the
ity’s policies. Usually, you’re told to try each patient’s doctor and protect yourself by docu-
of the following actions until you receive a sat- menting the incident thoroughly. In addition
isfactory answer: to normal drug charting information, include
• Look up the answer in a reliable drug refer- the patient’s reaction and any medical or
ence. nursing interventions taken.
• Ask your charge nurse. In the event of error, you should also file
• Ask the facility pharmacist. an incident report. Identify what happened,
• Ask the prescribing doctor. the names and functions of all personnel in-
• Continue to follow the chain of command. volved, and what actions were taken to pro-
• Get in touch with the facility administration tect the patient after the error was discov-
and explain your problem. ered. Incident reports help track harmful or
potentially harmful events so the manage-
An offer you CAN refuse ment team can devise plans to prevent fur-
Nurses have the legal right not to adminis- ther occurrences.
ter drugs they think will harm patients. You
may choose to exercise this right when you
think: Negligence
• the prescribed dosage is too high
• the drug is contraindicated because of pos- Because nurses are assuming an ever-widen-
sible dangerous interactions with other drugs ing list of patient care responsibilities, it isn’t
or with substances such as alcohol surprising that many nurses are anxious
about the possibility of facing a lawsuit some
day. Before you review the specific steps you
can take to avoid a lawsuit, you need to thor-
920137.qxd 8/7/08 4:01 PM Page 726
726 Law and ethics
oughly understand two important legal terms: someone under your supervision isn’t familiar
negligence and malpractice. with a piece of equipment, teach him how to
Negligence is usually defined as a failure to properly operate it before he uses it for the
exercise the degree of care that a person of first time. Report incompetent health care
ordinary prudence would exercise under the personnel to superiors through the facility’s
One of the best
same circumstances. A claim of negligence chain of command.
ways to avoid
malpractice is to requires that four criteria be met:
know the kinds of 1. A person owed a duty to the person making May I take your order?
assignments you’re the claim. Never treat any patient without orders from
fit to carry out on 2. The duty was breached. his doctor, except in an emergency. Don’t pre-
the job. 3. The breach resulted in injury to the person scribe or dispense any medication without au-
making the claim. thorization. In most cases, only doctors and
4. Damages were a direct result of the negli- pharmacists may legally perform these func-
gence of the health care provider. tions.
Malpractice is a specific type of negli- Don’t carry out any order from a doctor if
gence. It’s defined as a violation of profession- you have any doubt about its accuracy or ap-
al duty or a failure to meet a standard of care propriateness. Follow your facility’s policy for
or use the skills and knowledge of other pro- clarifying ambiguous orders. Document your
fessionals in similar circumstances. efforts to clarify the order and whether or not
You can take steps to avoid tort liability by the order was carried out.
using caution and common sense and by
maintaining heightened awareness of your le- Watch those medication mix-ups!
gal responsibilities. Follow the guidelines be- Medication errors are the most common and
low to steer clear of legal pitfalls. potentially most dangerous nursing errors.
Mistakes in dosage, patient identification, or
Know your own strengths…and drug selection by nurses have led to vision
weaknesses loss, brain damage, cardiac arrest, and death.
Don’t accept responsibilities that you aren’t
qualified for. If you make an error and then Staying on your patient’s good side
claim you weren’t familiar with the unit’s pro- Trial attorneys have a saying: “If you don’t
cedures, you won’t be protected against liabil- want to be sued, don’t be rude.” Always re-
ity. main calm when a patient or his family be-
comes difficult. Patients must be told the
You want me to work where? truth about adverse outcomes, but this infor-
You may be assigned to work on a specialized mation should be communicated with discre-
unit, which is reasonable as long as you’re as- tion and sensitivity.
signed duties you can perform competently
and as long as an experienced nurse on the Don’t offer opinions
unit assumes responsibility for the specialized Avoid offering your opinion when a patient
duties. Assigning you to perform total patient asks you what you think is the matter with
care on the unit is unsafe if you don’t have the him. If you give your opinion, you could be ac-
skills to plan and deliver that care. Notify your cused of making a medical diagnosis, which is
immediate supervisor if you believe an assign- practicing medicine without a license.
ment is unsafe.
Before you sign on that dotted
Delegation 101 line…Read!
Exercise great care when delegating duties Never sign your name as a witness without
because you may be held responsible for sub- fully understanding what you’re signing as
ordinates. Inspect all equipment and machin- well as the legal significance of your signa-
ery regularly, and make sure that subordi- ture.
nates use them competently and safely. If
920137.qxd 8/7/08 4:01 PM Page 727
Stick to the FACTs Follow facility policies and

From a legal standpoint, documenting care is procedures Restraints require
restraint. They need
as important as providing the actual care. If a Be familiar with the policies and procedures
to be applied
procedure wasn’t documented, the courts as- of the facility where you work. If they’re correctly and only
sume it wasn’t performed. Make sure you sound and in accordance with the nurse prac- when necessary.
document all observations, decisions, and ac- tice act and you follow them carefully, they Monitor patients in
tions. The patient’s chart, when taken into the can protect you against a malpractice claim. restraints according
court room, is a nurse’s “best evidence” of the to facility policy to
care given. The chart should follow the Provide a safe environment avoid malpractice
“FACT” rule: be Factual, Accurate, Complete, When providing care, don’t use faulty equip- claims.
and Timely. ment. Follow your facility’s policies and proce-
dures for handling and reporting faulty equip-
Assisting in procedures: A word of ment. Remove the equipment from the patient
caution area immediately. Clearly mark the equip-
Don’t assist with a surgical procedure unless ment as defective and unusable. Even after re-
you’re satisfied that the patient has given pairs are made, don’t use the repaired equip-
proper informed consent. Never force a pa- ment until technicians demonstrate that the
tient to accept treatment he has expressly re- equipment is operating properly. Document
fused. Don’t use equipment that you aren’t the steps you took to handle problems with
trained to use or that seems to be functioning faulty equipment to show that you followed
improperly. the facility’s policy and procedures.
Use of restraints: Get it in writing

Restraints need to be applied correctly and Documentation errors
checked according to the policies and proce-
dures of the facility. Documentation must be Complete, accurate, and timely documenta-
exact and should include the status of the re- tion is crucial to the continuity of each pa-
strained patient; the need, number, and kind tient’s care. A well-documented medical
of restraint used; and the reason for its use. record:
An omission or failure to monitor a restrained • reflects the patient care given
patient may result in a malpractice claim. • demonstrates the results of treatment
Proper
• helps to plan and coordinate the care con- documentation must
An ounce of prevention tributed by each professional be detailed and
Patient falls are a common area of nursing lia- • allows interdisciplinary exchange of infor- thorough but it’s
bility. Patients who are elderly, infirm, sedat- mation about the patient worth the effort. It
ed, or mentally incapacitated are the most • provides evidence of the nurse’s legal re- protects you and
likely to fall. The best way to avoid liability is sponsibilities toward the patient your patient.
to prevent falls from occurring in the first • demonstrates standards, rules, regulations,
place. and laws of nursing practice
• supplies information for analysis of cost-to-
Knowing it in advance benefit reduction
Some patients with life-threatening or termi- • reflects professional and ethical conduct
nal conditions may choose to exercise their and responsibility
right to a living will or durable power of attor- • furnishes information for a variety of uses:
ney. Be aware of your state’s laws regarding continuing education, risk management,
advance directives. diagnosis-related group assignment and reim-
bursement, continuous quality improvement,
case management monitoring, and research.
920137.qxd 9/22/08 2:58 PM Page 728
728 Law and ethics
Is everything covered?
With a large number of health care profes- Omissions — Include all significant facts
sionals involved in each patient’s care, nurs- that other nurses need to assess the patient.
ing documentation must be complete, accu- Otherwise, a court may conclude that you
rate, and timely to foster continuity of care. It failed to perform an action missing from the
should cover: record or tried to hide evidence.
• initial assessment using the nursing process
Personal opinions — Don’t enter personal
and applicable nursing diagnoses
opinions. Record only factual and objective
• nursing actions
observations and the patient’s statements.
• ongoing assessment, including the frequen-
cy of assessment Vague entries — Instead of “Patient had a
• variations from the assessment and plan good day,” state why: “Patient didn’t complain
• accountability information, including forms of pain.’’
signed by the patient, location of patient valu-
ables, and patient education Late entries — If a late entry is neces-
• health teaching, including content and pa- sary, identify it as such and sign and date it.
tient response Note the date and time you’re relating back
• procedures and diagnostic tests to.
• patient response to therapy, particularly to
nursing interventions, drugs, and diagnostic Improper corrections — Never erase or
tests obliterate an error. Instead, draw a single line
• statements made by the patient through it, label it “error,” and sign and date
• patient comfort and safety measures. it.
Unauthorized entries — Only you

Avoiding the Big 8 should be keeping your records.
In addition to their potential impact on patient
care, charting errors or omissions, even if Erroneous or vague abbreviations —
seemingly harmless, undermine your credi- Use only standard abbreviations and follow fa-
bility in court. Be careful to especially avoid cility policies.
these eight common documentation errors:
Illegibility and lack of clarity — Write
so that others can read your entry. Use a dic-
Even seemingly tionary if you’re unsure of spelling or usage.
harmless
documentation Sign language
errors can undermine
Sign all notes with your first initial, full last
your credibility in
court. name, and title. Place your signature on the
right side of the page as proof that you en-
tered all the information between the previ-
ous nurse’s signature and your own. If the last
entry is unsigned, request that the nurse who
made the entry sign it. Draw lines through
empty or remaining spaces to prevent subse-
quent amendments or additions.
920137.qxd 8/7/08 4:01 PM Page 729
Verbal cues Recognizing the problem

As a general rule, verbal and telephone or- Learn to recognize both the events that trig-
ders are acceptable only under acute or emer- ger abuse and the signs and symptoms that
gency circumstances, when the doctor can’t mark the abused and the abuser. Early in
promptly attend to the patient, or according to your relationship with an abused patient, you
facility policy. Record the order on the doc- need to be adept in order to spot the subtle
tor’s order sheet, note the date and time of behavioral and interactional clues that signal
the order, and record the order verbatim. an abusive situation.
Repeat the order back to the doctor for accu- Examine the patient’s relationship with the
racy. On the following line, write “v.o.” for ver- suspected abuser. For example, abused peo-
bal order or “t.o.” for telephone order and ple tend to be passive and fearful. An abused
record the doctor’s name, followed by your child usually fails to protest if his parent is
signature and the time. To avoid liability, be asked to leave the examining area. An abused
certain the doctor countersigns the order adult, on the other hand, usually wants her
within the time specified by facility policy. abuser to stay with her.
Abused persons may react to facility proce-
dures by crying helplessly and incessantly.
Abuse They also tend to be wary of physical contact,
including physical examinations.
As a nurse, you play a crucial role in recogniz- Many facilities have a policy, procedure, or
ing and reporting incidents of suspected protocol to help nurses and other health care
abuse. Abuse can be psychological, physical, providers make observations that aid in the
sexual, or financial in nature. Abuse victims identification of possible abuse victims. Learn-
can be of any age, gender, or socioeconomic ing these criteria makes spotting victims of
group. While caring for patients, you can abuse a more objective process and prevents
readily note evidence of apparent abuse. If cases from going unrecognized.
you do, you must pass the information along
to the appropriate authorities. In many states, Assessing the abuser
failure to report actual or suspected abuse Sometimes the abuser appears overly agitated
constitutes a crime. when dealing with facility personnel; for ex-
ample, he may get impatient if they don’t car-
Filing a report ry out procedures instantly. At other times, he
Make your report as complete and accurate may exhibit the opposite behavior: a total lack
as possible. Be careful not to let your personal of interest in the patient’s problems.
feelings affect the way you make out a report
or your decision to file the report. History lessons
Abuse cases can raise many difficult emo- When you take an abuse victim’s history, she
tional issues. Remember, however, that not fil- may be vague about how she was injured and
ing a report can have more serious conse- tell different stories to different people. When
quences than filing one that contains an unin- you ask directly about specific injuries, she
tentional error. It’s better to risk error than may answer evasively or not at all. Some-
to risk breaching the child abuse reporting times, a victim minimizes or tries to hide her
laws — and, in effect, perpetuating the abuse. injuries.
Contact your facility’s social work department
if you have questions about suspected abuse. Physical clues
Always report actual or suspected abuse ac- Look for characteristic signs of abuse. In most
cording to your facility’s policies and proce- cases of abuse, you’ll find old bruises, scars,
dures. or deformities the patient can’t or won’t ex-
plain. X-ray examinations may show many old
fractures.
920137.qxd 8/7/08 4:01 PM Page 730
730 Law and ethics
Getting on the SOAP box by teaching them how to deal with their
Always document your findings objectively; anger. Besides helping short-circuit abusive
try to keep your emotions out of your chart- behavior, a self-help group takes abusive par-
ing. One way to do this is to use the SOAP ents out of their isolation and introduces them
technique, which calls for these steps: to individuals who are capable of understand-
• In the subjective (S) part of the note, record ing their feelings. It also provides help in a
information in the patient’s own words. crisis, when members may be able to prevent
• In the objective (O) part, record your per- an abusive incident.
sonal observations. Telephone hot lines to crisis intervention
• Under assessment (A), record your evalua- services also give abusers someone to talk
tions and conclusions. with in times of stress and crisis and may help
• Under plan (P), list sources of facility and prevent abuse. Commonly staffed by volun-
community support available to the patient af- teers, telephone hot lines provide a link be-
ter discharge. tween those who seek help and trained coun-
selors.
Support for the victim These and other kinds of help are also avail-
Many support services have become available able through family-service agencies and oth-
for both abusers and their victims. For exam- er facilities. By becoming familiar with nation-
ple, if a female victim is afraid to return to the al and local resources, you’ll be able to re-
scene of her abuse, she may find temporary spond quickly and authoritatively when an
housing in a domestic abuse shelter. If no abuser or his victim needs your help.
such shelter is available, she may be able to
stay with a friend or family member.
Social workers or community liaison work-
ers may also be able to offer suggestions for
shelter. Another possibility is a church, syna-
gogue, or mosque, which may have members
willing to take the patient in. If no shelter can
be found, the patient may have to stay at the
facility for her safety.
Alert the patient to state, county, or city
agencies that can offer protection. The police
department should be called to collect evi-
dence if the patient wants to press charges
against the abuser. If the patient is a child, the
law usually requires filing a report with a gov-
ernment family-service agency.
Pump up on practice
Help for the abuser
questions
You need to evaluate the abuser’s ability to
handle stress. In some cases, you may be able 1. A nurse working at a busy hospital takes
to refer him to an appropriate local or state steps to challenge an assignment that may not
agency that can offer help. In most cases, an be within the practice limits for nurses in the
abuser poses a continued threat to others un- state where she works. Which of the follow-
til he gets help in understanding his behavior ing statutes defines the limits of each state’s
and how to change it. nursing practice?
For abusive fathers or mothers, a local 1. Contract law
chapter of Parents Anonymous (PA) may be 2. Nurse Practice Act
helpful. PA, a self-help group made up of for- 3. National Labor Relations Act
mer abusers, attempts to help abusive parents 4. Food, Drug, and Cosmetic Act
920137.qxd 8/7/08 4:01 PM Page 731
Answer: 2. Each state’s nurse practice act is 3. A client scheduled for a bronchoscopy
the most important law affecting nursing needs to sign an informed consent form be-
practice. The law outlines expectations for pa- fore the procedure. Which of the following is
tient care within defined practice limits. Giv- true about informed consent?
ing care beyond those limits makes the nurse 1. The client can’t refuse the procedure
vulnerable to charges of violating the state’s after the consent is signed.
nurse practice act. Contract law involves 2. If the client refuses to sign the con-
agreements between two or more persons to sent form, another family member can
do some type of remuneration — a “bargain sign for him.
for exchange.” The National Labor Relations 3. If the client refuses to sign the con-
Act allows nurses the right to unionize. The sent form, other treatment will be with-
Food, Drug, and Cosmetic Act restricts inter- drawn.
state shipment of drugs not approved for hu- 4. Informed consent should include an
man use and outlines the process for testing explanation of alternative treatments or
and approving new drugs. procedures.
Client needs category: Safe, effective Answer: 4. Informed consent should include
care environment an explanation of alternative treatments or
Client needs subcategory: Coordinated procedures. The client should also be told
care that he has the right to refuse the treatment
Cognitive level: Knowledge or procedure without having other care or
support withdrawn and that he can withdraw
2. The physician prescribes digoxin 4 mg consent after giving it. The client’s next of kin
P.O. for a client in atrial fibrillation. How can only sign the consent form if the client is
should the nurse proceed? deemed incompetent.
1. Check the client’s apical heart rate, Client needs category: Safe, effective
and then administer the dose. care environment
2. Administer 0.4 mg P.O. because the Client needs subcategory: Coordinated
physician most likely meant to write that care
dosage. Cognitive level: Knowledge
3. Question the physician about the
order.
4. Administer the dose, and then moni-
tor the client closely.
Answer: 3. As a licensed professional, the
nurse has the legal and ethical responsibility
to use her own knowledge and judgment
when providing client care. Therefore, the
nurse should act independently and ask the
physician to clarify the order. The dose pre-
scribed is 10 times the typical dose. If the
nurse administers this dose, she could be
held accountable for her actions in a court of
law. 4. A client is admitted to the hospital with a
Client needs category: Physiological closed head injury. He’s unconscious and re-
integrity quires mechanical ventilation. Which of the
Client needs subcategory: Pharmaco- following documents will most likely be used
logical therapies to make a medical decision for the client?
920137.qxd 8/7/08 4:01 PM Page 732
732 Law and ethics
1. Durable power of attorney for health Client needs category: Safe, effective
care care environment
2. Power of attorney Client needs subcategory: Coordinated
3. Advance directive care
4. Living will Cognitive level: Application
Answer: 1. A durable power of attorney for
health care designates a person who is autho- 6. A nurse administers a dose of penicillin
rized to make medical decisions for the client to a client, who suddenly develops hives and
when he isn’t competent to do so. This differs difficulty breathing. She notifies the physician
from the power of attorney, which requires and takes emergency measures. Which infor-
the client’s ongoing consent and deals only mation should the nurse include in her docu-
with financial concerns. A living will is an ad- mentation?
vance directive document that specifies a per- 1. Document the date, time, and site in
son’s wishes regarding medical care if he be- which the dose was administered.
comes unable to communicate. It’s commonly 2. In addition to the normal drug chart-
used in combination with the client’s durable ing information, include the client’s reac-
power of attorney. tion.
Client needs category: Safe, effective 3. In addition to the normal drug chart-
care environment ing information, include the client’s reac-
Client needs subcategory: Coordinated tion and any medical or nursing interven-
care tions taken.
Cognitive level: Application 4. Include the client’s reaction and any
nursing interventions taken.
5. A Jehovah’s Witness is admitted to the Answer: 3. When a client reacts negatively to a
hospital with upper GI bleeding. The physi- properly administered drug the nurse should
cian orders 2 units of packed red blood cells document the normal drug charting informa-
administered over 2 hours each. When the tion as well as the client’s reaction and any
nurse tells the client about the care plan, the medical or nursing interventions taken.
client refuses the transfusion. How should the Client needs category: Physiological
nurse proceed? integrity
1. Tell the client that the physician’s Client needs subcategory: Pharmaco-
order overrides his objections. logical therapies
2. Tell the client that he’s being ridicu- Cognitive level: Application
lous because he’ll die without the transfu-
sion. 7. After a medication error is made on her
3. Refuse to care for the client because unit, the nurse-manager should expect to re-
you don’t agree with his religious beliefs. ceive:
4. Tell him that you understand his reli- 1. an incident report.
gious concerns and notify the physician. 2. an oral report from the nurse.
Answer: 4. The nurse should tell the client 3. a copy of the medication Kardex.
that she understands his religious concern 4. an order change signed by the physi-
and then notify the physician. The infusion cian.
can’t be administered against the client’s Answer: 1. The nurse should complete an inci-
wishes. Doing so would violate the client’s dent report and give it to the nurse-manager,
right to freedom of religion and his right to who then gives the report to the risk manag-
refuse treatment. The nurse shouldn’t pass er. Incident reports are tools used by manage-
judgment on the client or refuse to care for a ment to track potentially harmful events and
client based on his religious beliefs. determine how future problems can be avoid-
ed. An oral report doesn’t serve as legal docu-
920137.qxd 8/7/08 4:01 PM Page 733
mentation. A copy of the medication Kardex vide an educational session about using the
isn’t sent with the incident report to the risk blood glucose monitor. The nurse should re-
manager. A physician wouldn’t change an or- view the manual but shouldn’t use the blood
der to cover the nurse’s mistake. glucose monitor without an educational ses-
Client needs category: Safe, effective sion that allows time to practice using the
care environment equipment. The nurse should never use a
Client needs subcategory: Coordinated piece of equipment without formal training. A
care need to use new equipment doesn’t automati-
Cognitive level: Knowledge cally justify refusal to care for the client.
8. A unit of blood is administered to a client care environment
without prior informed consent being ob- Client needs subcategory: Coordinated
tained. Performing a procedure, such as ad- care
ministering blood products, without receiving Cognitive level: Application
informed consent can lead to which of the fol-
lowing charges?
1. Assault and battery
2. Fraud
3. Breach of confidentiality
4. Harassment
Answer: 1. Performing a procedure on a client
without informed consent can be grounds for
charges of assault and battery. Fraud is to
cheat someone. Breach of confidentiality
refers to conveying information about the
client to people who aren’t directly involved in
his care. Harassment refers to annoying or
disturbing an individual. 10. The nurse is caring for a 72-year-old male
Client needs category: Safe, effective client who requires insertion of a central ve-
care environment nous catheter. Who’s responsible for obtain-
Client needs subcategory: Coordinated ing informed consent?
care 1. The attending physician
Cognitive level: Application 2. The physician who will insert the
catheter
9. The nurse returns from vacation and 3. The charge nurse
finds a new blood glucose monitor in use. 4. The nurse assisting with the proce-
How should the nurse proceed? dure
1. Read the blood glucose monitor man- Answer: 2. The responsibility for obtaining in-
ual before caring for the client. formed consent typically rests with the per-
2. Inform the charge nurse and ask her son who will perform the treatment or proce-
to provide an educational session about dure. It isn’t the responsibility of the attend-
how to use the blood glucose monitor. ing physician (unless he’s performing the
3. Use the blood glucose monitor be- procedure), the charge nurse, or the nurse as-
cause it’s somewhat like the old blood glu- sisting the physician with the procedure.
cose monitors on the unit. Client needs category: Safe, effective
4. Refuse to care for the client. care environment
Answer: 2. The nurse should inform the Client needs subcategory: Coordinated
charge nurse that she has never used this care
piece of equipment before and ask her to pro- Cognitive level: Application
920137.qxd 8/7/08 4:01 PM Page 734
734 Coordinating care

1. A client’s blood pressure is lower than the client’s right to privacy. During the inter-
the specified limits, so the nurse withholds view the nurse should use general leads, ask
his blood pressure medication. The nurse open-ended questions, and restate informa-
documents the omission on the medication tion.
administration record. Where should she doc- Client needs category: Safe, effective
ument the reason for withholding the medica- care environment
tion if there isn’t space in the medication ad- Client needs subcategory: Coordinated
ministration record? care
1. Patient care Kardex Cognitive level: Knowledge
2. Progress notes
3. Care plan 3. For a hospitalized client, the physician
4. Nowhere prescribes meperidine (Demerol), 75 mg
Answer: 2. If the medication administration I.M., every 3 hours as needed for pain. How-
record doesn’t provide space to document the ever, the client refuses to take injections.
omission, the nurse should document the rea- Which nursing action is most appropriate?
son in the progress notes. The patient care 1. Administering the injection as pre-
I’m ready! Kardex and care plan are used to guide pa- scribed
Ask me anything. tient care; they aren’t appropriate forms for 2. Calling the physician to request an al-
documentation. Any time a drug is omitted, ternative medication and administration
the reason for withholding it must be docu- route.
mented. 3. Withholding the injection until the
Client needs category: Safe, effective client understands its importance
care environment 4. Explaining that no other medication
Client needs subcategory: Coordinated can be given until the client receives the
care injection
Cognitive level: Application Answer: 2. The most appropriate action is to
call the physician to request an alternative
2. A client is admitted to your client care medication and administration route. By do-
area with a diagnosis of dehydration and ing so, the nurse is adhering to the client’s
pneumonia. After the client is settled in bed, wishes. Administering an injection without
the nurse begins collecting data on his health client consent is considered battery and may
history. Which of the following techniques lead to a lawsuit. Withholding medication
should the nurse avoid when conducting the without providing an alternative would violate
health history interview? the standards of care. Any attempt to manipu-
1. Using general leads to questions late the client into taking the medication also
2. Asking open-ended questions violates the standards of care.
3. Restating information Client needs category: Safe, effective
4. Asking persistent questions care environment
Answer: 4. The nurse should avoid asking per- Client needs subcategory: Coordinated
sistent questions during the history interview. care
She should make one or two attempts to get Cognitive level: Application
information and then stop. She should respect
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4. Nursing licensure and practice are regu- or completely cross it out because this looks
lated by: as if the nurse is trying to hide something.
1. nurse practice acts. Client needs category: Safe, effective
2. standards of care. care environment
3. civil law. Client needs subcategory: Coordinated
4. the American Nurses Association. care
Answer: 1. Nurse practice acts regulate nurs- Cognitive level: Application
ing licensure and practice. Each state has its
own nurse practice act. Standards of care of- 6. A nurse tells the primary nurse that she
fer guidelines for providing care and criteria was unable to complete her client’s admission
for evaluating care. Civil law protects an indi- database because of the client’s deteriorating
vidual’s rights and isn’t associated with regu- condition. The primary nurse reports this to
lation of nursing licensure or practice. The the oncoming shift. The initial admission as-
American Nurses Association, the profession- sessment must be completed within how
al organization for registered nurses in the many hours after admission?
United States, helps make policy and estab- 1. 12
lish nursing care standards. 2. 24
Client needs category: Safe, effective 3. 36
care environment 4. 48
Client needs subcategory: Coordinated Answer: 2. The Joint Commission requires an
care initial nursing assessment to be completed
Cognitive level: Knowledge within 24 hours of admission. However, the
primary nurse should check her facility’s poli-
cy because the facility may require the form
to be completed in a shorter time frame.
care environment
care
7. A 42-year-old client admitted with an

acute myocardial infarction asks to see his
chart. What should the nurse do first?
5. While documenting on a client’s patient 1. Allow the client to view his chart.
care flow sheet, the nurse notices that she 2. Contact the nurse-manager and physi-
made a mistake. How should the nurse pro- cian for approval.
ceed? 3. Ask the client if he has concerns
1. Use correction fluid and continue to about his care.
document. 4. Tell the client that he isn’t permitted
2. Draw a single line through the entry. to view his chart.
3. Cross out the error completely. Answer: 3. The client has a legal right to see
4. Erase the error. his chart. However, if he asks to see it, the
Answer: 2. The nurse should draw a single nurse should first ask him if he has any ques-
line through the entry and write “error” along tions about his care and try to clear up any
with her initials and the date and time above confusion. The client may be confused about
or next to the entry. The nurse should never his care. The nurse should check her facility’s
cover a mistake with correction fluid, erase it, policy to see whether the chart must be read
in the nurse’s presence. The nurse should
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inform the physician and nurse-manager of 9. A 92-year-old client falls when he at-
the client’s request. tempts to get out of bed on his own. Which in-
Client needs category: Safe, effective formation should the nurse include in her
care environment documentation of the incident?
Client needs subcategory: Coordinated 1. Describe what she saw and heard and
care the actions she took when she reached the
Cognitive level: Application client.
2. Mention that an incident report was
completed.
3. Describe what she thinks occurred.
4. Describe what the client said oc-
curred.
Answer: 1. The nurse should describe what
she saw and heard and the actions she took
when she reached the client’s bedside, as well
as the client’s account of the incident. She
shouldn’t document what she thinks occurred
or mention that an incident report was com-
pleted after charting the event. This destroys
8. A client will undergo a thoracotomy in the confidential nature of the report and may
the morning. The physician asks the nurse to result in a lawsuit.
witness the client signing the consent form. Client needs category: Safe, effective
What should the nurse do? care environment
1. Explain the procedure to the client Client needs subcategory: Coordinated
first. care
2. Tell the physician only a registered Cognitive level: Application
nurse can witness a consent.
3. Notify her nurse-manager. 10. A client asks to be discharged from the
4. Make sure the client is competent, health care facility against medical advice
awake, and alert before he signs the con- (AMA). What should the nurse do?
sent form. 1. Prevent the client from leaving.
Answer: 4. Before the nurse witnesses a 2. Notify the physician.
client’s consent, she should make sure that 3. Have the client sign an AMA form.
the client is competent, awake, and alert and 4. Call a security guard to help detain
is aware of what he’s doing. Although it’s im- the client.
portant to make sure that the client under- Answer: 2. If a client requests a discharge
stands the procedure and the associated AMA, the nurse should notify the physician
risks, it’s the physician’s responsibility to ex- immediately. If the physician can’t convince
plain the procedure to the client. It isn’t re- the client to stay, the physician will ask the
quired that a registered nurse witness the client to sign an AMA form, which releases
consent. There is no need to notify the nurse- the facility from legal responsibility for any
manager. medical problems the client may experience
Client needs category: Safe, effective after discharge. If the physician isn’t available,
care environment the nurse should discuss the AMA form with
Client needs subcategory: Coordinated the client and obtain the client’s signature. A
care client who refuses to sign the form shouldn’t
Cognitive level: Application be detained because this would violate the
client’s rights. After the client leaves, the
nurse should document the incident thor-
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oughly and notify the physician that the client Client needs category: Safe, effective
has left. care environment
Client needs category: Safe, effective Client needs subcategory: Coordinated
care environment care
Client needs subcategory: Coordinated Cognitive level: Comprehension
care
Cognitive level: Knowledge 13. While eating her lunch, a nurse over-
hears that a fellow nurse is being sued by a
11. A nursing assistant is assigned to pro- former client. What’s the most common tort
vide morning care to a client. How should the filed against health care providers by clients?
nurse document care given by the assistant? 1. Malpractice
1. “Morning care provided by B.C., 2. Negligence
nursing assistant.” 3. Assault
2. “Morning care given.” 4. Battery
3. There’s no need to document morn- Answer: 2. Negligence is the most common
ing care. tort filed by clients against health care
4. “Morning care given by Betsy Clarke, providers. Malpractice and assault and bat-
NA.” tery are criminal charges that are filed
Answer: 4. The nurse should document that against health care providers by law enforce-
morning care was given by the nursing assis- ment authorities.
tant, using the nursing assistant’s full name Client needs category: Safe, effective
and title. care environment
Client needs category: Safe, effective Client needs subcategory: Coordinated
care environment care
Client needs subcategory: Coordinated Cognitive level: Knowledge
care
12. A nurse discovers that the wrong I.V. flu-

id has been administered to a client. The hos-
pital’s risk manager should receive which of
the following items to document the incident?
1. Oral report from the nurse
2. Copy of the patient care Kardex
3. Order change written by the
physician
4. Incident report
Answer: 4. The risk manager should receive
an incident report when a client might be 14. A mother brings her 3-year-old child to
harmed. The incident report is used to deter- the emergency department. The mother
mine how future errors can be avoided. An states that she found a blood smear in her
oral report from the nurse doesn’t serve as le- daughter’s underwear. The physical examina-
gal documentation. A copy of the patient care tion reveals sexual assault with vaginal pene-
Kardex isn’t sent to the risk manager. A physi- tration. The mother doesn’t want the police
cian shouldn’t change an order to cover the notified because of the potential publicity.
nurse’s error. What action should the nurse take?
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1. No action is necessary because the state agency that provides money, food, or
mother is the child’s legal guardian. shelter for individuals who need it. It doesn’t
2. Report the findings to the police and necessarily deal with children who are victims
have a social worker talk with the mother. of abuse. Children’s Protective Services will
3. Encourage the mother to reconsider investigate the crime and may want to place
her decision. the child in a foster home or with other rela-
4. Ask the emergency department tives during the investigation. Homeless shel-
physician to talk to the mother. ters provide shelter and food for people in
Answer: 2. The nurse must report the crime need. They don’t necessarily have resources
to the authorities regardless of the mother’s for abused children and their mothers.
wishes. The emergency department physician Client needs category: Safe, effective
may talk to the mother, and the mother may care environment
be encouraged to reconsider her wishes; Client needs subcategory: Coordinated
however, the crime must be reported and care
evidence must be collected. Cognitive level: Application
care environment 16. A graduate nurse is being oriented to her
Client needs subcategory: Coordinated assigned unit. A client is admitted with end-
care stage leukemia. Which statement made by
Cognitive level: Application the graduate nurse is incorrect?
1. “The client can inform the physician
that he doesn’t want cardiopulmonary re-
suscitation if his heart stops beating.”
2. “The client could designate another
person to make end-of-life decisions when
he’s no longer able.”
3. “The client can write a living will indi-
cating his end-of-life preferences.”
4. “The law states that the client must
write a new living will each time he’s ad-
mitted to the hospital.”
Answer: 4. One living will covers all hospital-
15. A mother brings her child to the emer- izations unless the client decides to make
gency department after her husband physical- changes. The client typically discusses his
ly abused the child. She’s afraid to return wishes with the physician, who provides the
home. The nurse can refer the mother to sev- order for the client care status. A durable
eral social service agencies. Which one would power of attorney for health care designates a
be most appropriate? person to make decisions for the client in the
1. Domestic abuse shelter event the client can’t make decisions on his
2. Welfare bureau own. A living will explains a person’s end-of-
3. Children’s Protective Services life care preferences.
4. Homeless shelter Client needs category: Safe, effective
Answer: 1. A domestic abuse shelter can pro- care environment
vide services necessary for both mother and Client needs subcategory: Coordinated
child. The other alternatives may result in care
separation of the child from the mother and Cognitive level: Analysis
cause further trauma. The welfare bureau is a
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17. The nurse is collecting data on a client Answer: 3. The nurse-manager should use
admitted with pneumonia. When should the a nonthreatening manner to question the
nurse begin assisting with discharge planning nurse who signed out the narcotic. If the
for this client? nurse can’t give an adequate explanation,
1. The day before discharge the nurse-manager should follow the facility’s
2. When the client’s condition is stabi- procedures for providing help to a staff mem-
lized ber who might have a substance abuse prob-
3. At the time of admission lem. The physician must be notified that the
4. When the physician writes the dis- client didn’t receive the medication. The phar-
charge order macist should be notified of the discrepancies
Answer: 3. Discharge planning should begin in the narcotic count. If policy dictates, the
as soon as the client is admitted. Beginning nurse-manager should then file an incident re-
the planning as soon as possible gives the port.
staff time to allocate the resources the client Client needs category: Safe, effective
will require at discharge. Waiting until the care environment
day before discharge, until the client stabi- Client needs subcategory: Coordinated
lizes, or until the discharge order is written care
doesn’t allow adequate time for planning. Cognitive level: Application
care environment 19. A graduate nurse is having difficulty pro-
Client needs subcategory: Coordinated gressing through orientation. Which action
care by the nurse-manager is most appropriate?
Cognitive level: Analysis 1. Meet with the graduate nurse and for-
mulate a plan to help improve her perfor-
mance.
2. Speak with the employee relations di-
rector about terminating the graduate
nurse.
3. Tell the graduate nurse that if her per-
formance doesn’t improve by the deadline
she’ll be terminated.
4. Encourage the graduate nurse to
transfer to a less stressful unit.
18. The nurse-manager is checking a client’s Answer: 1. The nurse-manager should meet
chart when she notes that there’s no record with the graduate nurse and discuss her per-
of a narcotic being given to the client even ceived weaknesses. Together they should de-
though the nurse on the previous shift signed velop a plan to improve the nurse’s perfor-
one out. The client denies receiving anything mance. The other responses don’t provide the
for pain. Which action should the nurse- graduate nurse with the opportunity to im-
manager take first? prove her performance and they don’t provide
1. Notify the pharmacy that the client her with support.
didn’t receive the medication so he doesn’t Client needs category: Safe, effective
get charged for it. care environment
2. Notify the physician that the client Client needs subcategory: Coordinated
didn’t receive the medication. care
3. Question the nurse who signed out Cognitive level: Application
the narcotic to seek clarification about the
missing drug.
4. File an incident report.
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20. Which client care assignment would 21. A group of people has identified the lack
be most appropriate for a licensed practical of documentation when restraints are used.
nurse? As a result they recommend a change in the
1. An 83-year-old client with heart failure facility’s documentation form. These people
who was just transferred from the inten- are most likely members of which committee?
sive care unit 1. Quality control
2. A 35-year-old client admitted the day 2. Performance improvement
before with an acute exacerbation of 3. The Joint Commission
asthma 4. Unit council
3. A 44-year-old client with metastatic Answer: 2. The performance improvement
breast cancer who was prescribed comfort committee identifies problems that aren’t ad-
measures dressed by an established standard and then
4. A 76-year-old client who underwent recommends changes in the facility’s policies,
an open reduction and internal fixation of procedures, or documentation forms in an ef-
her right hip 5 days ago fort to improve client care. Quality control is a
Answer: 4. The most appropriate assignment term used in factory production. The Joint
for the licensed practical nurse is the 76-year- Commission is a private agency that establish-
old client who underwent an open reduction es guidelines for the operation of hospitals
and internal fixation of the hip 5 days ago. and other health care facilities. Unit council is
This client is stable and requires physical a group that represents the nursing unit and
care; therefore, she’s most appropriately voices the concerns of other staff members.
cared for by the licensed practical nurse. The Client needs category: Safe, effective
client who was just transferred from the inten- care environment
sive care unit requires frequent assessment Client needs subcategory: Coordinated
because he may become unstable. The 35- care
year-old client admitted with acute asthma the Cognitive level: Application
day before also requires frequent assessment
and should be cared for by a registered nurse. 22. A nurse failed to administer a medication
The 44-year-old client being maintained on to a client according to accepted standards.
comfort measures requires frequent assess- Consequently, the client suffered adverse ef-
ment and medication titration based on the as- fects. Which of the following terms is used to
sessment findings. A registered nurse would describe failure to provide the appropriate
be the most appropriate person to provide standard of care?
care for this client. 1. Breach of duty
Client needs category: Safe, effective 2. Breach of promise
care environment 3. Negligent duty
Client needs subcategory: Coordinated 4. Tort
care Answer: 1. Breach of duty means that the
Cognitive level: Application nurse has provided care that didn’t meet the
accepted standard. When investigating
breach of duty, the court asks how a reason-
able, prudent nurse with comparable training
and experience would have acted in compara-
ble circumstances.
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care environment
care
23. A staff nurse goes to the nurse-manager

because she feels stressed by her job even
though she enjoys the challenge. Which sug-
gestion is best to help the nurse?
1. “You should consider a position
change.”
2. “Take stress management classes.”
3. “Spend more time with your family.”
4. “Try not to take your work home with
you.”
Answer: 2. Stress management classes teach 24. The Patient Self-Determination Act of
nurses how to better manage stress in their 1990 requires all hospitals to inform clients of
lives. They help the nurse identify factors that advance directives. What should the nurse tell
contribute to her stress, which may help her the client about such advance directives as liv-
find alternatives to leaving the nursing job ing wills and health care powers of attorney?
she enjoys. Not spending enough time with 1. They provide specific instructions for
her family and not taking her job home with the client’s treatment in certain health care
her haven’t been identified as contributing situations.
factors in this scenario. 2. They can’t provide do-not-resuscitate
Client needs category: Safe, effective (DNR) orders for clients with terminal ill-
care environment nesses.
Client needs subcategory: Coordinated 3. They allow physicians to make deci-
care sions about treatment.
Cognitive level: Application 4. They permit physicians to give verbal
DNR orders.
Answer: 1. Advance directives are signed, wit-
nessed documents that provide specific
instructions for treatment if a client can’t give
those instructions personally when required.
Depending on the client’s wishes, they may or
may not include DNR orders. Advance direc-
tives allow the client, not the physician, to
make decisions about treatment. They don’t
permit verbal orders; all physician’s orders
must be written and signed to be legal.
care environment
care
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25. The nurse receives a report on her client 1. Notifying the American Cancer Soci-
assignments at shift change. On which client ety of the client’s diagnosis
should the nurse first collect data? 2. Requesting Meals on Wheels to pro-
1. A client with a DNR order whose last vide adequate nutritional intake
blood pressure reading was 70/34 mm Hg 3. Referring the client to a home health
2. A client admitted with chest pain 6 nurse for follow-up visits to provide
hours ago who has been pain-free since colostomy care
admission to the floor 4. Asking an occupational therapist to
3. A client just admitted with uncon- evaluate the client at home
trolled atrial fibrillation Answer: 3. Many clients are discharged from
4. A client who suffered a stroke and re- acute care settings so quickly that they don’t
quires frequent suctioning receive complete instructions. Therefore, the
Answer: 3. The nurse should begin by collect- first priority is to arrange for colostomy care.
ing data on the most acutely ill client — in this The American Cancer Society often sponsors
case, the newly admitted client with uncon- support groups, which are helpful when the
trolled atrial fibrillation. Although the client person is ready, but contacting this organiza-
with a DNR order has low blood pressure, tion doesn’t take precedence over ensuring
he’s most likely terminally ill and may not proper colostomy care. Requesting Meals on
need to be seen first. The client admitted with Wheels and an occupational therapy evalua-
chest pain has been pain-free since admission, tion are important but can occur later in reha-
so his data collection can be delayed until af- bilitation.
ter the more acute client is seen. The client Client needs category: Safe, effective
who suffered a stroke needs frequent nursing care environment
care, but his data collection can wait until af- Client needs subcategory: Coordinated
ter the more acutely ill client is seen. care
Client needs category: Safe, effective Cognitive level: Analysis
care environment
Client needs subcategory: Coordinated 27. A client with terminal breast cancer is
care being cared for by a long-time friend who’s a
Cognitive level: Analysis physician. The client has identified her twin
sister as the agent in her durable power of at-
torney for health care. The client loses deci-
sion-making capacity, and the twin sister says
to the nurse, “There will be a different physi-
cian caring for my sister now. I’ve dismissed
her friend.” In response, the nurse should:
1. inform the sister that she doesn’t
have the power to assign a different physi-
cian.
2. ask the dismissed physician if the
client ever stated she wanted a different
physician.
26. A client is being discharged after under- 3. abide by the wishes of the sister who
going abdominal surgery and colostomy for- is the durable power of attorney agent for
mation to treat colon cancer. Which nursing health care.
action is most likely to promote continuity of 4. politely ignore the sister’s statement
care? and continue to call the dismissed physi-
cian for orders.
920137.qxd 8/7/08 4:01 PM Page 743
Answer: 3. A durable power of attorney for Client needs category: Safe, effective
health care transfers all rights that the indi- care environment
vidual normally has regarding health care de- Client needs subcategory: Coordinated
cisions to the designated agent. It’s within the care
power of the twin sister to change the physi- Cognitive level: Application
cian caring for her terminally ill twin. The dis-
missed physician has no power to interfere
with the wishes of the durable power of attor-
ney for health care. It would be inappropriate
and unprofessional of the nurse to ignore the
wishes of the client’s agent.
care environment
care
29. The nurse-manager notices that a staff

nurse isn’t providing tracheostomy care to a
client according to policy. The nurse’s method
isn’t harmful to the client. How should the
nurse-manager proceed?
1. Pull the nurse aside in a private area
and tell her that she should review the pro-
cedure for tracheostomy care.
2. Do nothing because the nurse’s
method wasn’t harmful to the client.
3. Stop the nurse immediately and tell
28. A client refuses to take his 9 p.m. med- her she isn’t following the facility proce-
ication. How should the nurse document this dure for tracheostomy care.
on the medication administration record? 4. Wait until the nurse is at the nurses’
1. Leave the space blank where her ini- station with her peers and tell her she
tials would typically be written. should review the procedure because she
2. Circle the time the drug was to be ad- wasn’t performing tracheostomy care cor-
ministered. rectly.
3. Cross out the time the drug was to be Answer: 1. The nurse-manager should pull the
administered. nurse aside and tell her that she wasn’t per-
4. Circle the time the drug was to be ad- forming tracheostomy care according to the
ministered and record the reason for omis- established procedure and should review the
sion in the progress notes. policy as soon as possible. The nurse-manag-
Answer: 4. The nurse should circle the time er shouldn’t ignore the nurse’s actions be-
the drug was to be administered and record cause the nurse is performing a procedure
the reason for omission in the progress notes. that deviates from the accepted policy. Be-
Leaving the space blank would be perceived cause the nurse isn’t harming the client, the
as mistakenly omitting the dose. Crossing out nurse-manager can wait until the nurse com-
the time the dose was to be administered sug- pletes her care and then speak to her in a pri-
gests that the nurse has something to hide vate location; the nurse-manager shouldn’t
and would be questioned in a court of law correct the nurse in front of the client. The
should litigation proceed.
920137.qxd 8/7/08 4:01 PM Page 744
nurse-manager shouldn’t correct the nurse in Answer: 2. Providing information to a staff

front of her peers because this would embar- nurse who’s no longer involved in the client’s
rass the nurse and isn’t professional behavior. care can be interpreted as a breach in client
Client needs category: Safe, effective confidentiality. Only those directly involved in
care environment the client’s care, such as a consulting physi-
Client needs subcategory: Coordinated cian, can be given information about the
care client. Under certain circumstances, the
Cognitive level: Analysis physician or nurse may disclose confidential
information. For example, the courts allow
30. A nurse attends an inservice on confi- disclosure when the welfare of a person or a
dentiality issues. Which of the following sce- group of people is at stake. Not informing the
narios can be interpreted as a breach in client client’s family that he has been diagnosed
confidentiality? with epilepsy may place them, the client, or
1. The nurse provides the consulting others in danger should the client decide to
physician with an update of the client’s drive. Not disclosing the client’s intent to
hospital course. murder his sister could also place her in
2. The critical care nurse updates the grave danger.
floor nurse about a client transferred to Client needs category: Safe, effective
the critical care unit 2 days ago. care environment
3. The physician notifies the client’s fam- Client needs subcategory: Coordinated
ily about the client’s diagnosis of epilepsy care
against the client’s wishes. Cognitive level: Analysis
4. The physician notifies the client’s sis-
ter because the client has threatened to
kill his sister.
I answered every
question correctly!
Bring on
the NCLEX!
9201BM.qxd 8/7/08 5:05 PM Page 745
Appendices and index

Alternate-format questions review 747
Positioning clients 811
Selected references 822
Index 823
9201BM.qxd 8/7/08 5:05 PM Page 746
9201BM.qxd 8/7/08 5:05 PM Page 747
Alternate-format
questions review
Fundamentals of nursing
1. A teenage boy suffers a broken leg as a result of a car Answer: 1, 6. Supporting the wet cast with pillows prevents
accident. He’s taken to the emergency department, where a the cast from changing shape and interfering with the
plaster cast is applied. Before he’s discharged, the nurse alignment of the fractured bone. The nurse should instruct
provides him with instructions regarding cast care. Which the client not to place sharp objects, such as straws and
instructions are appropriate? Select all that apply. hangers, down the inside of the cast to avoid the risk of im-
□ 1. Support the wet cast with pillows until it dries. pairing the skin and causing infection. Using a hair dryer
□ 2. Use a hair dryer to speed the drying process. isn’t advised because it dries the cast unevenly, can cause
□ 3. Use the fingertips when moving the wet cast. burns to the tissue, can crack the cast, and can cause poor
□ 4. Apply powder to the inside of the cast after it dries. alignment of the injured bone. The palms, not the finger-
□ 5. Notify the physician if the leg itches under the cast. tips, should be used when handling the wet cast because
□ 6. Avoid putting straws or hangers inside the cast. fingertips can dent the cast, thus causing pressure points
that can affect the skin’s integrity. Powder shouldn’t be
used because it can cake under the cast. Itching is a com-
mon occurrence with casts because skin cells are unable
to slough as they normally would and the dry skin causes
itching. Normally, the physician isn’t called for this
problem.
Client needs subcategory: Basic care and comfort
2. A client with an I.V. line in place complains of pain at Answer: 2, 4, 5, 6. Redness, warmth, pain, and a hard, cord-
the insertion site. Examination of the site reveals a vein like vein at the I.V. insertion site suggest that the client has
that’s red, warm, and hard. Which actions should the nurse phlebitis. The nurse should remove the I.V. line and insert
take? Select all that apply. a new I.V. catheter proximal to or above the discontinued
□ 1. Slow the infusion rate. I.V. site or in the other arm. Applying warm soaks to the
□ 2. Discontinue the infusion. site reduces inflammation. The nurse should document the
□ 3. Restart the infusion distal to the discontinued I.V. site. appearance of the I.V. site, actions taken, and the client’s re-
□ 4. Restart the infusion in the opposite arm. sponse to the situation. When phlebitis is present, slowing
□ 5. Apply warm soaks to the I.V. site. the infusion rate won’t reduce the phlebitis. Restarting the
□ 6. Document the appearance of the I.V. site, the nurse’s infusion at a site distal to the phlebitis may contribute to the
actions, and the client’s response to the situation. inflammation.
Client needs subcategory: Pharmacological therapies
747
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748 Alternate-format questions review
3. A nurse is administering an I.M. Answer: The vastus lateralis is an I.M.

injection into the vastus lateralis mus- injection site located in the middle
cle of a client. Identify the area where third of the outer aspect of the thigh,
the nurse will inject the medication. from one handbreadth below the
greater trochanter to one hand-
breadth above the knee.
Client needs category:
Physiological integrity
Client needs subcategory:
Pharmacological therapies
4. When administering an injection into the deltoid mus- Answer: 2. The deltoid muscle is usually the site for inject-
cle, what’s the maximum amount of milliliters of medication ing a small amount of medication. Administration of more
that a nurse can administer? Record your answer using a than 2 ml into the deltoid muscle increases the risk of
whole number. brachial artery and nerve damage.
________________________ milliliters Client needs subcategory: Reduction of risk potential
5. A nurse transcribes the following physician’s order Answer: 1, 2. To ensure that medication errors don’t occur,
onto a client’s medication record: it’s important for the nurse to follow the six rights to safe
medication administration: right drug, right dose, right
Physician’s Order Sheet route, right time, right client, and right documentation. The
number of drops ordered is too great to be instilled into the
Administer 10 gtt of timolol eye. The medication wouldn’t be effective because the dose
3/15/08 1300
is too large and would overflow. Normally, physicians order
maleate (Timoptic) ophthalmic 1 or 2 drops to be instilled into the eyes. In addition, the
physician’s order doesn’t include the administration route.
solution daily. Client needs category: Safe, effective care
——— John Bloom, MD environment
Client needs subcategory: Safety and infection
control
Which components of the medication order should the
nurse question? Select all that apply.
□ 1. Number of drops
□ 2. Route
□ 3. Type of medication
□ 4. Signature
□ 5. Frequency of administration
□ 6. Date
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Fundamentals of nursing 749
6. A nurse is collecting data on a client who has a rash on Answer: 1, 2, 4, 5. Finding out when a rash first appeared
his chest and upper arms. Which questions should the helps the physician make a diagnosis and determine the
nurse ask to obtain more information about the client’s stage of the rash in the disease process. Obtaining an allergy
rash? Select all that apply. history is necessary because rashes related to allergies can
□ 1. “When did the rash start?” occur when a client changes medications, eats new foods,
□ 2. “Are you allergic to any medications, foods, or or has contact with allergens in the air (such as pollen).
pollen?” How the client has been treating the rash is important
□ 3. “How old are you?” because topical ointments and oral medications may make
□ 4. “What have you been using to treat the rash?” the rash worse. Recent travel outside of the country expos-
□ 5. “Have you recently traveled outside of the country?” es the client to foreign foods and environments that can
□ 6. “Do you smoke cigarettes or drink alcohol?” contribute to the onset of a rash. The client’s age and smok-
ing or drinking habits have no real value in determining the
cause of a rash.
Client needs subcategory: Physiological adaptation
7. An elderly client who’s 5⬘4⬙ (162.5 cm) and weighs Answer: 2, 3, 4. Inactivity, immobility, incontinence, and se-
145 lb (65.8 kg) is admitted to a long-term care facility. The dation are all risk factors for developing pressure ulcers.
admitting nurse takes this report: The client sits for long The client’s weight and poor eating habits at lunch and din-
periods in his wheelchair and has bowel and bladder incon- ner aren’t directly related to the risk of developing pressure
tinence. He’s able to feed himself and has a fair appetite, ulcers. However, a calorie count should be taken to see if
eating best at breakfast and poorly later in the day. He the client is receiving adequate calories and fluids because
doesn’t have family members living nearby and is often poor nutrition can contribute to pressure ulcers. The
noted to be crying and depressed. He also frequently re- client’s crying and depression have no direct bearing on
quires large doses of sedatives. Which factors place the this client’s risk for developing a pressure ulcer. However,
client at risk for developing a pressure ulcer? Select all clients with depression commonly aren’t as active, so his
that apply. activity levels should be closely monitored.
□ 1. Weight Client needs category: Physiological integrity
□ 2. Incontinence Client needs subcategory: Reduction of risk potential
□ 3. Sitting for long periods Cognitive level: Analysis
□ 4. Sedation
□ 5. Crying and depression
□ 6. Poor eating habits
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8. A nurse finds a client ly- Answer: The carotid artery

ing on the floor of a hospital is located in the neck in the
corridor. After determining groove between the trachea
unconsciousness and breath- and the sternocleidomastoid
lessness and providing two muscle. It’s the artery of
ventilations, the nurse choice for determining a
checks the client’s carotid pulse in this situation be-
artery for a pulse. Identify cause it’s usually the most
the area where the nurse accessible.
can best palpate the carotid Client needs category:
pulse. Physiological integrity
Physiological adaptation
9. A diabetic client comes Answer: The dorsalis pedal

to the clinic for medical at- pulse is located on the top
tention because of numb- portion of the foot. Because
ness and tingling in his low- clients with diabetes have
er extremities. A nurse ob- complications related to cir-
tains the client’s vital signs culation in the lower extrem-
and palpates the dorsalis ities, health care providers
pedis pulse. Identify the area should palpate dorsalis pedal
where the nurse should place pulses and check capillary refill.
her fingers to palpate the dorsalis pedal pulse. Client needs category: Health promotion and
maintenance
10. An adolescent client Answer: The submandibular

seeks medical attention be- lymph nodes are located be-
cause of a sore throat and neath the mandible, or lower
probable mononucleosis. jaw, halfway to the chin.
The nurse palpates the These nodes may be en-
client’s submandibular larged in a client with a
lymph nodes for enlarge- throat infection or mono-
ment. Identify the area nucleosis.
where the nurse should pal- Client needs category:
pate to best feel these nodes. Physiological integrity
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Fundamentals of nursing 751
11. An elderly client comes Answer: To perform Weber’s

to the clinic complaining of test, the tuning fork should
hearing loss. A nurse per- be struck and then placed on
forms Weber’s test to evalu- the midline of the head. We-
ate the client’s ability to ber’s test determines if
hear. Identify the location sound is heard equally in
where the nurse should both ears. If the client hears
place the tuning fork to the sound louder in one ear,
perform this test. he probably has unequal
hearing loss that requires
further intervention.
Client needs category: Health promotion and
maintenance
12. A 40-year-old client is Answer: The apical heart

admitted with a diagnosis of rate is best heard at the
new-onset atrial fibrillation. point of maximal impulse,
To obtain an accurate pulse which is generally in the fifth
count, the nurse counts the intercostal space at the mid-
apical heart rate. Identify the clavicular line.
area where the nurse should Client needs category:
place the stethoscope to best Health promotion and
hear the apical rate. maintenance
13. A 35-year-old client is Answer: Bronchovesicular

admitted to the hospital for breath sounds are best
routine outpatient surgery. heard next to the upper third
Before surgery, a nurse aus- of the sternum and between
cultates the client’s chest for the scapulae. These breath
breath sounds. Identify the sounds are equal in length
area where the nurse should during inspiration and expi-
expect to hear broncho- ration.
vesicular breath sounds. Client needs category:
Health promotion and
maintenance
None
Cognitive level: Knowl-
edge
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14. An adolescent boy Answer: Pain and tenderness

comes to the emergency de- during an acute attack of ap-
partment seeking medical at- pendicitis localize in the
tention for severe pain locat- right lower quadrant, mid-
ed in the area of the appen- way between the umbilicus
dix. Identify the area where and the crest of the ilium.
the nurse would expect the Client needs category:
pain to localize. Physiological integrity
Cognitive level: Knowl-
edge
15. An elderly client is ad- Answer: The murmur of aor-

mitted to the hospital for a tic stenosis is low-pitched,
fractured hip. He has a his- rough, and rasping. It’s loud-
tory of aortic stenosis. Iden- est in the second intercostal
tify the area where the nurse space, to the right of the
should place the stethoscope sternum.
to best hear the murmur. Client needs category:
maintenance
16. A 52-year-old client with a history of hypertension has Answer: 3.5. The correct formula to calculate a drug dosage
just had a total hip replacement. The physician orders is:
hydrochlorothiazide (Hydro-Chlor) 35 mg oral solution by Dose on hand Quantity on hand Dose desired X
mouth, once per day. The label on the solution reads hy-
drochlorothiazide 50 mg/5 ml. To administer the correct Therefore:
dose, how many milliliters should the nurse pour? Record 50 mg 5 ml 35 mg X
your answer using one decimal place. X 3.5 ml
________________________ milliliters Client needs subcategory: Pharmacological therapies
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Medical-surgical nursing 753
Medical-surgical nursing
1. A nurse is evaluating a client who’s at risk for cardiac Answer: 26. Pulse pressure is the difference between sys-
tamponade because of chest trauma sustained in a motorcy- tolic and diastolic pressures. Normally, systolic pressure
cle accident. What’s the client’s pulse pressure if his blood exceeds diastolic pressure by approximately 40 mm Hg.
pressure is 108/82 mm Hg? Record your answer using a Narrowed pulse pressure, a difference of less than
whole number. 30 mm Hg, is a sign of cardiac tamponade.
________________________ mm Hg Client needs subcategory: Physiological adaptation
2. The nurse is caring for a client who just had a cardiac Answer: 1, 3, 5. Pressure should be applied at the access
catheterization through a femoral access site. Which nurs- site to control bleeding and promote clot formation. The
ing interventions should be included in the client’s care dressing and access site must be observed frequently for
plan for the next 8 hours? Select all that apply. bleeding and hematoma formation. When the femoral ac-
□ 1. Maintain pressure over the femoral access site. cess site is used, the head of the bed may not be raised
□ 2. Allow the client to sit upright for meals. greater than 30 degrees and the affected leg must be kept
□ 3. Check the dressing and access site for bleeding. extended. Therefore, the client may not sit upright for
□ 4. Monitor vital signs every 4 hours. meals or use the bedside commode. After this procedure,
□ 5. Keep the extremity straight. the nurse should monitor vital signs every 15 minutes for
□ 6. Allow use of the bedside commode. the first hour, every 30 minutes for the next 2 hours, and
every 4 hours after that.
Client needs subcategory: Reduction of risk potential
3. A nurse is preparing a teaching plan for a client who Answer: 1, 4, 6. A client with an implanted pacemaker
recently underwent surgery for insertion of a permanent should check his heart rate daily and report rates that are
pacemaker. Which instructions should the nurse include in too fast or too slow. The nurse should instruct him to in-
the teaching plan? Select all that apply. spect the insertion site and report signs and symptoms of
□ 1. Check your heart rate for 1 minute daily. infection, such as redness, swelling, and discharge. MRI
□ 2. Check your respiratory rate for 1 minute daily. studies are contraindicated in a client with a permanent
□ 3. Report bulging at the insertion site. pacemaker because the magnet may move the metal pace-
□ 4. Report redness, swelling, or discharge at the insertion maker within the body, causing injury. It isn’t necessary to
site. obtain a respiratory rate to assess functioning of a pace-
□ 5. Stay away from airport metal detectors. maker. A slight bulge at the site of pacemaker insertion is
□ 6. Avoid magnetic resonance imaging (MRI) studies. normal. It’s safe for a client with a pacemaker to go through
an airport metal detector, but the pacemaker may activate
the metal detector. The client should carry his pacemaker
identification card to show to security personnel.
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4. Which signs and symptoms should the nurse expect to Answer: 1, 3, 4. Chest tightness, chest pressure, and jaw
find in a client with angina? Select all that apply. pain are all symptoms of angina. General muscle aching
□ 1. Chest tightness isn’t associated with angina. Respirations and heart rate
□ 2. General muscle aching typically increase, not decrease, with anginal attacks.
□ 3. Chest pressure Client needs category: Physiological integrity
□ 4. Jaw pain Client needs subcategory: Physiological adaptation
□ 5. Slowed respiratory rate Cognitive level: Application
□ 6. Bradycardia
5. A nurse is performing a Answer: Typically, the pul-

cardiac evaluation on a client monic valve is best heard at
with hypertension. Identify the second intercostal space,
the area where the nurse at the left sternal border.
should place the stethoscope Client needs category:
to best auscultate the pul- Physiological integrity
monic valve. Client needs subcategory:
Cognitive level: Applica-
tion
6. A nurse is checking the peripheral Answer: The posterior tibial pulse is lo-
pulses of a client who underwent cardiac cated behind and just below the medial
catheterization through the right groin. malleolus of the foot.
Identify the area where the nurse should Client needs category: Physiologi-
palpate the right posterior tibial artery. cal integrity
Client needs subcategory: Reduc-
tion of risk potential
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7. A client in the terminal stage of cancer is being trans- Answer: 1, 2, 5. Hospice care focuses on controlling symp-
ferred to hospice care. Which information should the nurse toms and relieving pain at the end of life. Care is provided
include in the teaching plan regarding hospice care? Select by a multidisciplinary team that may consist of nurses,
all that apply. physicians, chaplains, aides, and volunteers. After the
□ 1. Care focuses on controlling symptoms and relieving client’s death, hospice provides bereavement care to the
pain. grieving family. Hospice care is provided based on need,
□ 2. A multidisciplinary team provides care. not on ability to pay. It’s provided in various settings, includ-
□ 3. Services are provided based on the client’s ability to ing hospice centers, homes, hospitals, and long-term care
pay. facilities. Care is provided under the direction of a physi-
□ 4. Hospice care is provided only in hospice centers. cian, who’s a key member of the hospice care team.
□ 5. Bereavement care is provided to the family. Client needs category: Physiological integrity
□ 6. Care is provided in the home independent of physi- Client needs subcategory: Basic care and comfort
cians. Cognitive level: Application
8. A client with laryngeal cancer has undergone laryngec- Answer: 1, 2, 5. Radiation of the head and neck commonly
tomy and is receiving radiation therapy to the head and causes stomatitis (irritation of the oral mucous mem-
neck. The nurse should monitor the client for which ad- branes), xerostomia (dry mouth), and dysgeusia (a dimin-
verse effects of external radiation? Select all that apply. ished sense of taste). Thrombocytopenia (reduced platelet
□ 1. Xerostomia count) and leukopenia (reduced white blood cell count)
□ 2. Stomatitis may occur after systemic radiation. Cystitis may occur after
□ 3. Thrombocytopenia radiation of the genitourinary system.
□ 4. Cystitis Client needs category: Physiological integrity
□ 5. Dysgeusia Client needs subcategory: Reduction of risk potential
□ 6. Leukopenia Cognitive level: Application
9. A client with bladder cancer has undergone surgical Answer: 2, 3, 6. A dusky appearance of the stoma indicates
removal of the bladder and construction of an ileal conduit. decreased blood supply; a healthy stoma should appear
Which data collection findings indicate that the client is beefy-red. Protrusion indicates prolapse of the stoma.
developing complications? Select all that apply. Sharp abdominal pain and rigidity suggests peritonitis. Uri-
□ 1. Urine output is greater than 30 ml/hr. nary output greater than 30 ml/hr is a sign of adequate re-
□ 2. The stoma appears dusky. nal perfusion — a normal finding. Stomal edema is a normal
□ 3. The stoma protrudes from the skin. finding during the first 24 hours after surgery. Because mu-
□ 4. Mucus shreds are in the urine collection bag. cous membranes are used to create the conduit, mucus in
□ 5. Edema of the stoma is present during the first the urine is expected.
24 hours postoperatively. Client needs category: Physiological integrity
□ 6. The client experiences sharp abdominal pain and Client needs subcategory: Reduction of risk potential
rigidity. Cognitive level: Analysis
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10. A client receiving chemotherapy for breast cancer de- Answer: 1, 2, 3, 5. Chemotherapy can cause myelosuppres-
velops myelosuppression. Which instructions should the sion (reduced numbers of red blood cells, white blood cells,
nurse include in the discharge teaching plan? Select all that and platelets). Clients receiving chemotherapy should
apply. avoid people who have recently been vaccinated because
□ 1. Avoid people who have recently received attenuated such interaction may exaggerate myelosuppression. Fre-
vaccines. quent hand-washing is the best way to prevent the spread
□ 2. Avoid activities that may cause bleeding. of infection. In addition, because of their reduced platelet
□ 3. Wash your hands frequently. counts, chemotherapy clients should avoid activities that
□ 4. Increase your intake of fresh fruits and vegetables. can cause trauma and bleeding. Because of their reduced
□ 5. Avoid crowded places, such as shopping malls. ability to fight infection, they should also avoid crowded
□ 6. Treat a sore throat with over-the-counter products. places and people with colds during the flu season. Fresh
fruits and vegetables should be avoided because these
foods can harbor bacteria that aren’t easily removed by
washing. Signs and symptoms of infection, such as a sore
throat, fever, or cough, should be immediately reported to a
physician.
11. As part of a routine screening for colorectal cancer, a Answer: 2, 3, 4. The nurse should instruct the client to
client must undergo fecal occult blood testing. Which foods maintain a high-fiber diet and to refrain from eating red
should the nurse instruct the client to avoid 48 to 72 hours meat, poultry, fish, turnips, and horseradish for 48 to 72
before the test and throughout the collection period? Select hours before the test and throughout the collection period.
all that apply. Client needs category: Health promotion and
□ 1. High-fiber foods maintenance
□ 2. Red meat Client needs subcategory: None
□ 3. Turnips Cognitive level: Application
□ 4. Horseradish
□ 5. Tomatoes
□ 6. Apples
12. A 58-year-old client with osteoarthritis is admitted to Answer: 2, 3, 5. Peptic ulcer disease is characterized by nau-
the hospital with peptic ulcer disease. Which findings are sea, hematemesis, melena, weight loss, and left-sided epi-
commonly associated with peptic ulcer disease? Select all gastric pain — occurring 1 to 2 hours after eating — that’s
that apply. relieved with antacids. Nonsteroidal anti-inflammatory drug
□ 1. Localized, colicky periumbilical pain use is also associated with peptic ulcer disease. Appendici-
□ 2. History of using nonsteroidal anti-inflammatory drugs tis begins with generalized or localized colicky periumbili-
□ 3. Epigastric pain that’s relieved by antacids cal or epigastric pain, followed by nausea, a few episodes of
□ 4. Tachycardia vomiting, low-grade fever, and tachycardia.
□ 5. Nausea and weight loss Client needs category: Physiological integrity
□ 6. Low-grade fever Client needs subcategory: Physiological adaptation
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13. A client undergoes a barium swallow fluoroscopy that Answer: 2, 4, 5. The nurse should instruct the client with
confirms gastroesophageal reflux disease (GERD). Based GERD to follow a low-fat, high-fiber diet. Caffeine, carbon-
on this diagnosis, the client should be instructed to take ated beverages, alcohol, and smoking should be avoided
which actions? Select all that apply. because they promote symptoms of GERD. In addition, the
□ 1. Follow a high-fat, low-fiber diet. client should take antacids as prescribed (typically 1 hour
□ 2. Avoid caffeine and carbonated beverages. before and 3 hours after meals and at bedtime). Lying
□ 3. Sleep with the bed flat. down with the head of bed elevated, not flat, reduces intra-
□ 4. Stop smoking. abdominal pressure, thereby reducing the symptoms of
□ 5. Take antacids 1 hour before and 3 hours after meals. GERD.
□ 6. Limit alcohol consumption to one drink per day. Client needs category: Health promotion and
maintenance
14. A client with constipation is prescribed an irrigating en- Answer: 1, 2, 6. To administer an enema, the nurse should
ema. Which steps should the nurse take when administer- prepare the prescribed type and amount of solution. The
ing an enema? Select all that apply. standard volume of an irrigating enema for an adult is 750
□ 1. Assist the client into the left-lateral Sims’ position. to 1,000 ml. For an adult, the solution should be 100° F
□ 2. Lubricate the distal end of the rectal catheter. (37.8° C) to 105° F (40.6° C) to help reduce client discom-
□ 3. Warm the solution to 110° F (43.3° C). fort. The nurse should help the client into left-lateral Sims’
□ 4. Insert the tube 1⬙ to 11⁄ 2⬙ (2.5 to 3.8 cm) position. After lubricating the distal end of the rectal cathe-
□ 5. Administer 250 to 500 ml of irrigating solution. ter, the nurse should insert the tube 2⬙ to 3⬙ (5 to 7.6 cm).
□ 6. Be sure to keep the solution container lower than 18⬙ During infusion, the solution bag shouldn’t be higher than
(46 cm) above bed level. 18⬙ above bed level.
15. A 53-year-old client had a colonoscopy for colorectal Answer: 3, 4, 5. After a colonoscopy, the nurse should closely
cancer screening. A polyp was removed during the proce- observe the client for signs and symptoms of bowel perfo-
dure. Which nursing interventions are necessary when car- ration (malaise, rectal bleeding, abdominal pain and disten-
ing for the client immediately after colonoscopy? Select all tion, fever, and mucopurulent drainage). The nurse should
that apply. monitor vital signs frequently, until they become stable.
□ 1. When the client recovers from sedation, tell him he Because a polyp was removed during the procedure, the
must follow a clear liquid diet. nurse should inform the client that he may see some blood
□ 2. Instruct the client that he shouldn’t drive for 24 hours. in his stool and that he should immediately report exces-
□ 3. Observe the client closely for signs and symptoms of sive bleeding. The nurse should tell the client that he might
bowel perforation. pass large amounts of flatus resulting from air insufflated to
□ 4. Monitor vital signs frequently until they’re stable. distend the colon but it isn’t necessary to report it. When
□ 5. Inform the client that there may be blood in his stool the client has recovered from sedation, he may resume his
and that he should report excessive blood immediately. usual diet; a clear liquid diet isn’t necessary. The client
□ 6. Tell the client to report excessive flatus. shouldn’t drive for 12 hours after being sedated.
maintenance
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16. A client with cirrhosis is Answer: Abdominal girth

ordered to have a daily mea- should be measured at the
surement of his abdominal umbilicus to obtain the most
girth. Identify the anatomical accurate measurement. Us-
landmark where the tape ing any landmark wouldn’t
measure should be placed provide the correct measure-
when obtaining this mea- ment for the client’s abdomi-
surement. nal girth.
maintenance
None
17. Locate the abdominal Answer: The liver is located

quadrant where the nurse in the right upper abdominal
would expect to palpate the quadrant.
liver. Client needs category:
maintenance
Client needs subcate-
gory: None
Cognitive level:
Knowledge
18. Which nursing interventions are effective in prevent- Answer: 1, 4, 6. Nursing interventions that are effective in
ing pressure ulcers? Select all that apply. preventing pressure ulcers include cleaning the skin with
□ 1. Clean the skin with warm water and a mild cleaning warm water and a mild cleaning agent, and then applying a
agent; then apply a moisturizer. moisturizer; lifting — rather than sliding — the client when
□ 2. Slide the client when turning him and avoid lifting. turning him to reduce friction and shear; avoiding raising
□ 3. Avoid raising the head of the bed more than 90 de- the head of the bed more than 30 degrees, except for brief
grees. periods; repositioning and turning the client every 1 to 2
□ 4. Turn and reposition the client every 1 to 2 hours un- hours unless contraindicated; and using pillows to position
less contraindicated. the client and increase his comfort. If the client uses a
□ 5. If the client uses a wheelchair, seat him on a rubber or wheelchair, the nurse should offer a pressure-relieving
plastic doughnut. cushion as appropriate. She shouldn’t seat him on a rubber
□ 6. Use pillows to position the client and increase his or plastic doughnut because these devices can increase
comfort. localized pressure at vulnerable points.
Client needs category: Safe, effective care environment
Client needs subcategory: Safety and infection control
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19. Despite conventional treatment, a client’s psoriasis has Answer: 5. The correct formula to calculate a drug dose is:
worsened. His physician prescribes methotrexate 25 mg by Dose on hand Quantity on hand Dose desired X
mouth as a single weekly dose. The pharmacy dispenses
5 mg scored tablets. How many tablets should the nurse The physician prescribed a desired dose of 25 mg dose.
instruct the client to consume to achieve the prescribed The pharmacy dispenses 5 mg tablets, which is the dose on
dose? Record your answer using a whole number. hand. To solve the equation:
5 mg 1 tablet 25 mg X tablets
________________________ tablets X 5 tablets
20. Which instructions should be included in the teaching Answer: 2, 4. The nurse should instruct the client receiving
plan for a 19-year-old client with acne vulgaris. His physi- tretinoin that his skin should look pink and dry after treat-
cian has prescribed tretinoin, benzoyl peroxide, and tetra- ment. If the skin appears red or starts to peel, the prepara-
cycline. Select all that apply. tion may have to be weakened or applied less often. The
□ 1. Expect your skin to look red and start to peel after client should be instructed to take tetracycline on an empty
treatment. stomach. Because the prescribed regimen includes
□ 2. Take tetracycline on an empty stomach. tretinoin and benzoyl peroxide, the nurse should instruct
□ 3. Use tretinoin and benzoyl peroxide together in the the client to use one preparation in the morning and the
morning and at night. other at night. Tretinoin should be applied 30 minutes after
□ 4. Maintain the prescribed treatment because it’s more washing the face and at least 1 hour before bedtime. The
likely to improve acne than a strict diet and excessive nurse should also make sure that the client understands
scrubbing with soap and water. that the prescribed treatment is more likely to improve
□ 5. Apply tretinoin at least 30 minutes after washing your acne than a strict diet and excessive scrubbing with soap
face and at bedtime. and water. The nurse should advise the client to avoid expo-
□ 6. Avoid exposure to sunlight and don’t use a sunscreen. sure to sunlight or to use a sunscreen.
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21. A 35-year-old client is brought to the emergency de- Answer: 3, 5, 6. Immediate interventions for this client
partment with second- and third-degree burns over 15% of should aim to stop the burning and relieve the pain. The
his body. His admission vital signs are blood pressure nurse should begin I.V. therapy with a crystalloid such as
100/50 mm Hg, heart rate 130 beats/minute, and respi- lactated Ringer’s solution to prevent hypovolemic shock
ratory rate 26 breaths/minute. Which nursing interven- and to maintain cardiac output. She should administer pain
tions are appropriate for this client? Select all that apply. medication, as ordered. Typically, 2 to 25 mg of morphine
□ 1. Clean the burns with hydrogen peroxide. or 5 to 15 mg of meperidine are administered I.V. in small
□ 2. Cover the burns with saline-soaked towels. increments. Tetanus prophylaxis should be administered,
□ 3. Begin an I.V. infusion of lactated Ringer’s solution. as ordered. The nurse shouldn’t use hydrogen peroxide or
□ 4. Place ice directly on the burns. povidone-iodine solution to clean the burns because these
□ 5. Administer 6 mg of morphine I.V. preparations can further damage tissue. The nurse should
□ 6. Administer tetanus prophylaxis, as ordered. avoid the use of saline-soaked towels because they may
lead to hypothermia. Ice shouldn’t be placed directly on
burn wounds because the cold may cause further thermal
damage.
22. The nurse is planning care for a client with human im- Answer: 4, 5. Standard precautions include wearing gloves
munodeficiency virus (HIV). Which statement by the nurse for any known or anticipated contact with tissue, mucous
indicates her understanding of HIV transmission? Select all membranes, nonintact skin, and blood and other body
that apply. fluids. If the task or procedure may result in the splashing
□ 1. “I will wear a gown, mask, and gloves during all client or splattering of blood or other body fluids on the face, the
contact.” nurse should also wear a mask and a face shield or goggles.
□ 2. “I don’t need to wear any personal protective equip- If the task or procedure may result in the splashing or splat-
ment because of decreased risk of occupational expo- tering of blood or other body fluids, the nurse should wear
sure.” a fluid-resistant gown or apron. The nurse should wash her
□ 3. “I will wear a mask if the client has a cough caused by hands before and after client care and after removing
an upper respiratory infection.” gloves. A gown, mask, and gloves aren’t necessary for
□ 4. “I will wear a mask, gown, and gloves when the client care unless contact with bodily fluids, tissue, mucous
splashing of bodily fluids is likely.” membranes, or nonintact skin is expected. Nurses have an
□ 5. “I will wash my hands after client care.” increased, not decreased, risk of occupational exposure to
blood-borne pathogens. HIV isn’t transmitted in sputum
unless blood is present.
Client needs subcategory: Safety and infection control
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23. A nurse is preparing a client with systemic lupus ery- Answer: 1, 3, 4. The client with SLE should stay out of direct
thematosus (SLE) for discharge. Which instructions should sunlight and avoid other sources of ultraviolet light because
the nurse include in the teaching plan? Select all that apply. they may precipitate severe skin reactions and exacerbate
□ 1. Stay out of direct sunlight. the disease. The client should monitor his temperature, be-
□ 2. Avoid limiting activity between flare-ups. cause fever can signal an exacerbation, which he should re-
□ 3. Monitor body temperature. port to his physician. Corticosteroids must be tapered grad-
□ 4. Taper the corticosteroid dosage as order by the physi- ually after symptoms are relieved because they can sup-
cian when symptoms are under control. press the function of the adrenal glands. Abruptly stopping
□ 5. Apply cold packs to relieve joint pain and stiffness. corticosteroids can cause adrenal insufficiency, a potentially
life-threatening condition. Fatigue can cause a flare-up of
SLE, so encourage the client to pace activities and plan rest
periods. The client may apply either heat or cold—not just
cold—to relieve joint pain.
24. A nurse is preparing a client for bone Answer: A bone marrow biopsy may be
marrow biopsy to rule out leukemia. The taken from the anterior or posterior iliac
nurse explains that the sample will be crests, sternum, vertebral spinous
taken from the anterior iliac crest. Identify process, rib, or tibia.
this area. Client needs category: Physiologi-
cal integrity
logical adaptation
25. A client with leukemia Answer: The spleen is locat-

has enlarged lymph nodes, ed in the left upper quadrant
liver, and spleen. Identify the of the abdomen, posterior to
quadrant of the abdomen the stomach.
where the nurse would pal- Client needs category:
pate the enlarged spleen. Physiological integrity
gory: Physiological
adaptation
Cognitive level: Com-
prehension
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26. After falling off a ladder and suffering a brain injury, a Answer: 1, 4, 5. SIADH is an abnormality in which the body
client develops syndrome of inappropriate antidiuretic hor- produces an abundance of antidiuretic hormone. The pre-
mone (SIADH). Which findings indicate effectiveness of dominant feature, water retention, may be accompanied
the treatment he’s receiving? Select all that apply. by oliguria, edema, and weight gain. Evidence of successful
□ 1. Decrease in body weight treatment includes a reduction in weight, an increase in
□ 2. Rise in blood pressure and drop in heart rate urine output, and a decrease in urine concentration (urine
□ 3. Absence of wheezing in the lungs osmolarity).
□ 4. Increased urine output Client needs category: Physiological integrity
□ 5. Decreased urine osmolarity Client needs subcategory: Physiological adaptation
27. A 48-year-old female client is seen in the clinic for newly Answer: 2, 4, 5. Treatment for hypothyroidism includes a
diagnosed hypothyroidism. Which topics should the nurse high-fiber, low-calorie diet because weight gain and consti-
include in a client teaching plan? Select all that apply. pation are two symptoms of the disorder. Stool softeners
□ 1. Importance of a high-protein, high-calorie diet are prescribed to prevent constipation, and thyroid hor-
□ 2. Importance of a high-fiber, low-calorie diet mone replacements are needed to supplement the under-
□ 3. Plan for a thyroidectomy functioning thyroid gland. A high-protein, high-calorie diet
□ 4. Use of stool softeners is commonly used for clients with hyperthyroidism, along
□ 5. Use of thyroid hormone replacements with thyroidectomy or irradiation of the thyroid gland.
□ 6. Review of the procedure for thyroid radiation therapy Client needs category: Physiological integrity
28. A client who has been seen in the clinic is scheduled Answer: 1, 2, 4. A thyroid scan visualizes the distribution of
for an outpatient thyroid scan in 2 weeks. Which instruc- radioactive dye in the thyroid gland. Interventions before
tions should the nurse include in her client teaching so that the scan include stopping the ingestion of iodine, which is
this client will be prepared? Select all that apply. found in iodized salt, salt substitutes, and seafood. The
□ 1. Stop using iodized salt or iodized salt substitutes client should also be instructed not to take medication that
1 week before the scan. would interfere with the scan. The client doesn’t have to
□ 2. Stop eating seafood 1 week before the scan. refrain from consuming food or fluids after midnight if the
□ 3. Don’t consume food or fluids after midnight on the scan is done on an outpatient basis. The radioactive dye is
night before the scan. administered intravenously. Routinely prescribed medica-
□ 4. Don’t take the prescribed thyroid medication on the tions can be taken after the scan. Bed rest is maintained
day of the scan. with a thyroid biopsy, not a scan.
□ 5. Don’t take the prescribed thyroid medication until the Client needs category: Physiological integrity
results of the scan are known. Client needs subcategory: Reduction of risk potential
□ 6. Maintain bed rest for 24 hours after the scan. Cognitive level: Application
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29. A client is admitted to the hospital with signs and Answer: 1, 4, 6. Classic signs of diabetes mellitus include
symptoms of diabetes mellitus. Which finding is the nurse polydipsia (excessive thirst), polyphagia (excessive
most likely to observe in this client? Select all that apply. hunger), and polyuria (excessive urination). Because the
□ 1. Excessive thirst body is starving from the lack of glucose the cells are using
□ 2. Weight gain for energy, the client has weight loss, not weight gain.
□ 3. Constipation Clients with diabetes mellitus usually don’t present with
□ 4. Excessive hunger constipation.
□ 5. Urine retention Client needs category: Health promotion and
□ 6. Frequent, high-volume urination maintenance
30. A 56-year-old female client is being discharged after Answer: 2, 3. After removal of the thyroid gland, the client
having a thyroidectomy. Which discharge instructions are needs to take thyroid replacement medication. The client
appropriate for this client? Select all that apply. needs to report to the physician changes in body function-
□ 1. Report signs and symptoms of hypoglycemia. ing, such as lethargy, restlessness, cold sensitivity, and dry
□ 2. Take thyroid replacement medications, as ordered. skin. These changes may indicate the need to increase the
□ 3. Watch for changes in body functioning, such as lethar- medication dose. The thyroid gland doesn’t regulate the
gy, restlessness, sensitivity to cold, and dry skin, and serum glucose level; therefore, the client wouldn’t need to
report them to the physician. recognize the signs and symptoms of hypoglycemia. A
□ 4. Avoid over-the-counter (OTC) medications. client with Addison’s disease should avoid OTC medica-
□ 5. Carry injectable dexamethasone at all times. tions and carry injectable dexamethasone.
31. A client is seen in the clinic with suspected parathyroid Answer: 3, 6. A client with PTH deficiency is likely to have
hormone (PTH) deficiency. Part of the diagnosis of this con- abnormal serum calcium and phosphorous levels because
dition includes the analysis of serum electrolyte levels. The PTH regulates these two electrolytes. PTH deficiency
nurse would expect which electrolyte levels to be abnormal doesn’t affect sodium, potassium, chloride, or glucose
in a client with PTH deficiency? Select all that apply. levels.
□ 1. Sodium Client needs category: Health promotion and
□ 2. Potassium maintenance
□ 3. Calcium Client needs subcategory: None
□ 4. Chloride Cognitive level: Analysis
□ 5. Glucose
□ 6. Phosphorous
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32. A client is placed on hypocalcemia precautions after re- Answer: 1, 3, 4. When the parathyroid gland is removed, the
moval of a cancerous parathyroid gland. The nurse should body may not produce enough parathyroid hormone to reg-
observe the client for which symptoms? Select all that ulate calcium and phosphorous levels. The symptoms of
apply. hypocalcemia include peripheral numbness, tingling, and
□ 1. Numbness muscle spasms. Aphasia isn’t a symptom of calcium deple-
□ 2. Aphasia tion. Polyuria and polydipsia are symptoms of diabetes
□ 3. Tingling mellitus.
□ 4. Muscle twitching and spasms Client needs category: Physiological integrity
□ 5. Polyuria Client needs subcategory: Reduction of risk potential
□ 6. Polydipsia Cognitive level: Analysis
33. A 45-year-old female client is admitted to the hospital Answer: 1, 3, 5. Because weight gain and edema are com-
with Cushing’s syndrome. Which nursing interventions are mon symptoms of Cushing’s syndrome, appropriate inter-
appropriate for this client? Select all that apply. ventions include checking for peripheral edema, measuring
□ 1. Check for peripheral edema. intake and output, and weighing the client daily. A low-
□ 2. Stress the need for a high-calorie, high-carbohydrate calorie, low-carbohydrate, high-protein diet is ordered for a
diet. client with this disorder. Fluid restriction is commonly pre-
□ 3. Measure intake and output. scribed as well. Treatment of Cushing’s syndrome includes
□ 4. Encourage oral fluid intake. the administration of potassium replacements; therefore,
□ 5. Weigh the client daily. restricting foods high in potassium wouldn’t be appropriate.
□ 6. Instruct the client to avoid foods high in potassium. Client needs category: Physiological integrity
34. A client with type 2 diabetes mellitus needs instruction Answer: 2, 3, 5. Foot care for a client with diabetes mellitus
on proper foot care. Which instructions should the nurse includes keeping the feet dry and applying foot powder and
include in client teaching? Select all that apply. wearing cotton socks to absorb moisture. The podiatrist
□ 1. Be sure to use scissors to trim toenails. should check the client’s feet regularly to detect problems
□ 2. Wear cotton socks. early. Explain to the client that he can prevent injury to his
□ 3. Apply foot powder after bathing. feet by not cutting his toenails with scissors, walking bare-
□ 4. Go barefoot only when you know your home environ- foot, or wearing loose-fitting shoes.
ment. Client needs category: Physiological integrity
□ 5. See a podiatrist regularly to have your feet checked. Client needs subcategory: Reduction of risk potential
□ 6. Wear loose-fitting shoes. Cognitive level: Application
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35. A client is preparing for discharge from the hospital Answer: 4, 5, 6. The nurse should advise the client to avoid
after undergoing an above-the-knee amputation. Which exposing the skin around his stump to excessive perspira-
instructions should the nurse include in the teaching plan tion, which can be irritating. She should tell him to perform
for this client? Select all that apply. prescribed exercises to help minimize complications. In
□ 1. Massage the stump away from the suture line. addition, the nurse should tell the client that if the stump is
□ 2. Don’t apply heat to ease pain. sensitive to touch, he should rub it with a dry washcloth
□ 3. Report twitching, spasms, or phantom limb pain for 4 minutes three times per day. The nurse should tell the
immediately. client to massage the stump toward — not away from — the
□ 4. Avoid exposing the skin around the stump to exces- suture line to mobilize the scar and to prevent its adher-
sive perspiration. ence to bone. The client may experience twitching, spasms,
□ 5. Be sure to perform the prescribed exercises. or phantom limb pain while his muscles adjust to the ampu-
□ 6. Rub the stump with a dry washcloth for 4 minutes tation. This is a normal reaction and need not be reported.
three times per day if the stump is sensitive to touch. The nurse should advise the client that he can ease these
symptoms with heat, massage, or gentle pressure.
36. A client is diagnosed with gout. Which foods should Answer: 2, 3, 5. The client with gout should avoid foods that
the nurse instruct the client to avoid? Select all that apply. are high in purines, such as liver, cod, and sardines. Other
□ 1. Green leafy vegetables foods that should be avoided include anchovies, kidneys,
□ 2. Liver sweetbreads, lentils, and alcoholic beverages, especially
□ 3. Cod beer and wine. Green leafy vegetables, chocolate, eggs, and
□ 4. Chocolate whole milk aren’t high in purines and, therefore, aren’t
□ 5. Sardines restricted in the diet of a client with gout.
□ 6. Eggs Client needs category: Physiological integrity
□ 7. Whole milk Client needs subcategory: Basic care and comfort
37. A client is about to undergo total hip replacement Answer: 1, 2, 5. After hip replacement surgery, the client
surgery. Before the surgery, the nurse conducts a preoper- should avoid internally rotating his feet and bending more
ative teaching session with him. The nurse can tell that her than 90 degrees. These activities can compromise the hip
teaching has been effective when the client verbalizes the joint. The client should lie with his legs abducted. Leg
importance of which actions? Select all that apply. strengthening exercises, such as periodically tightening the
□ 1. Keeping his legs apart while lying in bed leg muscles, are recommended to maintain muscle strength
□ 2. Periodically tightening his leg muscles and reduce the risk of thrombus formation. A back- or side-
□ 3. Internally rotating his feet lying position is acceptable; however, some physicians
□ 4. Bending to pick items up from the floor tell their clients not to lie on the side where the hip was
□ 5. Sleeping in a back- or side-lying position replaced.
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38. A client who was involved in a motor vehicle accident Answer: 4, 5. The nurse should begin by evaluating the
has a fractured femur. The nurse caring for the client identi- client’s perception of pain, including characteristics, and
fies Acute pain as one of the nursing diagnoses in his care methods he previously found effective in managing pain.
plan. Which nursing interventions are appropriate? Select These interventions provide a baseline from which the
all that apply. nurse can plan interventions and evaluate their success.
□ 1. Tell the client which pain management option to use. The nurse should allow the client to decide which pain con-
□ 2. Encourage the client to use as little pain medication as trol management techniques to use to help increase his
possible to avoid addiction. feeling of being in control of his situation. Analgesics
□ 3. Avoid alternative and supplementary pain control should be administered as needed to relieve pain. Addiction
techniques. shouldn’t be a concern at this time. After receiving anal-
□ 4. Evaluate the client’s perception of pain. gesics, the client should indicate that he feels more com-
□ 5. Ask the client about methods he previously used to fortable, by reporting pain as a score of 3 or less on a scale
alleviate pain. of 0 to 10 (0 being without pain). The nurse should teach
the client alternative and supplementary pain control tech-
niques, such as imagery, distraction, and heat and cold ap-
plication. These techniques provide the client with options
for dealing with pain.
39. A client with a history of epilepsy is admitted to the Answer: 1, 2, 3. During a seizure, the nurse should assist
medical-surgical unit. While assisting the client from the the client to the floor to reduce the risk of falling and turn
bathroom, the nurse observes the start of a tonic-clonic the client on his side to help clear the mouth of oral secre-
seizure. Which nursing interventions are appropriate for tions. If available, it’s appropriate to place a pillow under
this client? Select all that apply. client’s head to protect him from injury. It’s inappropriate
□ 1. Assist the client to the floor. to introduce anything into the mouth during a seizure be-
□ 2. Turn the client to his side. cause of the risk of choking or compromising the airway;
□ 3. Place a pillow under the client’s head. therefore, oral medications and suction devices shouldn’t
□ 4. Give the prescribed dose of oral phenytoin (Dilantin). be used.
□ 5. Insert an oral suction device to remove secretions in Client needs category: Physiological integrity
the mouth. Client needs subcategory: Reduction of risk potential
40. The nurse is assigned to care for a client with early Answer: 3, 4, 5. A client with Alzheimer’s disease experi-
stage Alzheimer’s disease. Which nursing interventions ences progressive deterioration in cognitive functioning.
should be included in the client’s care plan? Select all that Familiar possessions may help to orient the client. The
apply. client should be encouraged to perform ADLs as much as
□ 1. Make frequent changes in the client’s routine. possible but may need assistance with certain activities. Us-
□ 2. Engage the client in complex discussions to improve ing a step-by-step approach helps the client complete tasks
memory. independently. A client with Alzheimer’s disease functions
□ 3. Furnish the client’s surroundings with familiar pos- best with consistent routines. Complex discussions don’t
sessions. improve the memory of a client with Alzheimer’s disease.
□ 4. Assist the client with activities of daily living (ADLs) Client needs category: Psychosocial integrity
as necessary. Client needs subcategory: None
□ 5. Assign tasks in simple steps. Cognitive level: Application
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41. A client is brought to the intensive care unit after un- Answer: 2, 5. The client should be turned on his right side
dergoing intracranial surgery to remove a tumor from the because lying on the left side would cause the brain to shift
left cerebral hemisphere. Which nursing interventions are into the space previously occupied by the tumor. A soft col-
appropriate for the client’s postoperative care? Select all lar keeps the neck in a neutral position, allowing for ade-
that apply. quate perfusion and venous drainage of the brain. Placing a
□ 1. Place a pillow under the client’s head so that his neck pillow under the head flexes the neck and impairs circula-
is flexed. tion to the brain. Flexion of the hip increases intracranial
□ 2. Turn the client on his right side. pressure and, therefore, is contraindicated. Exclusive use
□ 3. Place pillows under the client’s legs to promote hip of the supine position isn’t indicated.
flexion and venous return. Client needs category: Physiological integrity
□ 4. Maintain the client in the supine position. Client needs subcategory: Reduction of risk potential
□ 5. Apply a soft collar to keep the client’s neck in a neu- Cognitive level: Application
tral position.
42. The nurse is planning care for a client with multiple Answer: 1, 3, 5. Multiple sclerosis, a neuromuscular disor-
sclerosis. Which problems should the nurse expect the der, may cause vision disturbances, balance problems, and
client to experience? Select all that apply. mood disorders. Multiple sclerosis doesn’t cause coagula-
□ 1. Vision disturbances tion abnormalities or immunity problems.
□ 2. Coagulation abnormalities Client needs category: Physiological integrity
□ 3. Balance problems Client needs subcategory: Reduction of risk potential
□ 4. Immunity compromise Cognitive level: Application
□ 5. Mood disorders
43. The nurse is teaching a client with trigeminal neuralgia Answer: 2, 4, 5. The facial pain of trigeminal neuralgia is
how to minimize pain episodes. Which comments by the triggered by mechanical or thermal stimuli. Chewing food
client indicate that he understands the instructions? Select on the unaffected side and rinsing the mouth rather than
all that apply. brushing teeth reduce mechanical stimulation. Drinking
□ 1. “I’ll eat food that’s very hot.” fluids at room temperature reduces thermal stimulation.
□ 2. “I’ll try to chew my food on the unaffected side.” Eating hot food and washing the face with cold water are
□ 3. “I can wash my face with cold water.” likely to trigger pain.
□ 4. “Drinking fluids at room temperature should reduce Client needs category: Health promotion and
pain.” maintenance
□ 5. “If tooth brushing is too painful, I’ll try to rinse my Client needs subcategory: None
mouth instead.” Cognitive level: Comprehension
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44. A client is experiencing Answer: The cerebellum is

problems with balance and the portion of the brain that
fine and gross motor func- controls balance and fine
tion. Identify that area of the and gross motor function.
client’s brain that’s malfunc- Client needs category:
tioning. Physiological integrity
Reduction of risk
potential
Cognitive level: Compre-
hension
45. The nurse is caring for a client with pneumonia. The Answer: 24. The correct formula to calculate a drug dosage
physician orders 600 mg of ceftriaxone (Rocephin) oral sus- is:
pension to be given once per day. The medication label indi- Dose on hand Quantity on hand Dose desired X
cates that the strength is 125 mg/5 ml. How many milli-
liters of medication should the nurse pour to administer the Therefore:
correct dose? Record your answer using a whole number. 125 mg 5 ml 600 mg X
X 24 ml
________________________ milliliters Client needs category: Physiological integrity
46. The nurse is caring for a client who’s scheduled for a Answer: 1, 4, 5, 6. All procedures must be explained to the
bronchoscopy. Which interventions should the nurse per- client to obtain informed consent and to reduce anxiety. A
form to prepare the client for this procedure? Select all that signed informed consent form is required for all invasive
apply. procedures. Dentures need to be removed for bronchos-
□ 1. Explain the procedure. copy because they may become dislodged during the pro-
□ 2. Withhold food and fluids for 2 hours before the test. cedure. Atropine is administered before bronchoscopy to
□ 3. Provide a clear liquid diet for 6 to 12 hours before the decrease secretions. A sedative may be given to relax the
test. client. Food and fluids are restricted for 6 to 12 hours
□ 4. Confirm that a signed informed consent form has before the test to avoid the risk of aspiration during the
been obtained. procedure.
□ 5. Ask the client to remove his dentures. Client needs category: Physiological integrity
□ 6. Administer atropine and a sedative. Client needs subcategory: Reduction of risk potential
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47. A client has just undergone a bronchoscopy. Which Answer: 3, 4, 6. To prevent aspiration, the client shouldn’t
nursing interventions are appropriate after this procedure? receive food or fluids until his gag reflex returns. Although
Select all that apply. a small amount of blood in the sputum is expected if a biopsy
□ 1. Keep the client flat for at least 2 hours. was performed, frank bleeding indicates hemorrhage and
□ 2. Provide sips of water to moisten the client’s mouth. should be reported to the physician immediately. Vital
□ 3. Withhold food and fluids until the gag reflex returns. signs should be monitored after the procedure because a
□ 4. Monitor for hemoptysis and frank bleeding. vasovagal response may cause bradycardia, laryngospasm
□ 5. Resume food and fluids when the client’s voice can affect respirations, and fever may develop within the
returns. 24 hours of the procedure. To reduce the risk of aspiration,
□ 6. Monitor the client’s vital signs. the client should be placed in a semi-Fowler’s or side-lying
position after the procedure until his gag reflex returns.
The client doesn’t lose his voice after a bronchoscopy, so
voice shouldn’t be used as a gauge for resuming food and
fluid intake.
48. The nurse is caring for a client with pneumonia. The Answer: 2, 5, 6. The client with pneumonia may have a
nurse should expect to observe which signs and symptoms fever, use accessory muscles for breathing, and exhibit
when caring for the client? Select all that apply. crackles or rhonchi on auscultation. Other signs and symp-
□ 1. Dry cough toms of pneumonia include fever, malaise, pleuritic pain,
□ 2. Fever pleural friction rub, dyspnea, tachypnea, tachycardia, and a
□ 3. Bradycardia cough that produces rusty green or bloody sputum (in
□ 4. Pericardial friction rub pneumococcal pneumonia) or yellow-green sputum (in
□ 5. Use of accessory muscles during respiration bronchopneumonia). A dry cough, bradycardia, and a peri-
□ 6. Crackles or rhonchi cardial friction rub aren’t manifestations of pneumonia.
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49. The nurse is caring for a client with tuberculosis. Answer: 1, 2, 6. The nurse should always wear gloves when
Which precautions should the nurse take when providing handling items contaminated with sputum or body secre-
care for this client? Select all that apply. tions. All staff and visitors must wear face masks when
□ 1. Wear gloves when handling tissues containing coming in contact with the client in his room; masks must
sputum. be discarded before leaving the client’s room. Hand wash-
□ 2. Wear a face mask at all times. ing is required after direct contact with the client or conta-
□ 3. Keep the client in strict isolation. minated articles. Strict isolation isn’t required if the client
□ 4. When the client leaves the room for tests, have all adheres to special respiratory precautions. The client, not
people in contact with him wear a mask. the people in contact with him, must wear a mask when he
□ 5. Keep the client’s door open to allow fresh air into leaves the room for tests. The client should be in a nega-
room and prevent social isolation. tive-pressure, private room, and the door should remain
□ 6. Wash hands after direct contact with the client or closed at all times to prevent the spread of infection.
contaminated articles. Client needs category: Safe, effective care
environment
control
50. The nurse is caring for a Answer: The drainage cham-

client who has a chest tube ber is on the right. It has
connected to a three-chamber three calibrated columns
drainage system without suc- that show the amount of
tion. Identify the chamber drainage collected. When
that collects drainage from the first column fills,
the client. drainage empties into the
second; when the second
column fills, drainage flows
into the third. The water-seal
chamber is located in the
center. The suction-control
chamber is on the left.
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51. The nurse is about to Answer: When performing

perform nasopharyngeal nasopharyngeal suctioning,
suctioning on a client who the tip of the catheter is in-
recently had a stroke. troduced into the naris and
Identify the area where the advanced to the pharynx.
tip of the suction catheter The tip remains above the
should be placed. posterior wall of the mouth.
Cognitive level: Appli-
cation
52. A client is admitted with chronic obstructive pul- Answer: 2, 3, 5. Typical findings for clients with COPD in-
monary disease (COPD). Which signs and symptoms are clude dyspnea on exertion, a barrel chest, and clubbed fin-
characteristic of COPD? Select all that apply. gers and toes. Clients with COPD are usually tachypneic
□ 1. Decreased respiratory rate with a prolonged expiratory phase. Fever isn’t associated
□ 2. Dyspnea on exertion with COPD, unless an infection is also present.
□ 3. Barrel chest Client needs category: Physiological integrity
□ 4. Shortened expiratory phase Client needs subcategory: Physiological adaptation
□ 5. Clubbed fingers and toes Cognitive level: Comprehension
□ 6. Fever
53. The nurse is caring for a client who has a urinary tract Answer: 2, 3, 5. Typical findings for a client with a UTI in-
infection (UTI). Which statements should the nurse expect clude urinary frequency, burning on urination, and urinary
the client to make? Select all that apply. urgency. The client with a UTI typically reports that he
□ 1. “I urinate large amounts.” voids frequently in small amounts, not large amounts. The
□ 2. “I need to urinate frequently.” client with a UTI complains of foul-smelling, not sweet-
□ 3. “It burns when I urinate.” smelling, urine.
□ 4. “My urine smells sweet.” Client needs category: Physiological integrity
□ 5. “I need to urinate urgently.” Client needs subcategory: Physiological adaptation
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54. The nurse is teaching a client how to collect a 24-hour Answer: 2, 4, 5. When collecting a 24-hour urine sample, the
urine specimen for creatinine clearance. Which directions client should void, discard the urine, and record the time.
should the nurse give the client? Select all that apply. This assures that the client starts the collection period with
□ 1. “Save the first voiding and record the time.” an empty bladder. At the end of the 24-hour collection peri-
□ 2. “Discard the first voiding and record the time.” od, the client should void and save the urine. The first void-
□ 3. “Clean the perineal area before each voiding.” ing isn’t used because it isn’t known how long the urine has
□ 4. “Refrigerate the urine sample or keep it on ice.” been in the bladder. The urine sample should be refrigerat-
□ 5. “At the end of 24 hours, void and save the urine.” ed or kept on ice to keep it fresh. The perineum should be
□ 6. “At the end of 24 hours, void and discard the urine.” cleaned before obtaining a clean-catch urine specimen for
culture and sensitivity. It isn’t necessary to clean the
perineum for a 24-hour urine sample.
55. The nurse is collecting a Answer: A sterile urine speci-

sterile urine sample for cul- men is obtained from an in-
ture and sensitivity from an dwelling urinary catheter by
indwelling urinary catheter. clamping the catheter
Identify the area on the in- briefly, cleaning the rubber
dwelling urinary catheter port with an alcohol wipe,
where the nurse should in- and using a sterile syringe
sert the sterile syringe to and needle to withdraw the
obtain the urine sample. urine.
56. The nurse is completing an intake and output record Answer: 600. To calculate urine output, subtract the amount
for a client who’s receiving continuous bladder irrigation af- of irrigation solution infused into the bladder from the total
ter transurethral resection of the prostate. How many milli- amount of fluid in the drainage bag.
liters of urine should the nurse record as output for her Client needs category: Physiological integrity
shift if the client received 1,800 ml of normal saline irrigat- Client needs subcategory: Reduction of risk potential
ing solution and the output in the urine drainage bag is Cognitive level: Application
2,400 ml? Record your answer using a whole number.
________________________ milliliters
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57. The nurse is caring for a Answer: In a cystostomy, a

client with a cystostomy for catheter is inserted percuta-
urine drainage. Identify the neously through the supra-
area where the nurse should pubic area into the bladder.
check for cystostomy place- Client needs category:
ment. Physiological integrity
gory: Basic care and
comfort
Cognitive level: Com-
prehension
58. The nurse is caring for a client who’s receiving furo- Answer: 3, 4, 5. Some of the adverse effects associated with
semide (Lasix) for heart failure. The nurse should monitor furosemide therapy include, orthostatic hypotension (not
the client for which adverse effects of the drug? Select all hypertension), hypokalemia (not hyperkalemia), transient
that apply. deafness, leukopenia, and pancreatitis.
□ 1. Hypertension Client needs category: Physiological integrity
□ 2. Hyperkalemia Client needs subcategory: Pharmacological therapies
□ 3. Transient deafness Cognitive level: Application
□ 4. Leukopenia
□ 5. Pancreatitis
59. A client who suffered a stroke has an enteral feeding Answer: 1, 2, 4, 5. The nurse should withhold enteral feed-
tube in place. Which nursing interventions are appropriate ings for 1 hour before and 1 hour after phenytoin adminis-
when administering phenytoin (Dilantin) to this client? tration. She should monitor phenytoin levels closely to pre-
Select all that apply. vent toxicity. The nurse should also instruct the client to
□ 1. Withhold enteral feedings for 1 hour before and avoid switching brands or dosage forms; stress the impor-
1 hour after phenytoin administration. tance of good oral hygiene; and inform the client that
□ 2. Monitor phenytoin levels closely phenytoin may color urine pink, red, or reddish brown.
□ 3. Tell the client that switching brands after discharge Client needs category: Physiological integrity
might help reduce costs Client needs subcategory: Pharmacological therapies
□ 4. Stress the importance of good oral hygiene Cognitive level: Application
□ 5. Inform the client that the drug may color urine pink,
red, or reddish brown
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60. A client with deep vein thrombosis has an I.V. infusion Answer: 240. First, calculate how many units are in each
of heparin sodium infusing at 1,500 U/hour. The concentra- milliliter of the medication:
tion in the bag is 25,000 U/500 ml. How many milliliters of 25,000 U 500 ml 50 U ml
solution should the nurse document as intake from this in-
fusion for an 8-hour shift? Record your answer using a Next, calculate how many milliliters the client receives
whole number. each hour:
1 ml/50 U 1,500 U/hour 30 ml/hour
________________________ millliliters
Lastly, multiply by 8 hours:
30 ml/hour 8 hours 240 ml

61. The nurse suspects that her adult client is in cardiac Answer:
arrest. According to the American Heart Association, the Ordered responses
nurse should perform the actions listed below. Order these
2. Evaluate responsiveness.
actions in the sequence that the nurse should perform
them. 1. Activate the emergency response system.
Unordered responses
1. Activate the emergency response system. 3. Call for a defibrillator.
2. Evaluate responsiveness. 6. Check for breathing.
3. Call for a defibrillator. 4. Provide two slow breaths.
4. Provide two slow breaths. 5. Check for a pulse.
5. Check for a pulse. According to the American Heart Association, the nurse
should first evaluate responsiveness. If the client is unre-
6. Check for breathing. sponsive, the nurse should activate the emergency re-
sponse system, and then call for a defibrillator. Next, the
nurse should check for breathing by opening the airway
and then looking, listening, and feeling for respirations. If
respirations aren’t present, the nurse should administer two
slow breaths, then check for a pulse. If no pulse is
present, the nurse should start chest compressions.
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62. A client is prescribed lisinopril (Zestril) for treatment Answer: 2, 3, 5. Dizziness, headache, and hypotension are
of hypertension. The nurse should teach him about which all common adverse effects of lisinopril and other ACE in-
common adverse effects of angiotensin-converting enzyme hibitors. Lisinopril may cause diarrhea, not constipation.
(ACE) inhibitors? Select all that apply. Lisinopril isn’t known to cause hyperglycemia or
□ 1. Constipation impotence.
□ 2. Dizziness Client needs category: Physiological integrity
□ 3. Headache Client needs subcategory: Pharmacological therapies
□ 4. Hyperglycemia Cognitive level: Application
□ 5. Hypotension
□ 6. Impotence
63. The nurse is counseling a 52-year-old client about risk Answer: 1, 3, 5. Obesity, stress, high intake of sodium or
factors for hypertension. Which risk factors should the saturated fat, and family history are all risk factors for pri-
nurse list for primary hypertension? Select all that apply. mary hypertension. Diabetes mellitus, head injury, and hor-
□ 1. Obesity monal contraceptives are risk factors for secondary hyper-
□ 2. Head injury tension.
□ 3. Stress Client needs category: Health promotion and
□ 4. Hormonal contraceptives maintenance
□ 5. High intake of sodium or saturated fat Client needs subcategory: None
64. A 28-year-old client is admitted with inflammatory Answer: 4, 5. Corticosteroids, such as prednisone, reduce
bowel syndrome (Crohn’s disease). Which therapies the signs and symptoms of diarrhea, pain, and bleeding by
should the nurse expect to be part of the care plan? Select decreasing inflammation. Antidiarrheals, such as diphen-
all that apply. oxylate (Lomotil), combat diarrhea by decreasing peristal-
□ 1. Lactulose therapy sis. Lactulose is used to treat chronic constipation and
□ 2. High-fiber diet would aggravate the symptoms. A high-fiber diet and milk
□ 3. High-protein milkshakes and milk products are contraindicated in clients with
□ 4. Corticosteroid therapy Crohn’s disease because they may promote diarrhea.
□ 5. Antidiarrheal medications Client needs category: Safe, effective care environment
Client needs subcategory: Coordinated care
65. The nurse is awaiting the arrival of a client from the Answer: 3, 4, 5. Signs and symptoms of left-sided heart fail-
emergency department who has a left ventricular myocar- ure include dyspnea, orthopnea, and paroxysmal nocturnal
dial infarction and is being admitted. In caring for this dyspnea. Other signs and symptoms are fatigue, nonpro-
client, the nurse should be alert for which signs and symp- ductive cough and crackles, hemoptysis, point of maximal
toms of left-sided heart failure? Select all that apply. impulse displaced toward the left anterior axillary line,
□ 1. Jugular vein distention tachycardia and S3 and S4 heart sounds, and cool, pale skin.
□ 2. Hepatomegaly Jugular vein distention, hepatomegaly, and right upper
□ 3. Dyspnea quadrant pain are all signs of right-sided heart failure.
□ 4. Crackles Client needs category: Physiological integrity
□ 5. Tachycardia Client needs subcategory: Physiological adaptation
□ 6. Right upper quadrant pain Cognitive level: Application
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Maternal-infant nursing
1. The nurse is assisting with a Answer: When the fetus is in the
prenatal assessment on a client cephalic position (head down), fe-
who’s 32 weeks pregnant. She per- tal heart tones are best auscultated
forms Leopold’s maneuvers and midway between the symphysis
determines that the fetus is in the pubis and the umbilicus. When the
cephalic position. Identify where fetus is in the breech position, fetal
the nurse should place the Doppler heart sounds are best heard at or
to auscultate fetal heart sounds. above the level of the umbilicus.
Client needs category: Health
promotion and maintenance
2. To measure fundal height, the Answer: At 20 weeks, fundal height

nurse is palpating the uterus of a should be at approximately the um-
client who’s 20 weeks pregnant. bilicus. Fundal height should be
Identify the area on the abdomen measured from the symphysis pu-
where the nurse should expect to bis to the top of the uterus. Serial
feel the uterine fundus. measurements assess fetal growth
over the course of the pregnancy.
Between weeks 18 and 34, the cen-
timeters measured correlate ap-
proximately with the week of
gestation.
3. The nurse is teaching a Answer: After ejaculation,

course on the anatomy and the sperm travel by flagellar
physiology of reproduction. movement through the flu-
In the illustration of the fe- ids of the cervical mucus
male reproductive organs, into the fallopian tube to
identify the area where fertil- meet the descending ovum
ization occurs. in the ampulla. This is where
fertilization occurs.
maintenance
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Maternal-infant nursing 777
4. In early pregnancy, some Answer: As the uterus grows in

clients complain of abdominal pain early pregnancy, it deviates physi-
or pulling. Identify the area most cally to the right. This shift, or dex-
commonly associated with this trorotation, is due to the presence
pain. of the rectosigmoid colon in the
left lower quadrant. As a result,
many women complain of pain in
the right lower quadrant.
5. The nurse is assisting in monitoring a client who’s Answer: 1, 4, 5. Adverse effects of oxytocin in the mother in-
receiving oxytocin (Pitocin) to induce labor. The nurse clude hypertension, fluid overload, and uterine tetany. Oxy-
should be alert to which maternal adverse reactions? Select tocin’s antidiuretic effect increases renal reabsorption of
all that apply. water, leading to fluid overload — not dehydration. Jaundice
□ 1. Hypertension and bradycardia are adverse effects that may occur in the
□ 2. Jaundice neonate. Tachycardia — not bradycardia — is reported as a
□ 3. Dehydration maternal adverse effect.
□ 4. Fluid overload Client needs category: Physiological integrity
□ 5. Uterine tetany Client needs subcategory: Pharmacological therapies
□ 6. Bradycardia Cognitive level: Application
6. The nurse is caring for a client who has been diag- Answer: 1, 3, 6. Painful vaginal bleeding, uterine tenderness
nosed with abruptio placentae. What signs and symptoms on palpation, and abnormal or absent heart tones are signs
of abruptio placentae should the nurse expect to find when of abruptio placentae. Fundal height increases during
she’s collecting data on this client? Select all that apply. abruptio placentae as a result of blood becoming trapped
□ 1. Vaginal bleeding behind the placenta. The abdomen would feel hard and
□ 2. Decreased fundal height boardlike on palpation as blood permeates the myometrium
□ 3. Uterine tenderness on palpation and causes uterine irritability. The uterus would also be
□ 4. Soft abdomen on palpation hypertonic and enlarged.
□ 5. Hypotonic, small uterus Client needs category: Physiological integrity
□ 6. Abnormal fetal heart tones Client needs subcategory: Physiological adaptation
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7. A nurse is assigned to assist with the admission of a Answer: 1, 3, 6. The nurse should ask about the EDD and
client who’s in labor. Which actions are appropriate? Select then compare the response to the information in the prena-
all that apply. tal record. If the fetus is preterm, special precautions and
□ 1. Asking about the estimated date of delivery (EDD) equipment are necessary. Maternal and fetal vital signs
□ 2. Estimating fetal size should be obtained to evaluate the well-being of the client
□ 3. Taking maternal and fetal vital signs and fetus. Determining how far apart the contractions are
□ 4. Asking about the woman’s last menses provides the health care team with valuable baseline infor-
□ 5. Administering an analgesic mation. The physician estimates the size of the fetus. It
□ 6. Asking about the amount of time between contrac- wouldn’t be appropriate for the nurse to ask about the
tions client’s last menses. This information should be collected at
the first prenatal visit. It would be premature to administer
an analgesic, which could slow or stop labor contractions.
maintenance
8. The nurse is assisting in caring for a client who has just Answer: 3, 4, 5. Signs of placental separation include length-
given birth to a neonate through vaginal delivery. The ening of the umbilical cord, a sudden gush of blood from
nurse is monitoring for signs of placental separation. Which the vagina, a firmly contracted uterus, and change in uter-
signs indicate that the placenta has separated? Select all ine shape from discoid to globular. Sudden, sharp abdomi-
that apply. nal pain could indicate uterine rupture.
□ 1. Shortening of the umbilical cord Client needs category: Physiological integrity
□ 2. Sudden, sharp abdominal pain Client needs subcategory: Physiological adaptation
□ 3. Sudden gush of vaginal blood Cognitive level: Comprehension
□ 4. Change in shape of the uterus
□ 5. Lengthening of the umbilical cord
9. When examining a client who gave birth 3 hours ago, Answer: 2, 3. Checking vital signs provides information
the nurse finds that the client has completely saturated a about the client’s circulatory status and identifies signifi-
perineal pad within 15 minutes. Which actions should the cant changes that may need to be reported to the physician.
nurse take? Select all that apply. By palpating the client’s fundus, the nurse also gains valu-
□ 1. Begin an I.V. infusion of lactated Ringer’s solution. able assessment data. A boggy uterus may lead to exces-
□ 2. Check the client’s vital signs. sive bleeding. Starting an I.V. infusion requires a physi-
□ 3. Palpate the client’s fundus. cian’s order. Placing the client in high Fowler’s position
□ 4. Place the client in high Fowler’s position. may lower the blood pressure and be harmful to the client.
□ 5. Administer a pain medication. Administration of a pain medication doesn’t address the
current problem.
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10. The nurse observes several interactions between a Answer: 1, 2. Talking to, cooing to, and cuddling her son are
mother and her new son. Which behaviors by the mother positive signs that the mother is adapting to her new role.
would the nurse identify as evidence of mother-infant attach- Avoiding eye contact is a sign that the mother isn’t bonding
ment? Select all that apply. with her baby. Eye contact, touching, and speaking are im-
□ 1. Talks and coos to her son portant to establish attachment with an infant. Feeding the
□ 2. Cuddles her son close to her baby is an important role of a new mother and facilitates at-
□ 3. Doesn’t make eye contact with her son tachment. Encouraging the dad to hold the baby facilitates
□ 4. Requests the nurse to take the baby to the nursery for attachment between the newborn and the father. Resting
feedings while the infant is sleeping conserves needed energy and
□ 5. Encourages the father to hold the baby allows the mother to be alert and awake when her infant is
□ 6. Takes a nap when the baby is sleeping awake; however it isn’t evidence of bonding.
11. The nurse is instructing the client on breast-feeding. Answer: 2, 3, 4, 6. Mastitis is an infection commonly associ-
Which instructions should she include to help the mother ated with a break in the skin surface of the nipple. However,
prevent mastitis? Select all that apply. measures to prevent cracked and fissured nipples help to
□ 1. “Wash your nipples with soap and water.” prevent this condition. Changing breast pads frequently
□ 2. “Change the breast pads frequently.” and exposing the nipples to air part of the day help keep
□ 3. “Expose your nipples to air part of each day.” the nipples dry and prevent irritation. If the client washes
□ 4. “Wash your hands before handling your breast and her hands before handling her breasts, she can reduce the
breast-feeding.” chance of accidentally introducing organisms into the
□ 5. “Make sure that the baby grasps only the nipple.” breasts. Releasing the baby’s grasp on the nipple before re-
□ 6. “Release the baby’s grasp on the nipple before remov- moving the baby from the breast also reduces the chance
ing him from the breast.” of irritation. Nipples should be washed with water only.
Soap can remove the body’s natural oils and increases the
chance of cracking. The baby should grasp both the nipple
and areola.
maintenance
12. The nurse is palpating the Answer: The nurse should be able
uterine fundus of a client who de- to feel the uterus at the level of the
livered 8 hours ago. At what level umbilicus from 1 hour after birth
in the abdomen would the nurse to approximately 24 hours after
expect to feel the fundus? birth.
Client needs category: Phys-
iological integrity
Reduction of risk potential
Cognitive level: Comprehen-
sion
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13. The nurse is assisting in developing a care plan for a Answer: 3, 4. Sitz baths help decrease inflammation and ten-
client with an episiotomy. Which interventions would be sion in the perineal area. Kegel exercises improve circula-
included for the nursing diagnosis Acute pain related to tion to the area and help reduce edema. Ice packs should
perineal sutures? Select all that apply. be applied to the perineum for only the first 24 hours; after
□ 1. Apply an ice pack intermittently to the perineal area that time, heat should be used. Topical pain gels should be
for 3 days. applied to the suture area to reduce discomfort, as ordered.
□ 2. Avoid the use of topical pain gels. The perineal pad should be changed frequently to prevent
□ 3. Administer sitz baths three to four times per day. irritation caused by the discharge.
□ 4. Encourage the client to do Kegel exercises. Client needs category: Physiological integrity
□ 5. Limit the number of times the perineal pad is Client needs subcategory: Basic care and comfort
changed. Cognitive level: Application
14. In the nursery, the nurse is performing a neurologic Answer: 3, 4, 6. Failure of the toes to curl downward when
assessment on a 1-day-old neonate. Which findings would the soles are stroked and lack of response to a loud sound
indicate possible asphyxia in utero? Select all that apply. can be evidence that neurological damage from asphyxia has
□ 1. The neonate grasps the nurse’s finger when she puts occurred. The normal responses would be that the toes curl
it in the palm of his hand. downward with stroking and the arms and legs extend in re-
□ 2. The neonate does stepping movements when held sponse to a loud noise. Weak, ineffective sucking is another
upright with his sole touching a surface. sign of neurologic damage; a neonate should root and suck
□ 3. The neonate’s toes don’t curl downward when his when the side of his cheek is stroked. A neonate should also
soles are stroked. grasp a person’s finger when it’s placed in the palm of his
□ 4. The neonate doesn’t respond when the nurse claps hand, do stepping movements when held upright with the
her hands above him. soles touching a surface, and turn toward object when his
□ 5. The neonate turns toward an object when the nurse cheek is touched.
touches his cheek with it. Client needs category: Health promotion and
□ 6. The neonate displays weak, ineffective sucking. maintenance
15. Which instructions should the nurse provide on dis- Answer: 1, 2, 5. It’s necessary for a circumcised infant to
charge from the facility to the parents of a neonate who has void prior to discharge to ensure that the urethra isn’t ob-
been circumcised? Select all that apply. structed. A lubricating ointment, such as petroleum jelly,
□ 1. The infant must void before being discharged home. should be applied to the glans with each diaper change.
□ 2. Apply petroleum jelly to the glans of the penis with Typically, the penis heals within 2 to 4 days and circumci-
each diaper change. sion care is needed only during that period. Parents should
□ 3. Tub baths for the infant are acceptable while the avoid giving the neonate tub baths until the circumcision
circumcision heals. heals to prevent infection; only sponge baths are appropri-
□ 4. Report blood on the front of the diaper. ate. A small amount of bleeding is expected after circumci-
□ 5. The circumcision requires care for 2 to 4 days after sion; parents should report only large amounts of bleeding
discharge. to the physician.
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16. A 14-day-old neonate is ad- Answer: Gastroesophageal reflux

mitted for aspiration pneumo- is a neuromotor disturbance in
nia. The results of a barium which the cardiac sphincter is lax
swallow confirm a diagnosis of and allows easy regurgitation of
gastroesophageal reflux with gastric contents into the esopha-
resulting aspiration pneumonia. gus, causing possible aspiration
Identify the area of the stomach into the lungs. The cardiac
that’s weakened, contributing sphincter is located between the
to the reflux. stomach and the esophagus.
Client needs subcategory: Physiological adaptation.
17. The nurse is eliciting reflexes in a Answer: Touching the sole of the foot
neonate during a physical examination. near the base of the digits elicits a plan-
Identify the area the nurse would touch tar grasp reflex and causes flexion or
to elicit a plantar grasp reflex. grasping. This reflex disappears around
age 9 months.
18. The nurse notes that at 5 minutes after birth, a neonate Answer: 4. The Apgar score quantifies neonatal heart rate,
is pink, has a vigorous cry, cries when his soles are respiratory effort, muscle tone, reflexes, and color. Each
slapped, has a heart rate of 136 beats/minute. He’s actively category is assessed 1 minute after birth and again 5 min-
moving his arms and legs. What 5-minute Apgar score utes later. Scores in each category range from 0 to 2, as
should the nurse record for this neonate? shown at left. This neonate has a heart rate above 100 beats/
minute, which equals 2; is pink in color, which equals 2; is
Flow Chart
actively moving his arms and legs, which equals 2; has a
Sign Apgar score vigorous cry, which equals 2; and has a good response to
0 1 2 slapping the soles, which equals 2. Therefore, the nurse
should record a total Apgar score of 10.
Heart rate Absent Less than 100 beats/minute More than
(slow) 100 beats/minute
Respiratory Absent Slow, irregular Good crying Cognitive level: Analysis
effort
Muscle Flaccid Some flexion and resistance Active motion
tone to extension of extremities
Reflex No response Grimace or weak cry Vigorous cry
irritability
Color Pallor, Pink body, blue extremities Completely pink
cyanosis
□ 1. 6 □ 3. 8
□ 2. 7 □ 4. 10
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19. The nurse is demonstrating cord care to a mother of a Answer: 1, 4, 5. The diaper should be positioned below the
neonate. Which actions should the nurse teach the mother? cord to allow for it to air dry and to prevent urine from get-
Select all that apply. ting on it. Instruct the parents to sponge-bathe the infant
□ 1. Keep the diaper below the cord. until the cord falls off; soap and water shouldn’t be used.
□ 2. Tug gently on the cord to remove it as it begins to The entire cord should be cleaned with alcohol, using a
dry. cotton-tipped applicator or another appropriate method. Tell
□ 3. Apply antibiotic ointment to the cord twice daily. the parents not to pull on the cord; they should allow it to
□ 4. Only sponge-bathe the infant until his cord falls off. fall off naturally. Antibiotic ointments are contraindicated
□ 5. Clean the length of the cord with alcohol several unless signs of infection are present.
times daily. Client needs category: Safe, effective care
□ 6. Wash the cord with mild soap and water. environment
control
20. A pregnant client at 32 weeks’ gestation has mild pre- Answer: 1, 3, 5, 6. Headache, blurred vision, epigastric pain,
eclampsia. She’s discharged to go home with instructions to and severe nausea and vomiting can indicate worsening ma-
remain on bed rest. She should also be instructed to call her ternal disease. Decreased, not increased, urine output is a
physician if she experiences which symptoms? Select all that concern because it could indicate renal impairment. Diffi-
apply. culty sleeping, a common complaint during the third
□ 1. Headache trimester, is only a concern if it’s caused by any of the other
□ 2. Increased urine output symptoms on the list.
□ 3. Blurred vision Client needs category: Physiological integrity
□ 4. Difficulty sleeping Client needs subcategory: Reduction of risk potential
□ 5. Epigastric pain Cognitive level: Application
□ 6. Severe nausea and vomiting
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21. Assessment of a client progressing through labor re- Answer:

veals the following findings. Order the findings in the most Ordered responses
likely sequence in which they would have occurred.
Unordered responses 4. Strong Braxton-Hicks contractions
1. Uncontrollable urge to push 5. Mild contractions lasting 20 to 40 seconds
2. Cervical dilation of 7 cm 2. Cervical dilation of 7 cm
3. 100% cervical effacement 3. 100% cervical effacement
4. Strong Braxton-Hicks contractions 1. Uncontrollable urge to push
5. Mild contractions lasting 20 to 40 seconds Strong Braxton-Hicks contractions typically occur before
the onset of true labor and are considered a preliminary
sign of labor. During the latent phase of the first stage of la-
bor, contractions are mild, lasting approximately 20 to 40
seconds. As the client progresses through labor, contrac-
tions increase in intensity and duration. In addition, cervi-
cal dilation occurs. Cervical dilation of 7 cm indicates that
the client has entered the active phase of the first stage of
labor. Together with cervical dilation, cervical effacement
occurs. Effacement of 100% characterizes the transition
phase of the first stage of labor. Progression into the sec-
ond stage of labor is noted by the client’s uncontrollable
urge to push.
maintenance
22. The nurse is evaluating a client who’s 34 weeks preg- Answer: 1, 3, 5. The fernlike pattern that occurs when vagi-
nant for premature rupture of the membranes (PROM). nal fluid is placed on a glass slide and allowed to dry, pres-
Which findings indicate that PROM has occurred? Select ence of amniotic fluid in the vagina, and alkaline pH of fluid
all that apply. are all signs of ruptured membranes. The fernlike pattern
□ 1. Fernlike pattern when vaginal fluid is placed on a seen when the fluid is allowed to dry on a slide is a result of
glass slide and allowed to dry the high sodium and protein content of the amniotic fluid.
□ 2. Acidic pH of fluid when tested with nitrazine paper The presence of amniotic fluid in the vagina results from
□ 3. Presence of amniotic fluid in the vagina the expulsion of the fluid from the amniotic sac. Cervical
□ 4. Cervical dilation of 6 cm dilation and regular contractions are signs of progressing
□ 5. Alkaline pH of fluid when tested with nitrazine paper labor but don’t indicate PROM.
□ 6. Contractions occurring every 5 minutes Client needs category: Physiological integrity
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23. A mother with a past history of varicose veins has just Answer: 1, 3, 5. Sudden dyspnea with diaphoresis and con-
delivered her first baby. The nurse suspects that the moth- fusion are classic signs and symptoms of dislodgment of a
er has developed a pulmonary embolus. Which data would thrombus (stationary blood clot) from a varicose vein be-
lead to this nursing judgment? Select all that apply. coming an embolus (moving clot) that lodges itself into the
□ 1. Sudden dyspnea pulmonary circulation. Chills and fever would indicate an
□ 2. Chills, fever infection. A client with an embolus could be hypotensive,
□ 3. Diaphoresis not hypertensive.
□ 4. Hypertension Client needs category: Physiological integrity
□ 5. Confusion Client needs subcategory: Physiological adaptation
24. At 5 minutes of age, a neonate is pink with acro- Answer: 3. Apgar consists of a 0 to 2 point scoring system
cyanosis, has his knees flexed and fists clinched, has a for a neonate immediately following birth and at 5 minutes
whimpering cry, has a heart rate of 128, and withdraws his of age. The nurse evaluates the neonate for heart rate, res-
foot when slapped on the sole. What 5-minute Apgar score piratory effort, muscle tone, reflex irritability, and color.
would the nurse record for this neonate? This neonate has a heart rate above 100, which equals 2;
pink color with acrocyanosis, which equals 1; is well-flexed,
Flow Chart
which equals 2; has a weak cry, which equals 1; and has a
Sign Apgar score good response to slapping the soles of the feet, which
0 1 2 equals 2. Therefore, the nurse should record a total Apgar
score of 8.
Heart rate Absent Less than 100 beats/minute More than
(slow) 100 beats/minute
Respiratory Absent Slow, irregular Good crying Cognitive level: Analysis
effort
Muscle Flaccid Some flexion and resistance Active motion
tone to extension of extremities
Reflex No response Grimace or weak cry Vigorous cry
irritability
Color Pallor, Pink body, blue extremities Completely pink
cyanosis
□ 1. 6
□ 2. 7
□ 3. 8
□ 4. 10
25. A nurse is administering vitamin K (AquaMEPHY- Answer: 0.25. Use the following formula to calculate drug
TON) to a neonate after delivery. The medication comes in dosages:
a concentration of 2 mg/ml and the ordered dose is 0.5 mg Dose on hand Quantity on hand Dose desired X
to be given subcutaneously. How many milliliters should
the nurse administer? Record your answer using two deci- Plug in the values and the equation is as follows:
mal places. 2 mg ml 0.5 mg X
X 0.25 ml
________________________ milliliters
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Pediatric nursing 785
Pediatric nursing
1. The physician orders digoxin 0.1 mg orally every Answer: 0.25. To convert mg to mcg:
morning for a 6-month-old infant with heart failure. Digoxin 1,000 mcg 1 mg X mcg 0.1 mg
is available in a 400 mcg/ml concentration. How many milli- X 100 mcg
liters of digoxin should the nurse give? Record your answer
using two decimal places. To calculate drug dose:
Dose on hand Quantity on hand Dose desired X
________________________ milliliters 400 mcg ml 100 mcg X
X 0.25 ml
2. The nurse is preparing to administer chloramphenicol Answer: 1, 2, 4. The nurse should prepare to instill the
(Chloromycetin Otic) to a 2-year-old with an infection of the eardrops by washing her hands, gathering the needed sup-
external auditory canal. The order reads, “2 gtt right ear plies, and arranging them at the bedside. To avoid adverse
t.i.d.” Which steps should the nurse take to administer this effects resulting from eardrops that are too cold (such as
medication? Select all that apply. vertigo, nausea, and pain), the medication should be
□ 1. Wash her hands and arrange supplies at the bedside. warmed to body temperature in a bowl of warm water. The
□ 2. Warm the medication to body temperature. nurse should test the temperature of the drops by placing a
□ 3. Lie the child on his right side with his left ear facing drop on her wrist. Before instilling the drops, the ear canal
up. should be examined for drainage that may reduce the med-
□ 4. Examine the ear canal for drainage. ication’s effectiveness. The child should be placed on his
□ 5. Gently pull the pinna up and back and instill the drops left side with his right ear facing up. For an infant or a child
into the external ear canal. younger than age 3, gently pull the auricle down and back
because the ear canal is straighter in children of this age-
group.
3. The nurse is caring for a 1-month-old infant who fell Answer: 1, 4, 6. Full, tense, bulging fontanels; a high-
from the changing table during a diaper change. Which pitched cry; and irritability are signs and symptoms of in-
signs and symptoms of increased intracranial pressure (ICP) creased ICP in a 1-month-old. With increased ICP, blood
is the nurse likely to find in a 1-month-old infant? Select all pressure rises while heart rate falls. The infant may have a
that apply. headache, but the nurse is unable to evaluate this finding in
□ 1. Bulging fontanels an infant.
□ 2. Decreased blood pressure Client needs category: Physiological integrity
□ 3. Increased pulse Client needs subcategory: Physiological adaptation
□ 4. High-pitched cry Cognitive level: Analysis
□ 5. Headache
□ 6. Irritability
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4. The nurse is evaluating a 10-month-old infant during a Answer: 1, 4, 5. By age 3 months, an infant should be able to
checkup. Which developmental milestones would the nurse hold his head erect. By age 10 months, he should be able to
expect the infant to display? Select all that apply. sit on a firm surface without support and bear the majority
□ 1. Holding head erect of his weight on his legs (for example, he can walk while
□ 2. Self-feeding holding on to furniture). Feeding himself and controlling
□ 3. Demonstrating good bowel and bladder control his bowels and bladder are developmental milestones of
□ 4. Sitting on a firm surface without support toddlers. By age 12 months, the infant should be able to
□ 5. Bearing the majority of his weight on his legs stand alone and may take his first steps.
□ 6. Walking alone Client needs category: Health promotion and
maintenance
5. The nurse is teaching cardiopulmonary resuscitation Answer: 3, 5, 6. When performing CPR on an infant, check
(CPR) to the parents of a 1-month-old infant being dis- for a brachial pulse by palpating the inside of the upper
charged with an apnea monitor. Which steps are appropri- arm, midway between the elbow and shoulder. To provide
ate for performing CPR on an infant? Select all that apply. compressions to an infant, compress the sternum 1⁄ 2⬙ to 1⬙
□ 1. Open the airway by hyperextending the head. at a ratio of 15 compressions to 2 breaths. Tilting the head
□ 2. Pinch the nose before delivering a breath. of an infant too far back can block, rather than open, the air-
□ 3. Check for a pulse by palpating the brachial artery. way. To deliver a breath to an infant, the rescuer should
□ 4. Place the heel of one hand on lower third of sternum cover the infant’s mouth and nose with her mouth. When
to perform compressions. performing chest compressions on an infant, the tips of the
□ 5. Compress the sternum 1⁄ 2⬙ to 1⬙. middle and ring fingers should be placed on the sternum,
□ 6. Give 15 compressions to 2 breaths. one finger’s width below the nipple line.
6. The nurse is providing Answer: A ventricular septal

preoperative teaching to the defect is a hole in the sep-
parents of a 9-month-old in- tum between the ventricles.
fant who’s having surgery to The defect can be anywhere
repair a ventricular septal de- along the septum but is most
fect. Identify the area of the commonly located in the
heart where the defect is middle of the septum.
located. Client needs category:
Cognitive level: Compre-
hension
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7. An 11-month-old is diag- Answer: The eustachian tube

nosed with his second ear in- in an infant is shorter and
fection. The mother asks wider than in an adult or an
why children experience older child. It also slants hor-
more ear infections than izontally. Because of these
adults. The nurse shows the anatomical features, na-
mother a diagram of the ear sopharyngeal secretions can
and explains the differences enter the middle ear more
in the anatomy of a child. Identify the portion of the infant’s easily, stagnate, and tend to cause infections.
ear that allows fluid to stagnate and act as a medium for Client needs category: Health promotion and
bacteria. maintenance
8. The nurse is teaching the parents of an infant under- Answer: 2, 3, 5, 6. An infant with a repaired cleft lip should
going the repair of his cleft lip. Which instructions should be put to sleep on his back or side to prevent trauma to the
the nurse give? Select all that apply. surgery site. He should be fed in an upright position with a
□ 1. Offer a pacifier as needed. syringe and attached tubing to prevent stress to the suture
□ 2. Lay the infant on his back or side to sleep. line from sucking. To prevent crusts and scarring, the su-
□ 3. Sit the infant up for each feeding. ture line should be cleaned after each feeding by dabbing it
□ 4. Loosen the arm restraints every 4 hours. with half-strength hydrogen peroxide or saline solution.
□ 5. Clean the suture line after each feeding by dabbing it The infant should receive extra care and support because
with saline solution. he can’t meet emotional needs by sucking. Extra care and
□ 6. Give the infant extra care and support. support may also prevent crying, which stresses the suture
line. Pacifiers shouldn’t be used during the healing process
because they stress the suture line. Arm restraints are used
to keep the infant’s hands away from the mouth and should
be loosened every 2 hours.
9. A 10-month-old is found Answer: An infant’s pulse is

floating face down in a most accessible at the
swimming pool. A neighbor, brachial artery. The brachial
who’s a nurse, checks for artery is located inside the
the presence of respirations upper arm between the el-
and a pulse. Identify the bow and the shoulder. Car-
area that’s most appropriate diopulmonary resuscitation
to check for a pulse. guidelines recommend
using this area to assess for
a pulse.
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10. A nurse at the family clinic receives a call from the Answer: 2, 4, 5, 6. Colic consists of recurrent paroxysmal
mother of a 5-week-old infant. The mother states that her bouts of abdominal pain and is fairly common in infants. It
child was diagnosed with colic at the last checkup. Unfortu- usually disappears by age 3 months. Rocking, riding in a
nately, the symptoms have remained the same. Which car, humming, and offering a pacifier may be used to com-
teaching instructions are appropriate? Select all that apply. fort the infant. Decrease gas formation by frequent burp-
□ 1. Position the infant on his back after feedings. ing, give smaller feedings more frequently, and position the
□ 2. Soothe the child by humming and rocking. infant in an upright seat are also appropriate instructions.
□ 3. Immediately bring the infant to the emergency The infant shouldn’t be positioned on his back after feed-
department. ings because this increases gas formation. Colic is a man-
□ 4. Burp the infant adequately after feedings. ageable condition in the home. The infant doesn’t need to
□ 5. Provide small but frequent feedings to the infant. be taken to the emergency department unless the symp-
□ 6. Offer a pacifier if it isn’t time for the infant to eat. toms worsen, a temperature accompanies the symptoms, or
vomiting occurs with the symptoms.
11. The nurse is admitting a 14-month-old to the pediatric Answer: 1, 2, 3, 5. A strong hand grasp is demonstrated
floor with a diagnosis of croup. Which characteristics would within the first month of life. Holding one object while look-
the nurse expect the toddler to have if he’s developing nor- ing for another is accomplished by the 20th week. Within
mally? Select all that apply. the first year of life, the toddler masters smiling at familiar
□ 1. Strong hand grasp faces and voices, the Moro reflex disappears, and birth
□ 2. Tendency to hold one object while looking for another weight triples. The anterior fontanel closes at approximately
□ 3. Recognition of familiar voices (smiles in recognition) age 18 months.
□ 4. Presence of Moro reflex Client needs category: Health promotion and
□ 5. Weight that’s triple the birth weight maintenance
□ 6. Closed anterior fontanelle Client needs subcategory: None
12. A 13-month-old is admitted to the pediatric unit with a Answer: 2, 4, 5. A child experiencing nausea and vomiting
diagnosis of gastroenteritis. The toddler has experienced wouldn’t be able to tolerate a regular diet. He should be
vomiting and diarrhea for the past 3 days, and laboratory given sips of clear liquids, and the diet should be advanced
tests reveal that he’s dehydrated. Which nursing interven- as tolerated. Soups and broths without salt are appropriate
tions are correct to prevent further dehydration? Select all clear liquids. Milk shouldn’t be given because it can worsen
that apply. the child’s diarrhea. I.V. fluids should be monitored to
□ 1. Encourage the child to eat a balanced diet. maintain the fluid status and help to rehydrate the child.
□ 2. Give clear liquids in small amounts. Solid foods may be withheld throughout the acute phase;
□ 3. Give milk in small amounts. however, clear fluids should be encouraged in small
□ 4. Encourage the child to eat unsalted soups and broths. amounts (3 to 4 tablespoons every half hour).
□ 5. Monitor the I.V. solution per the physician’s order. Client needs category: Physiological integrity
□ 6. Withhold all solid food and liquids until the symptoms Client needs subcategory: Basic care and comfort
pass. Cognitive level: Application
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13. A toddler is ordered 350 mg of amoxicillin (Aug- Answer: 7. The formula used to calculate drug dosages:
mentin) by mouth, four times per day. The pharmacy sends Dose on hand Quantity on hand Dose desired X
a bottle of amoxicillin with a concentration of 250 mg/5 ml.
How many milliliters should the nurse administer per dose? The equation in this example:
Record your answer using a whole number. 250 mg 5 ml 350 mg X.
X 7 ml
________________________ milliliters Client needs category: Physiological integrity
14. A 3-year-old is admitted to the pediatric unit with pneu- Answer: 2, 3, 5, 6. Chest physiotherapy and postural
monia. He has a productive cough and appears to have diffi- drainage work together to help break up congestion and
culty breathing. The parents tell the nurse that the toddler then drain secretions. Coughing and deep breathing are
hasn’t been eating or drinking much and has been very in- also effective to remove congestion. A cool mist humidifier
active. Which interventions to improve airway clearance helps loosen thick mucus and relax airway passages. Flu-
should be included by the nurse in the care plan? Select all ids should be encouraged — not restricted. The child
that apply. should be placed in semi-Fowler’s to high Fowler’s position
□ 1. Restrict fluid intake. to facilitate breathing and promote optimal lung expansion.
□ 2. Perform chest physiotherapy as ordered. Client needs category: Physiological integrity
□ 3. Encourage coughing and deep breathing. Client needs subcategory: Basic care and comfort
□ 4. Keep the head of the bed flat. Cognitive level: Application
□ 5. Perform postural drainage.
□ 6. Maintain humidification with a cool mist humidifier.
15. The nurse is observing the parents of a 4-year-old who Answer: 1, 3, 4. The most effective means of minimizing the
has been admitted to the hospital. Which actions indicate child’s anxiety during hospitalization is to have the parents
that the parents understand how to best minimize anxiety stay with him. Having a familiar toy helps the child to deal
during their child’s hospitalization? Select all that apply. with the anxiety of unfamiliar surroundings. Sibling visita-
□ 1. The parents bring the child’s favorite toy to the tion can also help to ease the child’s anxiety. Explaining a
hospital. procedure to a young child in great detail only maximizes
□ 2. The parents explain all procedures to the child in fear. Parents can be effective in calming and comforting a
great detail. child during painful procedures, so they should remain in
□ 3. The parents remain at the child’s side during the the room. Rewards, not punishment, should be offered to a
hospitalization. preschool child.
□ 4. The parents bring the child’s siblings for a brief visit. Client needs category: Psychosocial integrity
□ 5. The parents leave the room when the child undergoes Client needs subcategory: None
a painful procedure. Cognitive level: Analysis
□ 6. The parents punish the child if the child isn’t coopera-
tive.
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16. A 5-year-old is admitted to the hospital for a tonsillec- Answer: 4, 5, 6. Clear liquids include clear broth, gelatin,
tomy. After the surgery, the physician orders a clear liquid clear juices, water, and ice chips. Cream of chicken soup,
diet. The nurse is correct in giving the child which items? orange juice, and ice cream are included in a full liquid diet.
Select all that apply. Client needs category: Physiological integrity
□ 1. Cream of chicken soup Client needs subcategory: Basic care and comfort
□ 2. Orange juice Cognitive level: Application
□ 3. Ice cream
□ 4. Apple juice
□ 5. Lime gelatin
□ 6. Chicken broth
17. The school nurse is conducting registration for a first Answer: 1, 2, 3, 6. Hepatitis B series, diphtheria-tetanus-
grader. Which immunizations should the school nurse verify pertussis series, H. influenzae type b series, and inactivated
the child has had on entering school? Select all that apply. poliovirus series are immunizations that the child should
□ 1. Hepatitis B series receive before entering first grade. The varicella zoster vac-
□ 2. Diphtheria-tetanus-pertussis series cine is administered only if the child hasn’t had chicken-
□ 3. Haemophilus influenzae type b series pox. Pneumonia vaccine isn’t required or routinely given to
□ 4. Varicella zoster children.
□ 5. Pneumonia vaccine Client needs category: Health promotion and
□ 6. Inactivated poliovirus series maintenance
18. A preschool child is in danger of becoming dehydrated Answer: 480. First, convert the child’s weight from pounds
as a result of vomiting and diarrhea. The nurse realizes that to kilograms. There are 2.2 kg in 1 lb. Thus, 44 2.2 20,
dehydration can be prevented if intake is sufficient to pro- and 3 ml 20 kg 8 hours 480.
duce an hourly urine output of 3 ml/kg/hr. The preschooler Client needs category: Physiological integrity
weighs 44 lb. What’s the minimum urine output in milliliters Client needs subcategory: Reduction of risk potential
that should be achieved in an 8-hour shift in order to prevent Cognitive level: Comprehension
dehydration? Record your answer using a whole number.
________________________ milliliters
19. An 11-year-old boy is brought to a rural clinic listless Answer: 2, 3, 5, 6. Characteristic manifestations of rheumatic
and pale. The parents state that the child had a “bad sore fever include polyarthritis, chorea, carditis, and a red rash.
throat” 2 weeks ago and that they had him gargle with salt The child doesn’t usually experience nausea and vomiting.
water. The parents report that they saw improvement but He may have a minor low-grade fever in the afternoon.
now the child has flulike symptoms. The child is diagnosed Client needs category: Physiological integrity
with rheumatic fever. Which signs and symptoms are asso- Client needs subcategory: Physiological adaptation
ciated with rheumatic fever? Select all that apply. Cognitive level: Application
□ 1. Nausea and vomiting
□ 2. Polyarthritis
□ 3. Chorea
□ 4. High-grade fever
□ 5. Carditis
□ 6. Rash
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20. When talking with an 10-year-old child about death, the Answer: 2, 3, 4. By age 9 or 10, most children know that
nurse should incorporate which guidelines? Select all that death is universal, inevitable, and irreversible. School-age
apply. children are curious about the physical aspects of death
□ 1. Logical explanations aren’t appropriate. and may wonder what happens to the body. Their cognitive
□ 2. The child will be curious about the physical aspects of abilities are advanced and they respond well to logical ex-
death. planations. They should be encouraged to ask questions.
□ 3. The child will know that death is inevitable and irre- The adults in their environment influence their attitudes to-
versible. wards death. Adults should be encouraged to include chil-
□ 4. The child will be influenced by the attitudes of the dren in the family rituals and should be prepared to answer
adults in their lives. questions that might seem shocking. Teaching about death
□ 5. Teaching about death and dying shouldn’t start before should begin early in childhood. Comparing death to sleep
age 11. can be frightening for children and cause them to fear
□ 6. Telling a child that death is the same as going to sleep falling asleep.
as a way of relieving fear is appropriate. Client needs category: Psychosocial integrity
21. A 7-year-old client is admitted to the hospital for treat- Answer: 2, 3. Topical anesthetics reduce the pain of a
ment of facial cellulitis. He’s admitted for observation and venipuncture. The cream should be applied about 1 hour
for administration of a 10-day course of I.V. antibiotics. before the procedure and requires a physician’s order. Ask-
Which interventions would help this client cope with the ing which hand the child draws with helps to identify the
insertion of a peripheral I.V. line? Select all that apply. dominant hand. The I.V. should be inserted into the oppo-
□ 1. Explain the procedure to the child immediately before site extremity so that the child can continue to play and to
it begins. do homework with a minimum amount of disruption.
□ 2. Apply a topical anesthetic to the I.V. site before the Younger school-age children don’t have the capability for
procedure. abstract thinking. The procedure should be explained using
□ 3. Ask the child which hand he uses for drawing. simple words. Definitions of unfamiliar terms should be
□ 4. Explain the procedure to the child using abstract provided. The child should have the procedure explained to
terms. him well before it takes place so that he has time to ask
□ 5. Don’t let the child see the equipment to be used in the questions. Although the topical anesthetic will relieve some
procedure. pain, there’s usually some pain or discomfort involved in
□ 6. Tell the child that the procedure won’t hurt. venipuncture, so the child shouldn’t be told otherwise.
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22. A 6-year-old female is brought to the pediatrician’s of- Answer: 2, 3, 5. Determining the mother’s understanding of
fice by her mother for evaluation. The child recently started UTI and its causes provides the nurse with a baseline for
wetting the bed and running a low-grade fever. A urinalysis teaching. The full course of antibiotics must be given to
is positive for bacteria and protein. A diagnosis of a urinary eradicate the organism and prevent recurrence, even if the
tract infection (UTI) is made and the child is prescribed an- child’s signs and symptoms decrease. Bubble bath can irri-
tibiotics. Which interventions are appropriate? Select all tate the vulva and urethra and contribute to the develop-
that apply. ment of a UTI. Fluids should be encouraged, not limited, in
□ 1. Limit fluids for the next few days to decrease the fre- order to prevent urinary stasis and help flush the organism
quency of urination. out of the urinary tract. Instructions should be given to the
□ 2. Determine the mother’s understanding of a UTI and child at her level of understanding to help her better under-
its causes. stand the treatment and promote compliance. The child
□ 3. Instruct the mother to administer the antibiotic as pre- should wipe from the front to the back, not back to front, to
scribed — even if the symptoms diminish. minimize the risk of contamination after elimination.
□ 4. Provide instructions only to the mother, not the child. Client needs category: Health promotion and
□ 5. Explain that the child shouldn’t use of bubble bath. maintenance
□ 6. Tell the mother to have the child wipe from the back Client needs subcategory: None
to the front after voiding and defecation. Cognitive level: Application
23. Which symptom reported by an adolescent’s parents Answer: 1, 3, 4. Amphetamines are central nervous system
indicates that the adolescent is abusing amphetamines? stimulants. Symptoms of amphetamine abuse include
Select all that apply. marked nervousness, restlessness, excitability, talkative-
□ 1. Restlessness ness, and excessive perspiration.
□ 2. Fatigue Client needs category: Health promotion and
□ 3. Excessive perspiration maintenance
□ 4. Talkativeness Client needs subcategory: None
□ 5. Watery eyes Cognitive level: Application
□ 6. Excessive nasal drainage
24. A nurse is conducting an infant nutrition class for par- Answer: 2, 4, 5. The first food provided to a neonate is breast
ents. Which foods should the nurse tell parents they can in- milk or formula. Between ages 4 and 6 months, rice cereal
troduce during the first year of life? Select all that apply. can be introduced, followed by pureed or strained fruits and
□ 1. Sliced beef vegetables. Then parents may introduce strained or ground
□ 2. Pureed fruits meat. Meats must be chopped or ground before feeding
□ 3. Whole milk them to an infant to prevent choking. Infants shouldn’t be
□ 4. Rice cereal given whole milk until they are at least 1 year old. Fruit
□ 5. Strained vegetables drinks provide no nutritional benefit and shouldn’t be
□ 6. Fruit drinks encouraged.
maintenance
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25. A parent is planning to enroll her 9-month-old infant in Answer: 2, 4, 5. A parent can assess infection-control mea-
a day-care facility. The parent asks the nurse what to look sures by appraising steps taken by the facility to prevent
for to help ensure that the day-care facility is adhering to the spread of potential diseases. Placing diapers in covered
good infection-control measures. How should the nurse receptacles, covering the diaper-changing surfaces with dis-
reply? Select all that apply. posable papers, and ensuring that sinks are available for
□ 1. The facility keeps boxes of gloves in the director’s personnel to wash their hands after activities are all indica-
office. tors that infection-control measures are being followed.
□ 2. Diapers are discarded into covered receptacles. Gloves should be readily available to personnel; therefore,
□ 3. Toys are kept on the floor for the children to share. they should be kept in every room — not in an office. Toys
□ 4. Disposable papers are used on the diaper-changing typically are shared by numerous children; however, this
surfaces. contributes to the spread of germs and infections. All soiled
□ 5. Facilities for hand washing are located in every class- clothing and cloth diapers should be placed in a sealed plas-
room. tic bag before the infant is sent home each day.
□ 6. Soiled clothing and cloth diapers are sent home in Client needs category: Safe, effective care
labeled paper bags. environment
control
26. The nurse is preparing a dose of amoxicillin for a Answer: 5. To calculate the child’s weight in kilograms, the
3-year-old child with acute otitis media. The child weighs nurse should use the following formula:
33 lb. The dosage prescribed is 50 mg/kg/day in divided 2.2 lb 1 kg 33 lb X kg
doses every 8 hours. The concentration of the drug is X 33 2.2
250 mg/5 ml. How many milliliters should the nurse X 15 kg
administer? Record your answer using a whole number.
Next, the nurse should calculate the daily dosage for the
________________________ milliliters child:
50 mg/kg/day 15 kg 750 mg/day
To determine the divided daily dosage, the nurse should

know that “every 8 hours” means three times per day. So,
she should perform that calculation in this way:
Total daily dosage 3 times per day
Divided daily dosage
750 mg/day 3 250 mg
The drug’s concentration is 250 mg/5 ml, so the nurse
should administer 5 ml.
Client needs subcategory: Pharmacological thera-
pies.
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27. A 44-lb preschool child is being treated for inflamma- Answer: 10. To perform this dosage calculation, the nurse
tion. The physician orders 0.2 mg/kg/day of dexametha- should first convert the child’s weight from pounds to kilo-
sone (Decadron) by mouth to be administered every grams:
6 hours. The elixir comes in a strength of 0.5 mg/5 ml. 44 lb 2.2 lb/kg 20 kg
How many milliliters of dexamethasone should the nurse
give this client per dose? Record your answer using a whole Then she should calculate the total daily dose for the
number. child:
20 kg 0.2 mg/kg/day 4 mg
________________________ milliliters
Next, the nurse should calculate the amount to be given
at each dose:
4 mg 4 doses 1 mg/dose
The available elixir contains 0.5 mg of the drug per 5 ml.

Therefore, to give 1 mg of the drug, the nurse should
administer 10 ml to the child for each dose.
28. The nurse is teaching an adolescent with inflammatory Answer: 1, 2, 3, 4, 6. Adverse effects of corticosteroids
bowel disease about treatment with corticosteroids. Which include acne, hirsutism, mood swings, osteoporosis, and
adverse effects are concerns for this client? Select all that adrenal suppression. Steroid use in children and adoles-
apply. cents may cause delayed growth, not growth spurts.
□ 1. Acne Client needs category: Physiological integrity
□ 2. Hirsutism Client needs subcategory: Pharmacological therapies
□ 3. Mood swings Cognitive level: Application
□ 4. Osteoporosis
□ 5. Growth spurts
□ 6. Adrenal suppression
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Psychiatric and mental health nursing 795
Psychiatric and mental health nursing

1. The nurse has developed a relationship with a client Answer: 1, 3, 6. Options 1, 3, and 6 are examples of the
who has an addiction problem. Which information would nurse-client working phase of an interaction. In the working
indicate that the therapeutic interaction is in the working phase, the client explores, evaluates, and determines solu-
stage? Select all that apply. tions to identified problems. Options 2, 4, and 5 address
□ 1. The client addresses how the addiction has con- what happens during the introductory phase of the nurse-
tributed to family distress. client interaction.
□ 2. The client reluctantly shares the family history of Client needs category: Psychosocial integrity
addiction. Client needs subcategory: None
□ 3. The client verbalizes difficulty identifying personal Cognitive level: Analysis
strengths.
□ 4. The client discusses the financial problems related to
the addiction.
□ 5. The client expresses uncertainty about meeting with
the nurse.
□ 6. The client acknowledges the addiction’s effects on the
children.
2. After receiving a referral from the occupational health Answer: 2, 4, 6. Client care should focus on reducing the
nurse, a client comes to the mental health clinic with a ten- anxiety, fear, and guilt associated with this disorder. This
tative diagnosis of obsessive-compulsive disorder. The can be accomplished by allowing the client to carry out rit-
client explains that his compulsion to wash his hands is in- ualistic behavior until he can be distracted to some other
terfering with his job. Which interventions are appropriate activity. The client should also be encouraged to use appro-
when caring for a client with this disorder? Select all that priate defense mechanisms and express his feelings of anxi-
apply. ety. Exploring patterns that lead to the compulsive behavior
□ 1. Don’t allow the client time to carry out the ritualistic may also be effective. The nurse should always listen atten-
behavior. tively to the client and offer feedback. Activities such as lis-
□ 2. Support the use of appropriate defense mechanisms. tening to music may divert the client’s attention from un-
□ 3. Encourage the client to suppress his anxious feelings. wanted thoughts.
□ 4. Explore the patterns leading to the compulsive Client needs category: Psychosocial integrity
behavior. Client needs subcategory: None
□ 5. Listen attentively, but don’t offer feedback. Cognitive level: Application
□ 6. Encourage activities, such as listening to music.
3. After being examined by the forensic nurse in the Answer: 1, 3, 6. Clients diagnosed with PTSD typically expe-
emergency department, a rape victim is prepared for dis- rience recurrent, intrusive recollections or nightmares,
charge. The nature of the attack puts the client is at risk for sleep disturbances, difficulty concentrating, chronic anxiety
posttraumatic stress disorder (PTSD). Which symptoms or panic attacks, memory impairment, and feelings of de-
are associated with PTSD? Select all that apply. tachment or estrangement that destroy interpersonal rela-
□ 1. Recurrent, intrusive recollections or nightmares tionships. Gingival and dental problems are associated with
□ 2. Gingival and dental problems bulimia. Flight of ideas and unusual talkativeness are char-
□ 3. Sleep disturbances acteristic of the acute manic phase of bipolar affective
□ 4. Flight of ideas disorder.
□ 5. Unusual talkativeness Client needs category: Psychosocial integrity
□ 6. Difficulty concentrating Client needs subcategory: None
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4. A physician prescribes clomipramine (Anafranil) for a Answer: 1, 2, 3. Clomipramine, a tricyclic antidepressant

client diagnosed with obsessive-compulsive disorder. What used to treat obsessive-compulsive disorder, may cause ad-
instructions should the nurse include when teaching the verse CNS effects. Therefore, the nurse should warn the
client about this medication? Select all that apply. client to avoid hazardous activities that require alertness or
□ 1. Avoid hazardous activities that require alertness or good coordination until its effects are known. The nurse
good coordination until adverse central nervous system should instruct the client to avoid alcohol and other depres-
(CNS) effects are known. sants. Dry mouth, a common adverse effect of this medica-
□ 2. Avoid alcohol and other depressants. tion, can be relieved with saliva substitutes or sugarless
□ 3. Use saliva substitutes or sugarless candy or gum to candy or gum. The nurse should tell the client to take the
relieve dry mouth. medication with meals (not on an empty stomach), espe-
□ 4. Take the drug on an empty stomach. cially during the adjustment period, to minimize adverse GI
□ 5. Avoid using over-the-counter products, except antihis- effects. Later, the entire daily dose can be taken at bedtime.
tamines and decongestants, without medical approval. The nurse should encourage the client to continue therapy,
□ 6. Discontinue the medication if adverse reactions are even if adverse reactions are troublesome. The client
troublesome. shouldn’t stop taking the medication without medical
approval.
5. A nurse caring for a client with generalized anxiety dis- Answer: 4, 5, 6. The nurse should observe the client for
order identifies a nursing diagnosis of Anxiety. The short- overt signs of anxiety to determine his anxiety level and es-
term goal identified is that the client will identify his physi- tablish care priorities. She should also help the client con-
cal, emotional, and behavioral responses to anxiety. Which nect anxiety with uncomfortable physical, emotional, or be-
nursing interventions will help the client achieve this goal? havioral responses. To modify the automatic response to
Select all that apply. stress, the client needs to connect the anxiety experience
□ 1. Avoid talking about the client’s sources of stress. with the unpleasant symptoms. The nurse should also intro-
□ 2. Advise the client that consuming one glass of red duce the client to new coping strategies, such as relaxation
wine per day may lessen his anxiety. techniques and exercise, which can enable him to take per-
□ 3. Explain to the client that expressing his feelings sonal responsibility for making changes. The nurse should
through journal writing may increase his anxiety. work with the client to identify sources of stress — not
□ 4. Observe the client for overt signs of anxiety. avoid talking about it. The nurse should advise the client to
□ 5. Help the client connect anxiety with uncomfortable avoid using caffeine, nicotine, and alcohol to cope with anx-
physical, emotional, or behavioral responses. iety. Nicotine and caffeine are stimulants; alcohol acts as a
□ 6. Introduce the client to new strategies for coping with depressant but, over time, requires increased use to
anxiety, such as relaxation techniques and exercise. achieve the desired effect. The increased use may lead to
alcohol abuse. The nurse should encourage the client to
use a journal to record feelings, behaviors, stressful events,
and coping strategies used to address anxiety. Documenta-
tion may help the client become aware of his anxiety and
the ways it affects his overall functioning.
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6. The nurse is caring for a client who talks freely about Answer: 1, 2, 4. Clients who are depressed and express
feeling depressed. During an interaction, the nurse heard hopelessness also tend to manifest inappropriate
the client state, “Things will never change.” What other in- expressions of anger, periods of irritability, and feelings of
dications of hopelessness would the nurse look for? Select worthlessness. Options 3 and 5 are usually seen in clients
all that apply. with schizophrenia; they aren’t typically seen in those who
□ 1. Bouts of anger express hopelessness
□ 2. Periods of irritability Client needs category: Psychosocial integrity
□ 3. Preoccupation with delusions Client needs subcategory: None
□ 4. Feelings of worthlessness Cognitive level: Analysis
□ 5. Intense interpersonal relationships
7. The nurse interviews the family of a client who’s hospi- Answer: 4, 5, 6. When working with the family of a de-
talized with severe depression and suicidal ideation. Which pressed client, it’s helpful for the nurse to be aware of the
family assessment information is essential to formulating family’s communication style, the role expectations for its
an effective care plan? Select all that apply. members, and current family stressors. This information
□ 1. Physical pain can help identify family difficulties and teaching points that
□ 2. Personal responsibilities could benefit the client and his family. Information concern-
□ 3. Employment skills ing physical pain, personal responsibilities, and employ-
□ 4. Communication patterns ment skills wouldn’t be helpful because these areas aren’t
□ 5. Role expectations directly related to their experience of having a depressed
□ 6. Current family stressors family member.
8. A client is prescribed sertraline (Zoloft), a selective Answer: 1, 3, 5. Common adverse effects of Zoloft include
serotonin reuptake inhibitor. Which information about this agitation, sleep disturbance, and dry mouth. Agranulocyto-
drug’s adverse effects would the nurse include when creat- sis, intermittent tachycardia, and seizures are adverse
ing a medication teaching plan? Select all that apply. effects of clozapine (Clozaril).
□ 1. Agitation Client needs category: Physiological integrity
□ 2. Agranulocytosis Client needs subcategory: Pharmacological therapies
□ 3. Sleep disturbance Cognitive level: Knowledge
□ 4. Intermittent tachycardia
□ 5. Dry mouth
□ 6. Seizures
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9. The nurse is evaluating a client to determine whether Answer: 1, 4, 5, 6. Common characteristics of dementia in-
he’s suffering from dementia or depression. Which infor- clude a slow onset of symptoms, difficulty identifying when
mation helps the nurse to suspect dementia? Select all that the symptoms first occurred, noticeable changes in the
apply. client’s personality, and impaired ability to pay attention to
□ 1. The progression of symptoms is slow. other people. Options 2 and 3 are symptoms of depression,
□ 2. The client answers questions with, “I don’t know.” not dementia.
□ 3. The client acts apathetic and pessimistic. Client needs category: Psychosocial integrity
□ 4. The family can’t identify when the symptoms first Client needs subcategory: None
appeared. Cognitive level: Analysis
□ 5. The client’s basic personality has changed.
□ 6. The client has great difficulty paying attention to
others.
10. A client has been diagnosed with an adjustment disor- Answer: 2, 3. A client with an adjustment disorder is likely
der of mixed anxiety and depression. Which nursing diag- to have impaired social interaction and self-esteem distur-
noses are associated with a client who has an adjustment bance. The other nursing diagnoses aren’t related to the
disorder? Select all that apply. diagnosis of adjustment disorder.
□ 1. Activity intolerance Client needs category: Psychosocial integrity
□ 2. Impaired social interaction Client needs subcategory: None
□ 3. Self-esteem disturbance Cognitive level: Analysis
□ 4. Disturbed personal identity
□ 5. Acute confusion
□ 6. Impaired memory
11. A physician prescribes lithium for a client diagnosed Answer: 2, 5, 6. Client teaching should cover the signs and
with bipolar disorder. The nurse needs to provide appropri- symptoms of drug toxicity as well as the need to report
ate teaching for the client on this drug. Which topics them to the physician. The nurse should instruct the client
should the nurse cover? Select all that apply. to monitor his lithium levels on a regular basis to avoid toxi-
□ 1. The potential for addiction city. She should explain that 7 to 21 days may pass before
□ 2. Signs and symptoms of drug toxicity the client notes a change in his mood. Lithium doesn’t have
□ 3. The potential for tardive dyskinesia addictive properties. Tyramine is a potential concern to
□ 4. Information about a low-tyramine diet clients taking monoamine-oxidase inhibitors.
□ 5. The need to consistently monitor blood levels Client needs category: Physiological integrity
□ 6. Changes in his mood may take 7 to 21 days Client needs subcategory: Pharmacological therapies
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12. The nurse is monitoring a client who appears to be hal- Answer: 2, 3, 6. Using a calm voice, the nurse should reas-
lucinating. She notes paranoid content in the client’s speech sure the client that he’s safe. She shouldn’t challenge the
and he appears agitated. The client is gesturing at a figure client; rather, she should acknowledge his hallucinatory ex-
on the television. Which nursing interventions are appropri- perience. It isn’t appropriate to request that the client stop
ate? Select all that apply. the behavior. Implementing restraints isn’t warranted at
□ 1. In a firm voice, instruct the client to stop the behavior. this time. Although the client is agitated, no evidence exists
□ 2. Reinforce that the client isn’t in any danger. that the client might harm himself or others.
□ 3. Acknowledge the presence of the hallucinations. Client needs category: Psychosocial integrity
□ 4. Instruct other team members to ignore the client’s Client needs subcategory: None
behavior. Cognitive level: Application
□ 5. Immediately implement physical restraint procedures.
□ 6. Use a calm voice and simple commands.
13. A client with schizophrenia is taking the atypical an- Answer: 1, 4. Sore throat, fever, and the sudden onset of
tipsychotic medication clozapine (Clozaril). Which signs other flulike symptoms are signs of agranulocytosis. The
and symptoms indicate the presence of adverse effects condition is caused by the lack of a sufficient number of
associated with this medication? Select all that apply. granulocytes (a type of white blood cell), which causes sus-
□ 1. Sore throat ceptibility to infection. The client’s white blood cell count
□ 2. Pill-rolling movements should be monitored at least weekly throughout the course
□ 3. Polyuria of treatment. Pill-rolling movements can occur in a client
□ 4. Fever who’s experiencing extrapyramidal adverse effects associ-
□ 5. Polydipsia ated with antipsychotic medication that has been prescribed
□ 6. Orthostatic hypotension for much longer than a medication such as clozapine. Poly-
dipsia (excessive thirst) and polyuria (increased urine) are
common adverse effects of lithium. Orthostatic hypotension
is an adverse effect of tricyclic antidepressants.
14. A delusional client approaches the nurse, stating, “I’m Answer: 1, 6. Continued reality-based orientation is neces-
the Easter Bunny,” and insisting that the nurse refer to him sary, so the nurse should use the client’s name in any inter-
as such. The belief appears to be fixed and unchanging. action. Structured activities can help the client refocus and
Which nursing interventions should the nurse implement resolve his delusion. The nurse shouldn’t contribute to the
when working with this client? Select all that apply. delusion by going along with the situation or smiling at the
□ 1. Consistently use the client’s name in interaction. humor of the circumstances. Logical arguments and an
□ 2. Smile at the humor of the situation. as-needed medication aren’t likely to change the client’s
□ 3. Agree that the client is the Easter Bunny. beliefs.
□ 4. Logically point out why the client couldn’t be the Client needs category: Psychosocial integrity
Easter Bunny. Client needs subcategory: None
□ 5. Provide an as-needed medication. Cognitive level: Analysis
□ 6. Provide the client with structured activities.
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15. A physician starts a client on the antipsychotic medica- Answer: 1, 2, 4. Neuroleptic malignant syndrome is a life-
tion haloperidol (Haldol). The nurse is aware that this med- threatening extrapyramidal adverse effect of antipsychotic
ication has extrapyramidal adverse effects. Which mea- medications such as Haldol. It’s associated with a rapid in-
sures should the nurse take while the client is receiving crease in temperature. The most common extrapyramidal
Haldol? Select all that apply. adverse effect, akathisia, is a form of psychomotor restless-
□ 1. Closely monitor the client’s vital signs, especially ness that can often be relieved by pacing. Haldol and the
temperature. anticholinergic medications that are provided to alleviate its
□ 2. Provide the client with the opportunity to pace. extrapyramidal effects can result in dry mouth. Having the
□ 3. Monitor blood glucose levels. client suck on hard candy can help alleviate this problem.
□ 4. Provide hard candy for the client. Haldol doesn’t affect blood glucose levels. Urticaria isn’t
□ 5. Monitor for signs and symptoms of urticaria. usually associated with Haldol administration.
16. Which interventions would be supportive for a client Answer: 1, 2, 4, 5. Smaller meals may be better tolerated by
with a nursing diagnosis of Imbalanced nutrition: Less than the client and will gradually increase her daily caloric in-
body requirements related to dysfunctional eating patterns? take. The nurse should monitor the client’s weight because
Select all that apply. an anorexic will hide weight loss. Anorexics are emotionally
□ 1. Provide small, frequent feedings. restrained and afraid of their feelings, so journaling can be a
□ 2. Monitor weight gain. powerful tool that assists in recovery. Anorexic clients are
□ 3. Allow the client to skip meals until the antidepressant obsessed with gaining weight and will skip all meals if
levels are therapeutic. given the opportunity. Because of self-starvation, they
□ 4. Encourage journaling to promote the expression of seldom can tolerate large meals three times a day.
feelings. Client needs category: Psychosocial integrity
□ 5. Monitor the client at mealtimes and for an hour after Client needs subcategory: None
meals. Cognitive level: Analysis
□ 6. Encourage the client to eat three substantial meals a
day.
17. While collecting data on a client who was diagnosed Answer: 1, 2, 4. A client with an impulse control disorder
with impulse control disorder (and displays violent, aggres- who displays violent, aggressive, and assaultive behavior
sive, and assaultive behavior), the nurse can expect to find generally functions well in other areas of his life. The de-
which assessments? Select all that apply. gree of the client’s aggressiveness is disproportionate to
□ 1. The client functions well in other areas of his life. the stressor, and the client commonly has a history of
□ 2. The degree of aggressiveness is out of proportion to parental alcoholism, as well as a chaotic family life. The
the stressor. client often verbalizes sincere guilt and remorse for the
□ 3. The client often uses a stressor to justify his violent aggressive behavior.
behavior. Client needs category: Psychosocial integrity
□ 4. The client has a history of parental alcoholism and a Client needs subcategory: None
chaotic, abusive family life. Cognitive level: Application
□ 5. The client shows no remorse about his inability to
control his behavior.
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18. The parents of a client with attention deficit hyperactivity Answer: 1, 3, 5. Discussion of feelings and frustrations
disorder (ADHD) are taught strategies to assist their child about the behavior helps to prevent the child’s acting out.
in coping with this childhood psychiatric disorder. Which Setting limits prevents escalation of inappropriate behav-
items would the nurse include in the teaching plan. Select all iors. Internal states of thirst, hunger, and fatigue can precip-
that apply. itate a hyperactive response. Clients with ADHD don’t need
□ 1. Assist the child to express feelings of frustration. to be oriented to their surroundings and don’t necessarily
□ 2. Orient the child to his surroundings. have a pattern of declining physiological functioning.
□ 3. Set limits on the child’s behavior. Neither physical nor chemical restraints are ever used on
□ 4. Prepare for a decline in the child’s physical clients with ADHD.
functioning. Client needs category: Health promotion and
□ 5. Monitor the child’s bodily functions. maintenance
□ 6. Use restraints on the child when behavior is out of Client needs subcategory: None
control. Cognitive level: Application
19. The nurse is speaking with an adolescent diagnosed Answer: 1, 2, 3. The nurse establishes a consistent, pre-
with conduct disorder. While working on the goal of meet- dictable environment to reduce manipulative behavior. A
ing personal needs without manipulating others, the nurse behavioral contract is used to reinforce problem solving and
would implement which strategies? Select all that apply. encourage the use of social skills. When clients are allowed
□ 1. Discuss rules and consequences for not following the to make some choices, there are opportunities for them to
rules. have some control over their lives. Clients with conduct dis-
□ 2. Establish a behavioral contract. order typically aren’t shy and withdrawn in social situations.
□ 3. Allow the client some opportunities to make choices. Verbalization of negative feelings to others can escalate and
□ 4. Prevent the client from going into social withdrawal. result in acting out. Clients with conduct disorders tend to
□ 5. Encourage the client to verbalize negative feelings to be the ones who generate stress for others.
others. Client needs category: Health promotion and
□ 6. Discuss with the client how others can generate anxi- maintenance
ety in the client. Client needs subcategory: None
20. The nurse is explaining to a family that their father is in Answer: 2, 4, 6. In the late stage of Alzheimer’s disease, the
the late stages of Alzheimer’s disease. Which characteris- client is unable to recognize self or significant others. He’ll
tics would the nurse explain to the family? Select all that have difficulty swallowing, and he may have difficulty with
apply. eating and some weight loss. In addition, the client will
□ 1. Periods of confusion have increased. have minimal communication and will resort to communi-
□ 2. The client is unable to recognize family members. cating only with sounds. Increasing periods of confusion
□ 3. The client demonstrates periods of forgetfulness are symptoms of the early stage of Alzheimer’s disease,
about his personal effects. as is forgetfulness and noticeable changes in the client’s
□ 4. The client experiences difficulty eating and loses performance of ADLs.
weight. Client needs category: Health promotion and
□ 5. The client has difficulty performing his usual activi- maintenance
ties of daily living (ADLs). Client needs subcategory: None
□ 6. The client communicates less and less and sometimes Cognitive level: Application
only with sounds.
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21. A client with the diagnosis of schizophrenia demon- Answer: 2, 3, 4. Speaking to the client in a simple and direct
strates disorganized thinking. Which nursing interventions manner decreases anxiety and mistrust. It also promotes
would be effective for this client? Select all that apply. his ability to accomplish daily activities. By being informed
□ 1. Consult with others when the client’s verbalizations about what will be happening, the client can feel more se-
aren’t understood. cure and can cooperate without experiencing a high degree
□ 2. Speak to the client in simple, direct language. of stress. It’s important for the client to talk about problems
□ 3. Explain all procedures before carrying them out. that occur because of the presence of disturbing thoughts.
□ 4. Discuss any upsetting thoughts that the client has. When the nurse doesn’t understand what the client says,
□ 5. Determine how the use of denial inhibits accurate she must acknowledge this situation and address it directly
self-expression. with the client. Clients with disorganized thinking commonly
□ 6. Keep client expectations to a minimum. aren’t reality based, rather than in denial of what’s happen-
ing. The client responds better if expectations are made
clear and consistent, and well-defined rules for the unit are
reinforced by the nurse.
environment
22. A client with the diagnosis of schizophrenia is working Answer: 1, 2, 3, 4, 6. By having contact with a small group of
on the goal of establishing acceptable social skills. Which people, the client can begin to experience brief peer interac-
nursing interventions would be effective for this client? tions. Role-playing helps the client practice what to say and
Select all that apply. how to express himself appropriately. The suitable expres-
□ 1. Create opportunities for the client to socialize in sion of feelings can be difficult for a client who tends to stay
small-group settings. away from social situations. Family members can be valu-
□ 2. Encourage the client to role play with the nurse able resources in assisting the client with practicing com-
before social activities. munication and social skills. Having the client focus on peo-
□ 3. Teach the client how to express his feelings in socially ple and situations that are of interest helps make his experi-
acceptable ways. ence in learning realistic and meaningful. Therapy groups
□ 4. Have family members visit and provide opportunities usually have eight to ten people in the group. The client
for interaction. needs one-on-one and small group interactions to practice
□ 5. Use group therapy as a way to promote socialization social skills.
with peers. Client needs category: Psychosocial integrity
□ 6. Talk to the client about the people that he would like Client needs subcategory: None
to interact with socially. Cognitive level: Application
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23. The nurse evaluates a bipolar client’s activity level Answer: 1, 5, 6. Psychomotor agitation is defined by constant
while the client is in the community room. The observation motion, such as pacing, wringing hands, biting nails, and
includes the client’s pacing around the room, scanning the other types of energetic body movements. The client with
environment, and rubbing both hands together. Which bipolar disorder can be easily distracted. The client is re-
signs and symptoms would the nurse chart to communicate leasing pent-up emotions through physical movement
the client’s behaviors to the health care team? Select all that rather than through verbalization of concerns or problems.
apply. Psychophysiologic insomnia refers to difficulty attaining or
□ 1. Psychomotor agitation maintaining sleep; it doesn’t relate to the physiological
□ 2. Psychophysiologic insomnia symptoms of depression. Tardive dyskinesia refers to invol-
□ 3. Tardive dyskinesia untary movements associated with the adverse effects of
□ 4. Withdrawal syndrome antipsychotic medications. Withdrawal syndrome occurs
□ 5. Excessive distractibility when there’s an abrupt stoppage of a substance that the
□ 6. Decreased verbalizations client has become dependent upon as a result of pro-
longed use.
environment
24. The nurse is teaching the family of a client who has a Answer: 1, 3, 5, 6. By assisting the family members in han-
diagnosis of generalized anxiety disorder. Which informa- dling their anxiety effectively, they’ll communicate less anx-
tion will the nurse include in the teaching plan? Select all iety to the client. The level of family functioning can either
that apply. positively or negatively influence the individual client’s level
□ 1. Teach the family members methods to handle their of functioning. It isn’t useful for the family to take on the
anxiety. client’s responsibilities. It’s better for the client to learn
□ 2. Teach the family how to prevent the client from how to handle stress and the tasks that need to be done. If
becoming paranoid. the family has sufficient problem-solving ability, they can
□ 3. Help the family assess their own level of functioning. role-model problem-solving behavior for the client. Clients
□ 4. Develop a family plan for emergency intervention. who experience generalized anxiety don’t necessarily be-
□ 5. Encourage family members not to take on the client’s come paranoid. A plan for emergency intervention typically
responsibilities. isn’t required if the client is closely monitored, and urgent
□ 6. Discuss the family’s ability to solve problems. situations are handled promptly.
environment
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25. The nurse is working with a client who has a diagnosis Answer: 1, 3, 5. The nurse must accept the client’s pain, as
of pain disorder. Which nursing interventions would help this enables a relationship to occur instead of creating a sit-
the client understand the relationship between pain and uation where the client uses energy to defend the pain. Dis-
emotional problems? Select all that apply. cussion about the client’s anxiety will help the client iden-
□ 1. Acknowledge the client’s pain instead of challenging tify stressors and recognize the need for a plan to deal with
it. them. It’s important for the client to recognize the connection
□ 2. Use open-ended questions to guide the client through between escalating anxiety and pain. Although open-ended
the pain experience. questions are useful in therapeutic conversations, the inter-
□ 3. Talk about sources of anxiety in the client’s life. action must focus on the specific physical and emotional
□ 4. Explain situations that may cause the client’s pain. stressors that influence the client’s pain. It isn’t therapeutic
□ 5. Assist the client in determining if anxiety accentuates to tell the client what’s causing the pain disorder. Clients
the pain. with pain disorders don’t necessarily have difficulty orga-
□ 6. Help the client work on organizing his thoughts about nizing their thoughts and expressing themselves.
the pain experience. Client needs category: Psychosocial integrity
26. The nurse is co-leading a group for clients with sexual Answer: 1, 3, 5, 6. Preoccupation with body image, social
disorders. Several group members are undergoing legally isolation, ineffective coping related to individual or family
mandated treatment because they were diagnosed with dysfunction, and abnormal sexual fantasies are all charac-
paraphilias. Which assessment data would the nurse expect teristics associated with paraphilias. Pain during intercourse
to find in their charts? Select all that apply. is associated with sexual pain disorders, not with para-
□ 1. Preoccupation with body image philias. Performance anxiety is typically associated with
□ 2. Pain during intercourse sexual desire and arousal disorders, not with paraphilias.
□ 3. Social isolation Client needs category: Psychosocial integrity
□ 4. Performance anxiety Client needs subcategory: None
□ 5. Ineffective coping Cognitive level: Application
□ 6. Abnormal sexual fantasies
27. The nurse is having a therapeutic conversation with a Answer: 2, 3, 5. The client needs to have the nurse commu-
female client with bulimia nervosa. What are some of the nicate empathetically about her fear of losing control. By
communication strategies that the nurse should use while discussing with the client ways to build a positive sense of
interacting with this client? Select all that apply. self, the nurse changes the client’s focus away from nega-
□ 1. Verbalize interest in the client’s current physical tive thought and feelings. A discussion about the client’s
health problems. physical health problems isn’t as useful to the client as a
□ 2. Talk about the client’s fear of losing self control. discussion about her negative feelings about herself. There
□ 3. Discuss ways to promote a positive sense of self. are no medications that can alleviate bulimia nervosa.
□ 4. Describe the medications that can alleviate bulimia Sometimes antidepressant or antianxiety medications may
nervosa. be prescribed if anxiety or depression are present.
□ 5. Facilitate hope for developing a functional lifestyle. Client needs category: Physiological integrity
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28. The family of a client who had outpatient surgery calls Answer:
the nurse and asks about alcohol withdrawal symptoms. Ordered responses
The family states that it has been 14 hours since the client’s
last alcoholic drink. The nurse explains the progression of 3. Hand tremors
alcohol withdrawal symptoms and assists the family in
obtaining treatment for the client. 1. Elevated blood pressure
Place all of the symptoms listed below in ascending
chronological order. Use all of the options. 2. Restlessness and irritability
Unordered responses
4. Transient hallucinations
1. Elevated blood pressure In 4 to 12 hours after the client stops drinking alcohol, he’s
likely to experience alcohol withdrawal symptoms. The first
2. Restlessness and irritability
withdrawal symptoms are typically coarse tremors of the
hands. Next, changes in vital signs occur, such as elevated
3. Hand tremors
blood pressure and tachycardia. The client becomes in-
4. Transient hallucinations creasingly anxious, restless, and irritable. The symptoms of
transient hallucinations, seizures, and delirium tremens are
the final symptoms to occur in the withdrawal process if the
client isn’t treated for his condition.
29. A client with a diagnosis of anorexia nervosa is speak- Answer: 2, 4, 6. Having appropriate expectations allows the
ing to the nurse about her stressful life. The nurse and the client to become realistic about her needs and develop ap-
client agree to work on coping skills. Which strategies propriate goals. Use of relaxation techniques helps to re-
would the nurse include in the teaching? Select all that lieve stress and allows the client to become more comfort-
apply. able in handling daily life stressors. The client needs pleas-
□ 1. Work with the client to discuss her fears and develop ant activities to redirect her energies away from her
a treatment program. preoccupation with food, body image, and fear of becoming
□ 2. Encourage the client to develop realistic expectations fat. Clients with fears should be evaluated for a desensitiza-
of herself. tion treatment program. Although identification of trauma
□ 3 Have the client identify any trauma experienced, and is an important part of the nursing assessment, this client
assist her in obtaining legal support. requires that the nurse focus on developing skills to enable
□ 4. Teach relaxation techniques and have the client prac- the client to lead a healthy lifestyle. A behavioral contract
tice them daily. would be used to assist the client to meet the goal of weight
□ 5. Develop a behavioral contract to ensure the use of gain, not the goal of developing healthy coping skills.
healthy coping skills when stress occurs. Client needs category: Psychosocial integrity
□ 6. Have the client develop hobbies or other pleasant Client needs subcategory: None
ways to spend some of her time. Cognitive level: Application
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Physiologic changes
in aging
Aging is characterized by the loss of some body cells and reduced metabolism in other cells.
These processes cause a decline in body function and changes in body composition. This chart
will help you recognize the gradual changes in body function that normally accompany aging so
you can adjust your assessment techniques accordingly.
Area of assessment Age-related changes
Nutrition • Protein, vitamin, and mineral requirements usually unchanged

• Energy requirements possibly decreased by about 200 calories per
day because of diminished activity
• Loss of calcium and nitrogen (in patients who aren’t ambulatory)
• Diminished absorption of calcium and vitamins B1 and B2 due to
reduced pepsin and hydrochloric acid secretion
• Decreased salivary flow and decreased sense of taste (may reduce
appetite)
• Diminished intestinal motility and peristalsis of the large intestine
• Brittle teeth due to thinning of tooth enamel
• Loss of teeth
• Decreased biting force
• Diminished gag reflex
• Limited mobility (may affect ability to obtain or prepare food)
Skin • Facial lines resulting from subcutaneous fat loss, dermal thinning,
decreasing collagen and elastin, and 50% decline in cell replacement
• Delayed wound healing due to decreased rate of cell replacement
• Decreased skin elasticity (may seem almost transparent)
• Brown spots on skin due to localized melanocyte proliferation
• Dry mucous membranes and decreased sweat gland output (as the
number of active sweat glands declines)
• Difficulty regulating body temperature because of decrease in size,
number, and function of sweat glands and loss of subcutaneous fat
Hair • Decreased pigment, causing gray or white hair

• Thinning as the number of melanocytes declines
• Pubic hair loss resulting from hormonal changes
• Facial hair increase in postmenopausal women and decrease in men
806
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Eyes and vision • Baggy and wrinkled eyelids due to decreased elasticity, with eyes
sitting deeper in sockets
• Thinner and yellow conjunctivae; possible pingueculae (fat pads)
• Decreased tear production due to loss of fatty tissue in lacrimal
apparatus
• Corneal flattening and loss of luster
• Fading or irregular pigmentation of iris
• Smaller pupil, requiring three times more light to see clearly;
diminished night vision and depth perception
• Scleral thickening and rigidity; yellowing due to fat deposits
• Vitreous degeneration, revealing opacities and floating debris
• Lens enlargement; loss of transparency and elasticity, decreasing
accommodation
• Impaired color vision due to deterioration of retinal cones
• Decreased reabsorption of intraocular fluid, predisposing to
glaucoma
Ears and hearing • Atrophy of the organ of Corti and the auditory nerve (sensory
presbycusis)
• Inability to distinguish high-pitched consonants
• Degenerative structural changes in the entire auditory system
Respiratory system • Nose enlargement from continued cartilage growth

• General atrophy of tonsils
• Tracheal deviation due to changes in the aging spine
• Increased anteroposterior chest diameter as a result of altered
calcium metabolism and calcification of costal cartilage
• Lung rigidity; decreased number and size of alveoli
• Kyphosis
• Respiratory muscle degeneration or atrophy
• Declining diffusing capacity
• Decreased inspiratory and expiratory muscle strength; diminished
vital capacity
• Lung tissue degeneration, causing decrease in lungs’ elastic recoil
capability and increase in residual capacity
• Poor ventilation of the basal areas (from closing of some airways),
resulting in decreased surface area for gas exchange and reduced
partial pressure of oxygen
• Oxygen saturation decreased by 5%
• 30% reduction in respiratory fluids, heightening risk of pulmonary
infection and mucus plugs
• Lower tolerance for oxygen debt
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808 Physiologic changes in aging
Cardiovascular system • Slightly smaller heart size

• Loss of cardiac contractile strength and efficiency
• 30% to 35% diminished cardiac output by age 70
• Heart valve thickening, causing incomplete closure (systolic murmur)
• 25% increase in left ventricular wall thickness between ages 30
and 80
• Fibrous tissue infiltration of the sinoatrial node and internodal atrial
tracts, causing atrial fibrillation and flutter
• Vein dilation and stretching
• 35% decrease in coronary artery blood flow between ages 20 and 60
• Increased aortic rigidity, causing increased systolic blood pressure
disproportionate to diastolic, resulting in widened pulse pressure
• Electrocardiogram changes: increased PR interval, QRS complex,
and QT interval; decreased amplitude of QRS complex; shift of QRS axis
to the left
• Heart rate takes longer to return to normal after exercise
• Decreased strength and elasticity of blood vessels, contributing to
arterial and venous insufficiency
• Decreased ability to respond to physical and emotional stress
GI system • Diminished mucosal elasticity

• Reduced GI secretions, affecting digestion and absorption
• Decreased motility, bowel wall and anal sphincter tone, and
abdominal wall strength
• Liver changes: decreases in weight, regenerative capacity, and
blood flow
• Decline in hepatic enzymes involved in oxidation and reduction,
causing less efficient metabolism of drugs and detoxification of
substances
Renal system • Decline in glomerular filtration rate

• 53% decrease in renal blood flow secondary to reduced cardiac
output and atherosclerotic changes
• Decrease in size and number of functioning nephrons
• Reduction in bladder size and capacity
• Weakening of bladder muscles, causing incomplete emptying and
chronic urine retention
• Diminished kidney size
• Impaired clearance of drugs
• Decreased ability to respond to variations in sodium intake
Male reproductive system • Reduced testosterone production, resulting in decreased libido as

well as atrophy and softening of testes
• 48% to 69% decrease in sperm production between ages 60 and 80
• Prostate gland enlargement, with decreasing secretions
• Decreased volume and viscosity of seminal fluid
• Slower and weaker physiologic reaction during intercourse, with
lengthened refractory period
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Female reproductive system • Declining estrogen and progesterone levels (about age 50) cause:
– cessation of ovulation; atrophy, thickening, and decreased size of
ovaries
– loss of pubic hair and flattening of labia majora
– shrinking of vulval tissue, constricted introitus, and loss of tissue
elasticity
– vaginal atrophy; thin and dry mucus lining; more alkaline pH of
vaginal environment
– shrinking uterus
– cervical atrophy, failure to produce mucus for lubrication, thinner
endometrium and myometrium
– pendulous breasts; atrophy of glandular, supporting, and fatty
tissue
– nipple flattening and decreased size
– more pronounced inframammary ridges.
Neurologic system • Degenerative changes in neurons of central and peripheral nervous

system
• Slower nerve transmission
• Decrease in number of brain cells by about 1% per year after age 50
• Hypothalamus less effective at regulating body temperature
• 20% neuron loss in cerebral cortex
• Slower corneal reflex
• Increased pain threshold
• Decrease in stage III and IV of sleep, causing frequent awakenings;
rapid eye movement sleep also decreased
Immune system • Decline beginning at sexual maturity and continuing with age
• Loss of ability to distinguish between self and nonself
• Loss of ability to recognize and destroy mutant cells, increasing
incidence of cancer
• Decreased antibody response, resulting in greater susceptibility to
infection
• Tonsillar atrophy and lymphadenopathy
• Lymph node and spleen size slightly decreased
• Some active blood-forming marrow replaced by fatty bone marrow,
resulting in inability to increase erythrocyte production as readily as
before in response to such stimuli as hormones, anoxia, hemorrhage,
and hemolysis
• Diminished vitamin B12 absorption, resulting in reduced erythrocyte
mass and decreased hemoglobin level and hematocrit
9201BM.qxd 8/7/08 5:05 PM Page 810
810 Physiologic changes in aging
Musculoskeletal system • Increased adipose tissue

• Diminished lean body mass and bone mineral contents
• Decreased height from exaggerated spinal curvature and
narrowing intervertebral spaces
• Decreased collagen formation and muscle mass
• Increased viscosity of synovial fluid, more fibrotic synovial
membranes
Endocrine system • Decreased ability to tolerate stress

• Blood glucose concentration increases and remains elevated
longer than in a younger adult
• Diminished levels of estrogen and increasing levels of follicle-
stimulating hormone during menopause, causing coronary thrombosis
and osteoporosis
• Reduced progesterone production
• 50% decline in serum aldosterone levels
• 25% decrease in cortisol secretion rate
9201BM.qxd 8/7/08 5:05 PM Page 811
Positioning
clients
This chart lists various positions in which clients may be placed. These positions may be used
for client comfort, but proper positioning also maintains functional body alignment and client
safety, promotes respiration and circulation, relieves pressure, and aids in administering treat-
ment.
Position Implementation Rationale Indications
Elevation of Use the bed controls to el- • Promotes circulation • Thrombophlebitis

extremity evate the lower extremi- and comfort • After cast application
ties, or use pillows to ele- • Enables examina- • Edema
vate the upper and lower tions and procedures • After surgery on
extremities. extremity
Dorsal Place the client on his back • Immobilizes the • Spinal cord injury
recumbent with his knees slightly spine • Urinary catheter
(supine) flexed. Place a pillow be- insertion
neath his head for comfort. • Vaginal examination
Fowler’s Elevate the head of the bed • Enables examination • Head injury, cranial
to 45 degrees, and raise • Immobilizes the surgery, increased in-
the bed section under the spine tracranial pressure (ICP)
client’s knees, flexing them • Promotes drainage, • After abdominal surgery
slightly. cardiac output, and • Dyspnea
ventilation • Vomiting
• Prevents aspiration • After thyroidectomy
of food and secretions • After eye surgery
High Fowler’s Elevate the head of the bed • Promotes drainage, • Head injury, cranial
to 90 degrees, and raise cardiac output, and surgery, increased ICP
the bed section under the ventilation • Dyspnea, respiratory
client’s knees, flexing them • Prevents aspiration distress
slightly. of food and secretions • Feeding (during and after
meals)
• Hiatal hernia
Lateral Place the client on his side, • Promotes safety • After abdominal surgery
(side-lying) with weight being mostly • Prevents atelecta- • Coma
supported by the lateral assis, pressure ulcers, • Pressure ulcer
pect of the lower scapula and aspiration of food • Enema or rectal
and the lower ileum. and secretions irrigation
Support with pillows.
811
9201BM.qxd 8/7/08 5:05 PM Page 812
812 Positioning clients
Position Implementation Rationale Indications
Lithotomy Place the client on his back • Enables examination • Perineal or rectal proce-
(either flat or with the head of the pelvis dure
slightly elevated). His
knees should be flexed at
right angles and his feet
placed in stirrups.
Prone Place the client on his • Enables examination • Immobilization

stomach with the head of the back and spine • Acute respiratory dis-
turned to one side. Position • Promotes gas ex- tress syndrome
his arms at the side or change • After lumbar puncture or
above the head. Make sure myelogram
that his legs are extended.
Reverse Elevate the head of the bed • Provides counter- • Cervical traction
Trendelenburg’s and lower the client’s feet. balance for traction • After lower extremity
• Promotes blood flow vessel surgery
to the lower extremi-
ties
Semi-Fowler’s Elevate the head of the bed • Promotes drainage, • Head injury, cranial
to 30 degrees, and raise cardiac output, and surgery, increased ICP
the bed section under the ventilation • After abdominal surgery
client’s knees, flexing them • Prevents aspiration • Dyspnea
slightly. of food and secretions • Vomiting
• After thyroidectomy
• After eye surgery
Sims’ Position the client on his • Enables examination • Coma

side with a small pillow be- of the back and rectum • Rectal injuries
neath his head. Flex one • Prevents pressure
knee toward his abdomen, ulcers and atelectasis
with the other knee only
slightly flexed. Place one
arm behind his body and
the other in a comfortable
position. Support with
pillows.
Trendelenburg’s Position the client supine • Promotes postural • Shock

with his feet elevated 30 to drainage and venous • Cystic fibrosis
40 degrees higher than his return
head.
9201BM.qxd 8/7/08 5:05 PM Page 813
State boards
of nursing
Alabama Colorado
Alabama Board of Nursing Colorado Board of Nursing
770 Washington Ave. 1560 Broadway, Suite 1350
RSA Plaza, Suite 250 Denver, CO 80202
P.O. Box 303900 Phone: (303) 894-2430
Montgomery, AL 36130-3900 Fax: (303) 894-2821
Phone: (334) 242-4060 Web site: www.dora.state.co.us/nursing
Fax: (334) 242-4360
Web site: www.abn.state.al.us Connecticut
Connecticut Board of Examiners for Nursing
Alaska Department of Public Health
Alaska Board of Nursing 410 Capitol Ave., MS# 13PHO
550 W. 7th Ave., Suite 1500 P.O. Box 340308
Anchorage, AK 99501-3567 Hartford, CT 06134-0328
Phone: (907) 269-8161 Phone: (860) 509-7624
Fax: (907) 269-8196 Fax: (860) 509-7553
Web site: www.dced.state.ak.us/occ/pnur.htm Web site: www.state.ct.us/dph
Arizona Delaware
Arizona State Board of Nursing Delaware Board of Nursing
4747 North 7th St., Suite 200 861 Silver Lake Blvd.
Phoenix, AZ 85014-3653 Cannon Building, Suite 203
Phone: (602) 889-5150 Dover, DE 19904
Fax: (602) 889-5155 Phone: (302) 744-4500
Web site: www.azbn.gov Fax: (302) 739-2711
Web site: www.dpr.delaware.gov/boards/
Arkansas nursing
Arkansas State Board of Nursing
University Tower Building District of Columbia
1123 S. University, Suite 800 District of Columbia Board of Nursing
Little Rock, AR 72204-1619 Department of Health
Phone: (501) 686-2700 717 14th St., NW, Suite 600
Fax: (501) 686-2714 Washington, DC 20005
Web site: www.arsbn.org Phone: (877) 672-2174
Fax: (202) 727-8471
California Web site: hpla.doh.dc.gov/hpla/cwp/view,A,
California Board of Registered Nursing 1195,Q,488526,hpla,Nav/306611,.asp
1625 North Market Blvd., Suite N-217
Sacramento, CA 95834-1924
Phone: (916) 322-3350
Fax: (916) 574-7697
Web site: www.rn.ca.gov
813
9201BM.qxd 8/7/08 5:05 PM Page 814
814 State boards of nursing
Florida Indiana
Florida Board of Nursing Indiana State Board of Nursing
4052 Bald Cypress Way BIN C02 Professional Licensing Agency
Tallahassee, FL 32399-3252 402 W. Washington St., Room W072
Phone: (850) 245-4125 Indianapolis, IN 46204
Fax: (850) 245-4172 Phone: (317) 234-2043
Web site: www.doh.state.fl.us/mqa Fax: (317) 233-4236
Web site: www.in.gov/pla
Georgia
Georgia State Board of Licensed Iowa
Practical Nurses Iowa Board of Nursing
237 Coliseum Drive RiverPoint Business Park
Macon, GA 31217-3858 400 S.W. 8th St., Suite B
Phone: (478) 207-2440 Des Moines, IA 50309-4685
Fax: (478) 207-1354 Phone: (515) 281-3255
Web site: www.sos.state.ga.us/plb/rn Fax: (515) 281-4825
Web site: www.iowa.gov/nursing
Hawaii
Hawaii Board of Nursing Kansas
PVLD/DCCA Kansas State Board of Nursing
ATTN: Board of Nursing Landon State Office Bldg.
P.O. Box 3469 900 S.W. Jackson, Suite 1051
Honolulu, HI 96801 Topeka, KS 66612-1230
Phone: (808) 586-3000 Phone: (785) 296-4929
Fax: (808) 586-2689 Fax: (785) 296-3929
Web site: www.hawaii.gov/dcca/areas/pvl/ Web site: www.ksbn.org
boards/nursing
Kentucky
Idaho Kentucky Board of Nursing
Idaho Board of Nursing 312 Whittington Parkway, Suite 300
280 N. 8th St., Suite 210 Louisville, KY 40222-5172
P.O. Box 83720 Phone: (502) 429-3300
Boise, ID 83720-0061 Fax: (502) 429-3311
Phone: (208) 334-3110 Web site: www.kbn.ky.gov
Fax: (208) 334-3262
Web site: www.2.state.id.us/ibn Louisiana
Louisiana State Board of Nursing
Illinois 3421 N. Causeway Blvd., Suite 505
Illinois Board of Nursing Metairie, LA 70002
James R. Thompson Center Phone: (504) 838-5791
100 W. Randolph St., Suite 9-300 Fax: (504) 838-5279
Chicago, IL 60601 Web site: www.lsbn.state.la.us
Phone: (312) 814-2715
Fax: (312) 814-3145
Web site: www.idfpr.com/dpr/WHO/nurs.asp
9201BM.qxd 8/7/08 5:05 PM Page 815
Maine Missouri
Maine State Board of Nursing Missouri State Board of Nursing
158 State House Station 3605 Missouri Blvd.
Augusta, ME 04333 P.O. Box 656
Phone: (207) 287-1133 Jefferson City, MO 65102-0656
Fax: (207) 287-1149 Phone: (573) 751-0681
Web site: www.maine.gov/boardofnursing Fax: (573) 751-0075
Web site: www.pr.mo.gov/nursing.asp
Maryland
Maryland Board of Nursing Montana
4140 Patterson Ave. Montana State Board of Nursing
Baltimore, MD 21215-2254 301 South Park, Suite 401
Phone: (410) 585-1900 P.O. Box 200513
Fax: (410) 358-3530 Helena, MT 59620-0513
Web site: www.mbon.org Phone: (406) 841-2345
Fax: (406) 841-2305
Massachusetts Web site: www.nurse.mt.gov
Massachusetts Board of Registration
in Nursing Nebraska
Commonwealth of Massachusetts Nebraska Board of Nursing
239 Causeway St., 2nd Floor 301 Centennial Mall South
Boston, MA 02114 Lincoln, NE 68509-4986
Phone: (617) 973-0800 Phone: (402) 471-4376
Fax: (617) 973-0984 Fax: (402) 471-1066
Web site: www.mass.gov/dpl/boards/rn/ Web site: www.hhs.state.ne.us/crl/nursing/
nursingindex.htm
Michigan
Michigan IDCH/Bureau of Health Professions Nevada
Ottawa Towers North Nevada State Board of Nursing
611 W. Ottawa, 1st Floor Licensure and Certification
Lansing, MI 48933 2500 W. Sahara Ave., Suite 207
Phone: (517) 335-0918 Las Vegas, NV 89102-4292
Fax: (517) 373-2179 Phone: (702) 486-5800
Web site: www.michigan.gov/healthlicense Fax: (702) 486-5803
Web site: www.nursingboard.state.nv.us
Minnesota
Minnesota Board of Nursing New Hampshire
2829 University Ave. SE, Suite 200 New Hampshire Board of Nursing
Minneapolis, MN 55414-3253 21 S. Fruit St., Suite 16
Phone: (612) 617-2770 Concord, NH 03301-2431
Fax: (612) 617-2190 Phone: (603) 271-2323
Web site: www.nursingboard.state.mn.us Fax: (603) 271-6605
Web site: www.state.nh.us/nursing
Mississippi
Mississippi Board of Nursing
1935 Lakeland Dr., Suite B
Jackson, MS 39216
Phone: (601) 987-4188
Fax: (601) 364-2352
Web site: www.msbn.state.ms.us
9201BM.qxd 8/7/08 5:05 PM Page 816
816 State boards of nursing
New Jersey Oklahoma

New Jersey Board of Nursing Oklahoma Board of Nursing
P.O. Box 45010 2915 N. Classen Blvd., Suite 524
124 Halsey St., 6th Floor Oklahoma City, OK 73106
Newark, NJ 07101 Phone: (405) 962-1800
Phone: (973) 504-6430 Fax: (405) 962-1821
Fax: (973) 648-3481 Web site: www.youroklahoma.com/nursing
Web site: www.state.nj.us/lps/ca/medical/
nursing.htm Oregon
Oregon State Board of Nursing
New Mexico 17938 S.W. Upper Boones Ferry Rd.
New Mexico Board of Nursing Portland, OR 97224
6301 Indian School NE, Suite 710 Phone: (971) 673-0685
Albuquerque, NM 87110 Fax: (971) 673-0684
Phone: (505) 841-8340 Web site: www.osbn.state.or.us
Fax: (505) 841-8347
Web site: www.bon.state.nm.us/index.html Pennsylvania
Pennsylvania State Board of Nursing
New York P.O. 2649
New York State Board of Nursing Harrisburg, PA 17105-2649
Education Bldg. Phone: (717) 783-7142
89 Washington Ave., 2nd floor, West Wing Fax: (717) 783-0822
Albany, NY 12234-1000 Web site:
Phone: (518) 474-3817 ext. 280 www.dos.state.pa.us/bpoa/cwp/view.asp?a=
Fax: (518) 474-3706 1104&9=432869
Web site: www.nysed.gov/prof/nurse.htm
Rhode Island
North Carolina Rhode Island Board of Nurse Registration
North Carolina Board of Nursing and Nursing Education
3724 National Drive, Suite 201 105 Cannon Bldg., Three Capitol Hill
Raleigh, NC 27602 Providence, RI 02908
Phone: (919) 782-3211 Phone: (401) 222-5700
Fax: (919) 781-9461 Fax: (401) 222-3352
Web site: www.ncbon.com Web site: www.health.ri.gov
North Dakota South Carolina

North Dakota Board of Nursing South Carolina State Board of Nursing
919 S. 7th St., Suite 504 110 Centerview Drive, Suite 202
Bismarck, ND 58504-5881 Columbia, SC 29210
Phone: (701) 328-9777 Phone: (803) 896-4550
Fax: (701) 328-9785 Fax: (803) 896-4525
Web site: www.ndbon.org Web site: www.llr.state.sc.us/pol/nursing
Ohio South Dakota

Ohio Board of Nursing South Dakota Board of Nursing
17 S. High St., Suite 400 4305 S. Louise Ave., Suite 201
Columbus, OH 43215-7410 Sioux Falls, SD 57106-3115
Phone: (614) 466-3947 Phone: (605) 362-2760
Fax: (614) 466-0388 Fax: (605) 362-2768
Web site: www.nursing.ohio.gov Web site: www.state.sd.us/doh/nursing
9201BM.qxd 8/7/08 5:05 PM Page 817
Tennessee Washington
Tennessee State Board of Nursing Washington State Nursing Care Quality
227 French Landing, Suite 300 Assurance Commission
Heritage Place Metro Center Department of Health
Nashville, TN 37243 HPQA #6
Phone: (615) 532-5166 310 Israel Rd. SE
Fax: (615) 741-7899 Tumwater, WA 98501-7864
Web site: www.health.state.tn.us/Boards/ Phone: (360) 236-4700
Nursing/index.htm Fax: (360) 236-4738
Web site: fortress.wa.gov/doh/hpqa1/hps6/
Texas Nursing/default.htm
Texas Board of Nurse Examiners
333 Guadalupe, Suite 3-460 West Virginia
Austin, TX 78701 West Virginia Board of Examiners
Phone: (512) 305-7400 for Licensed Practical Nurses
Fax: (512) 305-7401 101 Dee Drive
Web site: www.bon.state.tx.us Charleston, WV 25311-1620
Phone: (304) 558-3572
Utah Fax: (304) 558-4367
Utah State Board of Nursing Web site: www.lpnboard.state.wv.us
Heber M. Wells Bldg., 4th Floor
160 E. 300 South Wisconsin
Salt Lake City, UT 84111 Wisconsin Department of Regulation
Phone: (801) 530-6628 and Licensing
Fax: (801) 530-6511 1400 E. Washington Ave., Rm. 173
Web site: www.dopl.utah.gov/licensing/ Madison, WI 53708
nursing.html Phone: (608) 266-0145
Fax: (608) 261-7083
Vermont Web site: www.drl.state.wi.us
Vermont State Board of Nursing
Office of Professional Regulation Wyoming
National Life Bldg. North Fl.2 Wyoming State Board of Nursing
Montpelier, VT 0563402 1810 Pioneer Ave.
Phone: (802) 828-2396 Cheyenne, WY 82001
Fax: (802) 828-2484 Phone: (307) 777-7601
Web site: www.vtprofessionals.org/opr1/ Fax: (307) 777-3519
nurses Web site: nursing.state.wy.us
Virginia
Virginia Board of Nursing
Department of Health Professions
Perimeter Center
9960 Maryland Dr., Suite 300
Richmond, VA 23233
Phone: (804) 367-4515
Fax: (804) 527-4455
Web site: www.dhp.virginia.gov/nursing
9201BM.qxd 8/7/08 5:05 PM Page 818
NANDA
Nursing diagnoses
Here is a list of the 2007-2008 current nursing diagnoses classifications according to their
domains.
DOMAIN DOMAIN
Health promotion Elimination and Exchange

• Effective therapeutic regimen management • Bowel incontinence
• Health-seeking behaviors (specify) • Constipation
• Impaired home maintenance • Diarrhea
• Ineffective community therapeutic regimen • Functional urinary incontinence
management • Impaired gas exchange
• Ineffective family therapeutic regimen • Impaired urinary elimination
management • Overflow urinary incontinence
• Ineffective health maintenance • Perceived constipation
• Ineffective therapeutic regimen • Readiness for enhanced urinary elimination
management • Reflex urinary incontinence
• Readiness for enhanced immunization • Risk for constipation
status • Risk for urge urinary incontinence
• Readiness for enhanced nutrition • Stress urinary incontinence
• Readiness for enhanced therapeutic • Total urinary incontinence
regimen management • Urge urinary incontinence
• Urinary retention
DOMAIN
Nutrition
• Excess fluid volume
• Imbalanced nutrition: Less than body
requirements
• Imbalanced nutrition: More than body
requirements
• Impaired swallowing
• Ineffective infant feeding pattern
• Readiness for enhanced fluid balance
• Risk for deficient fluid volume
• Risk for imbalanced fluid volume
• Risk for imbalanced nutrition: More than
body requirements
• Risk for impaired liver function
• Risk for unstable blood glucose level
818
9201BM.qxd 8/7/08 5:05 PM Page 819
DOMAIN DOMAIN
Activity/Rest Perception/Cognition
• Activity intolerance • Acute confusion
• Bathing/hygiene self-care deficit • Chronic confusion
• Decreased cardiac output • Deficient knowledge (specify)
• Deficient diversional activity • Disturbed sensory perception (specify: visual,
• Delayed surgical recovery auditory, kinesthetic, gustatory, tactile)
• Dressing/grooming self-care deficit • Disturbed thought processes
• Dysfunctional ventilatory weaning response • Impaired environmental interpretation
• Energy field disturbance syndrome
• Fatigue • Impaired memory
• Feeding self-care deficit • Impaired verbal communication
• Impaired bed mobility • Readiness for enhanced communication
• Impaired physical mobility • Readiness for enhanced decision making
• Impaired spontaneous ventilation • Readiness for enhanced knowledge (specify)
• Impaired transfer ability • Risk for acute confusion
• Impaired walking • Unilateral neglect
• Impaired wheelchair mobility • Wandering
• Ineffective tissue perfusion (specify type: DOMAIN
renal, cerebral, cardiopulmonary,
gastrointestinal, peripheral) Self-perception
• Insomnia • Chronic low self-esteem
• Readiness for enhance self-care • Disturbed body image
• Readiness for enhanced sleep • Disturbed personal identity
• Risk for activity intolerance • Hopelessness
• Risk for disuse syndrome • Powerlessness
• Sedentary lifestyle • Readiness for enhanced hope
• Sleep deprivation • Readiness for enhanced power
• Toileting self-care deficit • Readiness for enhanced self-concept
• Risk for compromised human dignity
• Risk for loneliness
• Risk for powerlessness
• Risk for situational low self-esteem
• Situational low self-esteem
9201BM.qxd 8/7/08 5:05 PM Page 820
820 NANDA nursing diagnoses
DOMAIN • Readiness for enhanced family coping

• Readiness for enhanced organized infant
Role relationships behavior
• Relocation stress syndrome
• Caregiver role strain
• Risk for autonomic dysreflexia
• Dysfunctional family processes: Alcoholism
• Risk for complicated grieving
• Effective breast-feeding
• Risk for disorganized infant behavior
• Impaired parenting
• Risk for post-trauma syndrome
• Impaired social interaction
• Risk for relocation stress syndrome
• Ineffective breast-feeding
• Risk-prone health behavior
• Ineffective role performance
• Stress overload
• Interrupted breast-feeding
• Interrupted family processes
DOMAIN
• Parental role conflict
• Readiness for enhanced family processes
• Readiness for enhanced parenting
Life principles
• Risk for caregiver role strain • Decisional conflict (specify)
• Risk for impaired parent/infant/child • Impaired religiosity
attachment • Moral distress
• Risk for impaired parenting • Noncompliance (specify)
• Readiness for enhanced decision making
DOMAIN • Readiness for enhanced hope
• Readiness for enhanced religiosity
Sexuality • Readiness for enhanced spiritual well-being
• Risk for impaired religiosity
• Ineffective sexuality patterns
• Risk for spiritual distress
• Sexual dysfunction
• Spiritual distress
DOMAIN
Coping/Stress tolerance
• Anxiety
• Autonomic dysreflexia
• Chronic sorrow
• Complicated grieving
• Compromised family coping
• Death anxiety
• Decreased intracranial adaptive capacity
• Defensive coping
• Disabled family coping
• Disorganized infant behavior
• Fear
• Grieving
• Ineffective community coping
• Ineffective denial
• Post-trauma syndrome
• Rape-trauma syndrome
• Rape-trauma syndrome: Compound reaction
• Rape-trauma syndrome: Silent reaction
• Readiness for enhanced community coping
• Readiness for enhanced coping (individual)
9201BM.qxd 8/7/08 5:05 PM Page 821
DOMAIN DOMAIN
Safety/Protection Comfort
• Contamination • Acute pain
• Hyperthermia • Chronic pain
• Hypothermia • Nausea
• Impaired dentition • Readiness for enhanced comfort
• Impaired oral mucous membrane • Social isolation
• Impaired skin integrity
• Impaired tissue integrity DOMAIN
• Ineffective airway clearance
• Ineffective protection Growth/Development
• Ineffective thermoregulation • Adult failure to thrive
• Latex allergy response • Delayed growth and development
• Readiness for enhanced immunization • Risk for delayed development
status • Risk for disproportionate growth
• Risk for aspiration
• Risk for contamination
• Risk for falls
• Risk for imbalanced body temperature
• Risk for impaired skin integrity
• Risk for injury
• Risk for latex allergy response
• Risk for perioperative positioning injury
• Risk for peripheral neurovascular
dysfunction
• Risk for poisoning
• Risk for self-directed violence
• Risk for self-mutilation
• Risk for sudden infant death syndrome
• Risk for suffocation
• Risk for suicide
• Risk for trauma
• Self-mutilation
© NANDA International. (2007). NANDA-I Nursing Diagnoses: Definitions and Classifications 2007-2008. Philadelphia: NANDA.
Reprinted with permission.
9201BM.qxd 8/7/08 5:05 PM Page 822
Selected
references
Assessment Made Incredibly Easy, 4th ed. Lippincott’s Nursing Procedures, 5th ed.
Philadelphia: Lippincott Williams & Philadelphia: Lippincott Williams &
Wilkins, 2008. Wilkins, 2008.
Bickley, L., Bates’ Guide to Physical Examina- McKinney, E., et al. Maternal-Child Nursing,
tion and History Taking, 10th ed. Philadel- 2nd ed. Philadelphia: W.B. Saunders, 2007.
phia: Lippincott Williams & Wilkins, 2008. Meiner, S., and Lueckenatte, A. Gerontologic
Buchholz, S. Henke’s Med-Math, 6th ed. Nursing, 3rd ed. St. Louis: Mosby, 2006.
Philadelphia: Lippincott Williams & Mohr, W. Psychiatric-Mental Health Nursing,
Wilkins, 2008. 7th ed. Philadelphia: Lippincott Williams &
Cardiovascular Care Made Incredibly Easy, Wilkins, 2008.
2nd ed. Philadelphia: Lippincott Williams NANDA Nursing Diagnoses: Definitions and
& Wilkins, 2008. Classification 2007-2008. Philadelphia:
Chernecky, C., and Berger, B. Laboratory North American Nursing Diagnosis Asso-
Tests and Diagnostic Procedures, 5th ed. ciation, 2007.
Philadelphia: W.B. Saunders, 2008. Nursing2008 Drug Handbook, 28th ed.
Cohen, M. Medication Errors, 2nd ed. Wash- Philadelphia: Lippincott Williams &
ington, D.C.: American Pharmaceutics As- Wilkins, 2008.
sociation, 2007. Nursing Pharmacology Made Incredibly Easy,
Comprehensive Accreditation Manual for Hos- 2nd ed. Philadelphia: Lippincott Williams
pitals: The Official Handbook. Oakbrook & Wilkins, 2008.
Terrace, Ill.: The Joint Commission, 2008. Ogden, S. Calculation of Drug Dosages, 8th
Drug Facts and Comparisons, 62nd ed. ed. St. Louis: Mosby, 2007.
Philadelphia: Lippincott Williams & Pathophysiology Made Incredibly Easy, 4th ed.
Wilkins, 2008. Philadelphia: Lippincott Williams &
ECG Interpretation Made Incredibly Easy, 4th Wilkins, 2008.
ed. Philadelphia: Lippincott Williams & Perry, A., and Potter, P. Clinical Nursing Skills
Wilkins, 2008. and Techniques, 6th ed. St. Louis: Mosby-
Fischbach, F.T. A Manual of Laboratory and Year Book, Inc., 2006.
Diagnostic Tests, 8th ed. Philadelphia: Lip- Physicians’ Desk Reference, 62nd ed. Oradell,
pincott Williams & Wilkins, 2008. N.J.: Medical Economics Company, 2008.
Hess, C. Clinical Guide to Skin and Wound Price, D., and Given, J. Pediatric Nursing, 10th
Care, 6th ed. Philadelphia: Lippincott ed. Philadelphia: W.B. Saunders, 2008.
Williams & Wilkins, 2007. Roach, S., and Ford, S. Introductory Clinical
Karch, A. Focus on Nursing Pharmacology, 4th Pharmacology. Philadelphia: Lippincott
ed. Philadelphia: Lippincott Williams & Williams & Wilkins, 2007.
Wilkins, 2006.
822
9201Index.qxd 8/7/08 4:02 PM Page 823
Index
A Acute poststreptococcal glomerulonephritis, 304,

Abdomen, neonatal assessment of, 536 313–314
Abdominal aortic aneurysm, 22, 34–36 Acute renal failure, 304, 314–316
types of, 35 classifying, 314
Abdominal girth, measuring, 276, 758 Acute respiratory distress syndrome, 70, 80–81
ABO blood typing, 124, 165 Acute respiratory failure, 70, 82–83
in child, 593–594 Acute secretory otitis media, 618–620
Abruptio placenta, 496, 504, 777 Acute sequestration crisis in sickle cell anemia, 160
Absence seizure, 621t, 625 Acute suppurative otitis media, 618–620
Abuse, 719, 729–730 Acyclovir, adverse effects of, 193
assessing person responsible for, 729 Addisonian crisis, 287
characteristic signs of, 729 treatment for, 301
documenting findings in, 730 Addison’s disease, 278, 287–288
helping person responsible for, 730 Adjustment disorder, 798
obtaining history of victim of, 729 Adolescent
recognizing, 729 developmental milestones for, 560, 563
reporting, 729, 737–738 signs of sexual maturation in, 564, 565
support services for victims of, 730, 738 Adolescent pregnancy, 472, 483–484
types of, 729 Adrenal crisis. See Addisonian crisis.
Acetaminophen poisoning, 644, 648–649 Adrenal glands, 277, 281
hepatotoxicity in, 648 Adrenal hypofunction, 278, 287–288
Acid-base balance, kidneys’ role in, 303 Adrenocorticotropic hormone, 277
Acid-base imbalance Adult chorea, 173, 197–198
metabolic acidosis and, 119, 148–149 Aerosols as inhalants, 431
metabolic alkalosis and, 119, 149
Afterpains, causes of, 550–551
respiratory acidosis and, 76, 104–105
Aggressive behavior, 460
respiratory alkalosis and, 76, 105–106
Agoraphobia, 393
Acidosis
AIDS. See Acquired immunodeficiency syndrome.
metabolic, 119, 148–149
Akinesia, 461
respiratory, 76, 104–105
Akinetic seizure, 621t, 625
Acne vulgaris, 684, 686–688
Alcohol as depressant, 431, 435
patient teaching for, 759
Acquired immunodeficiency syndrome, 114, 127–129 Alcohol disorder, 430, 431–432, 434–435, 436
in child, 592, 594–595, 606 Alcoholics Anonymous, philosophy of, 464
indicator diseases in, 127 Alcohol withdrawal, symptoms of, 805
as pregnancy complication, 472, 482–483 Aldosterone, 277
transmission of, 127–128 Alimentary canal, 643
Acrocyanosis, 537 Alkalosis
Acromegaly, 278, 285–287 metabolic, 119, 149
Acute angle-closure glaucoma, 194–195 respiratory, 76, 105–106
Acute coronary syndrome, 36, 52–55 Alpha-fetoprotein level, purpose of measuring, 334
Acute glomerulonephritis, 304, 313–314 ALS. See Amyotrophic lateral sclerosis.
Acute head injury. See Head injury, acute. Alternate formats for test questions, 5, 7
Acute idiopathic polyneuritis, 173, 195–196 Alveoli, 69
Acute infective tubulointerstitial nephritis, 672–673, Alzheimer’s-type dementia, 399, 400, 401–402, 406,
676–678, 680, 681 408, 801
Acute pericarditis, 56–57 caregiver strain and, 403
i refers to an illustration; t refers to a table.
823
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Alzheimer’s-type dementia (continued) Antigout drugs, adverse effects of, 224

measuring progression of, 399, 401 Antimotivational syndrome, 442
nursing interventions for, 766 Antipsychotic drugs, adverse effects of, 461–462
stages of, 401–402 Antisocial personality disorder, 409, 410, 411, 412,
Ambivalence, 465 415, 467
Ambulatory electrocardiography, 31 Anxiety, alleviating, in patient with leukemia, 144
Amnesic disorder, 400, 402–403, 408 Anxiety disorders, 387, 388, 389, 391, 393–396
Amniocentesis, 480, 548 concepts of, 387
preparing client for, 548 practice questions related to, 396–398
Amnioinfusion, 507 Aortic arch syndrome, 123, 164–165
Amnion, 478 Aortic insufficiency, 29, 30, 63, 64
Amniotic fluid, 479 Aortic stenosis, 569–571
Amniotic fluid embolism, 496, 505 murmur in, 752
emergency birth and, 512–513 Aortic valve, 21
Amniotomy, interventions for, 516 Apgar scoring system, 535t, 781, 784
Amphetamines, 431, 435 Apical heart rate, auscultating, 751
abuse of, 792 Aplastic anemia, 115, 132–133
Amputation, aftercare for, 41, 765 Aplastic crisis in sickle cell anemia, 160
Amylase, 281 Apocrine sweat glands, 339
Amyotrophic lateral sclerosis, 170, 182–184 in adolescent, 683
Analgesics related to opiates, 431 Appendicitis, 238, 247–249
Anaphylaxis, 114, 129–130 location of pain in, 752
preventing, 130 Aqueous humor, 177
Androgens, 277 ARDS. See Acute respiratory distress syndrome.
Anemia
Argon laser trabeculoplasty, 194
aplastic, 115, 132–133
Arm fracture, 216, 220–221
iron deficiency, 117, 140–141
Arnold-Chiari malformation, 616
in child, 592, 597–598, 602, 603–604
Arrhythmias, 22–23, 37–39
pernicious, 119, 151–152
as myocardial infarction complications, 54t
sickle cell, 122, 159–160
Arterial blood gas analysis, 33–34, 79
in child, 593, 601–603, 604
in child, 579
Anesthesia for labor pain, 503
Arterial occlusive disease, 23–24, 39–41
Aneurysm
arteries affected by, 39–40
abdominal aortic, 22, 34–36
cerebral, 171–172, 189–190 Arteries, 30
thoracic aortic, 28–29, 60–61 Arteriography, 31
Angel dust, 431 adverse aftereffects of, 355
Angina, 22, 36–37 in child, 611
forms of, 36 Arterioles, 31
signs and symptoms of, 754 Arthrocentesis, 219
Angiography, 31 Arthroscopy, 219
Angiotensin-converting enzyme inhibitors, adverse in child, 629, 639
effects of, 775 postprocedure assessment of, 233
Angle-closure glaucoma, 173, 194–195 Artificially acquired active immunity, 591, 593
Ankle, passive range-of-motion exercises for, 209 Artificially acquired passive immunity, 593
Ankylosing spondylitis, 115, 131–132 Asbestosis, 70–71, 83, 85
progression of, 131 Ascending aortic aneurysm, 61
Anorexia nervosa, 453–455, 456–457, 458–459, 462, Aspartate aminotransferase measurement, 356
800, 805 Asphyxia, 71, 85–86
Antepartum period, 471–494. See also Pregnancy. in utero, 780
complications of, 472–474, 482–491 Aspirin overdose, 645, 657–658
diagnostic tests for, 480–482 Assertive behavior, 460
practice questions related to, 492–494 Asthma, 71, 86–87
Anterior cerebral artery, clinical features of injury in child, 578, 580–582, 588
to, 208. See also Stroke. Cushing’s syndrome as therapy complication of, 301
Anterior chamber of the eye, 177 prevention techniques for, 87
Antidiuretic hormone, 277 Asystole, 22, 23, 37, 38
deficiency of, 279, 289–290 Ataxic cerebral palsy, 613–615

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Atelectasis, 71–72, 87–89 Bipolar disorder (continued)

Athetoid cerebral palsy, 613–615 genetic component in, 398
Atonic seizure, 621t, 625 manic phase of, 387, 466
Atopic asthma, 86–87 Blackhead, 687
Atopic dermatitis, 340, 342–343 Bladder, 303
Atopic eczema, 340, 342–343 inflammation of, 306, 324–325
Atrial fibrillation, 22, 23, 37, 38 neurogenic, 307, 327–328
Atrial septal defect, 569–571 Bladder cancer, 305, 317–318
Atrioventricular valves, 21 treatment options for, 318
Attention deficit disorder. See Attention deficit hy- Bladder irrigation, continuous, removing blockage
peractivity disorder. in, 356
Attention deficit hyperactivity disorder, 608, Blood
612–613, 627, 699, 801 circulation through heart, 21, 30
diagnostic criteria for, 612 components of, 591
Attitude as labor component, 495 functions of, 591
Audiometry, 181 Blood glucose monitor, how to use, 353
Audiovisual tools as study aids, 17 Blood vessels, types of, 30–31
Auditory acuity test, 180 B lymphocytes, 124
Auditory hallucinations, 417, 425–426, 465 Body image, accepting changes in, 358–359
Autocratic management style, 707 Body surface area, estimating, in burn patient, 343–344
Autoimmune thyroiditis, 281, 298–299 Bone healing, 629
Autonomic nervous system, 177 Bone lengthening, 629
Axons, 169 Bone marrow, 113, 215
biopsy, 761
B examination, 126
Babinski’s reflex, 537 transplantation, 599
Bacterial endocarditis, 25, 46–47 Bone scan, 127, 219
Ballottement, 471 Borderline personality disorder, 410, 411–412, 467–468
Barbiturates as depressants, 431 Boston brace, 636
Barium enema, 244, 268 Braces, 636
aftercare for, 274–275 Brachial pulse, locating, 787
in child, 646 Brain, 169
Barium swallow test, 244 cognitive disorders and, 399
in child, 643, 646 Brain abscess, 171, 185–187
Barlow’s sign, 633 Brain attack. See Stroke.
Barotitis media, 618–620 Brain stem, 177
Barotrauma, 618 Brain tumor, 171, 187–188, 214
Bartholin’s glands, 309 classifying, 187
Basal cell carcinoma, 341, 349 Braxton Hicks contractions, 471, 494, 495
Basilar artery occlusion, 39–41 Breast cancer, 305, 319–320, 337
B cells, 124 Breast engorgement, avoiding, 554
Beck Depression Inventory, 367 Breast-feeding
Bed-to-wheelchair transfer technique, 214 avoiding engorgement during, 554
Bell’s palsy, 170–171, 184–185 evaluating effectiveness of, 555
Benchmarking, 711, 715 immunity passed on through, 603
Benign prostatic hyperplasia, 304, 316 infant’s nutritional needs and, 563–564
Benzodiazepines as depressants, 431 mastitis and, 520, 524
Beta2–adrenergic agonists, evaluating effectiveness Breasts, 310
of, 111 postpartum assessment of and interventions for,
Beta-human chorionic gonadotropin level, purpose 522–523
of measuring, 334 Breathing, process of, 577
Binge eating, 457 Breathing exercises, 110–111
Biological therapies, emotional and behavioral dis- Breathing-related sleep disorder, 374, 378, 380, 381
turbances and, 368 Breath sounds, implications of changes in, 356
Biophysical profile of fetus, 481–482 Broad openings as communication technique, 363
Bipolar disorder, 387, 388, 390, 803 Bronchi, 69
common patterns in, 387 Bronchiectasis, 72, 89–90
depressive phase of, 390 forms of, 89

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Bronchioles, 69 Cardiopulmonary resuscitation in infant, 786

Bronchiolitis, 578, 582–583 Cardiovascular system, 21–68. See also Pediatric
Bronchopulmonary dysplasia, 578, 583 cardiovascular system.
Bronchoscopy, 78 age-related changes in, 808t
aftercare for, 769 anatomy of, 21
preparing client for, 768 antepartum chanes in, 471, 474–475
vasovagal response during, 110 changes in, during labor, 500
Bronchovesicular breath sounds, auscultating, 751 circulation and, 21, 30–31
Brudzinski’s sign, 200 components and functions of, 21, 30–31
Bryant’s traction, 636 diagnostic tests for, 31–34
Bulbourethral glands, 311 disorders of, 22–30, 34–65
Bulimia nervosa, 454, 455–456, 457–459, 804 neonatal adaptations and, 531
Burns, 340, 343–345 postpartum changes in, 519
in child, 684, 688–689, 693–694, 704 practice questions related to, 65–68
classifying, 343 Care, delegating, as test pitfall, 12
donor site care for, 352 Caregiver, coping strategies for, 403
emergency care for, 693 Carotid artery, clinical features of injury to, 208. See
estimating extent of, 343–344 also Stroke.
nursing interventions for, 760 Carotid artery occlusion, 39–41
preventing hypovolemic shock in, 351 Carotid pulse, palpating, 750
Carpal tunnel syndrome, 216, 222–223
C Carpopedal spasms, 105
Caffeine, 431 Cartilage, 215
CAGE Questionnaire, 367, 432, 434, 436 Caseation, 109
Calcium Cast
function of, 133 caring for, 231, 636, 640, 700–701, 747
imbalance of, 115–116, 133–135 hip-spica, 636
Cancer Cataplexy, 380
bladder, 305, 317–318 Cataract, 171, 188–189
breast, 305, 319–320 positioning patient after removal of, 214
cervical, 305, 320–321 Catatonic schizophrenia, 418, 419–421, 426, 427
colorectal, 239, 252–254 Celiac disease, 644, 649–650, 659
esophageal, 240, 257, 259 Cell-mediated immunity, 124
gastric, 240, 259–260 Central alveolar hypoventilation syndrome, 374,
lung, 74, 96–97 378, 380, 381
ovarian, 307, 328–330 Central nervous system, 169, 177
pancreatic, 280–281, 295–297 in child, 607
prostate, 308, 330–331 Central sleep apnea syndrome, 374, 378, 380, 381
skin, 341, 349 Cephalohematoma, 535
testicular, 308–309, 333–335 Cerebellum, 169, 768
thyroid, 281, 297–298 abscess in, 171, 185–187
Cannabis, 429, 431, 435 tumor in, 171, 187–188
Capillaries, 31 Cerebral aneurysm, 171–172, 189–190
Caput succedaneum, 535 aftercare for repair of, 213
Carbidopa-levodopa, evaluating effectiveness of, 360 classifying, 189
Carcinoma in situ, 305, 320–321 Cerebral angiogram, 178
Cardiac arrest, treatment algorithm for, 774 in child, 611
Cardiac catheterization, 31 Cerebral hemorrhages, classifying, 181
aftercare for, 753 Cerebral palsy, 608, 613–615
in child, 573, 696–697 classifying, 613
in pediatric patient, 567, 569 Cerebrospinal fluid, excessive amount of, in brain.
Cardiac output, 30 See Hydrocephalus.
Cardiac sphincter, 237 Cerebrospinal fluid analysis, 179
Cardiac tamponade, 24, 41–42, 753 Cerebrovascular accident. See Stroke.
Cardiogenic shock, 24–25, 42–44 Cerebrum, 169
as myocardial infarction complication, 54t Cervical cancer, 305, 320–321
Cardiomyopathy, 25, 44–45 classifying, 320
types of, 44 Cervicitis, 305–306, 321–322

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Cervix, 310 Clear liquids, 790

Cesarean delivery, 513 Cleft lip and palate, 644, 650–652, 659–660
Chadwick’s sign, 471 aftercare for repair of, 787
Charting. See Documentation. feeding neonate with, 549
Cheiloplasty, 650, 651 parent teaching for repair of, 701
positioning infant after, 659 Client needs categories in NCLEX, 3, 4t
Chest, neonatal assessment of, 536 Client positions, 811–812t
Chest pain Client safety, reviewing, as test strategy, 10–11
in angina, 36 Clinical pathways, 710–711
in coronary artery disease, 45 Clitoris, 309
in myocardial infarction, 53 Clomipramine, adverse effects of, 796
Chest physiotherapy Clonic seizure, 621t
client positioning for, 110 Closed pneumothorax, 101–103
pediatric patient and, 581, 588–589 Clozapine, adverse effects of, 799
timing of, 90 Clubfoot, 630, 632–633, 640
Chest tube drainage, 770 types of, 632
interventions for client undergoing, 112 Coagulation study, 127
Chest X-ray, 33, 78 Coarctation of the aorta, 569–571
in child, 580 Cocaine, 431, 463
Chickenpox, skin lesions in, 351 Cocaine Addiction Severity Test, 367
China white as designer drug, 431 Cocaine Assessment Profile, 367
Chlamydia, 305–306, 321–322 Cocaine-use disorder, 430, 433
in child, 672, 675, 682 Codeine, 431
Chloride Cognitive Assessment Scale, 367
function of, 136 Cognitive Capacity Screening Examination, 367
imbalance of, 116, 136–137 Cognitive disorders, 399–408
Cholangiography, 245 clinical features of, 399
Cholecystitis, 238, 249–250 factors that contribute to, 399
Cholecystojejunostomy, 296 practice questions related to, 405–408
Choledochoduodenostomy, 296 Cognitive therapy, 368
Choledochojejunostomy, 296 Cold stress in neonate, 547, 553, 555. See also Hypo-
Chorioamnionitis, 509 thermia in neonate.
Chorion, 478 Cold therapy, applying, 225
Chorionic tumor. See Hydatidiform molar pregnancy. Colic in infant, 788
Chorionic villi sampling, 480 Collaboration, suggesting, as communication tech-
Christmas disease, 116–117, 138–140 nique, 364
Chronic bronchitis, 72, 90–91 Colon, inflammation of, 243, 272–273
Chronic constrictive pericarditis, 56–57 Colonoscopy, 246–247
Chronic glomerulonephritis, 306, 322 aftercare for, 757
Chronic obstructive pulmonary disease, findings in, in child, 646
771. See also Asthma, Chronic bronchitis, Colorectal cancer, 239, 252–254
and Emphysema. surgery for, 253
Chronic open-angle glaucoma, 194–195 warning sign of, 359
Chronic progressive chorea, 173, 197–198 Comedo, types of, 687
Chronic renal failure, 306, 323–324 Communicable diseases and infections, pediatric
foods to avoid in, 338 patient and, 591
Chronic secretory otitis media, 618–620 Communicating hydrocephalus, 616–617
Chronic suppurative otitis media, 618–620 Compartment syndrome, 216–217, 223
Circadian rhythm sleep disorder, 378, 379, 380, 381, 383 pain associated with, 236
Circulatory status, assessing, 40 testing for, 223
Circulatory system, 21, 30–31 Compulsive behavior, 393
Circumcision, 780 Computed tomography scan, 178
Circumoral paresthesia, 105 in child, 607, 610, 631
Cirrhosis, 238–239, 250–252 Computer testing, 4–5
Clang association, 429 Concentration, maintaining, 14–15
Clarification as communication technique, 363 Conception, 477
Clavicular fractures, 629 Conduct disorder, 801

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Confabulation, 384 Cystoscopy, 312

Confused state, acute, causes of, 426 Cystostomy, 773
Congenital heart defects, 568, 569–572, 576 Cystourethrography, 313
Congestive cardiomyopathy, 44–45
Conjunctiva, 177 D
Conjunctivitis, 172, 190–191 DASH diet for hypertension, 50t
chlamydia in child with, 675 Day-care facility, guide to selecting, 793
types of, 190–191 Deep vein thrombophlebitis, 62–63
Consciousness, disturbance of. See Delirium. Defibrination syndrome, 116, 137–138
Consumption coagulopathy, 116, 137–138 Degenerative joint disease, 217–218, 229–230
Contact dermatitis, 684–685, 689–690, 694–695, 704 Dehydration in child, 788, 790
Controlled substances, classes of, 429, 431 Delegation, guidelines for, 709, 726
Conversion disorder, 374, 376, 385 Delirium, 399, 400–401, 404, 405–406, 407
Cool mist tent, 581, 588 Delivery of fetus, 502
Coping mechanisms, assessing, 364 nursing interventions during, 502
Cornea, 177 pain relief during, 502–503
Corneal abrasion, 172, 192 physiologic changes after, 519
Coronary arteries, 21 Delivery date, estimating, 477
Coronary artery disease, 25, 45–46
Delusional disorder, 417, 419, 423–424, 799
Cor pulmonale, 72–73, 91–93
characteristics of, 417
Corticosteroids
Delusional themes, 417
adverse effects of, 794
Delusions, 417
blood chemistry changes caused by, 351
Delusions of persecution, 465
Corticosterone, 277
Dementia, 399, 462–463, 798
Corticotropin, 277
Alzheimer’s-type, 399, 400, 401–402, 406, 408
Cortisol, 277
multi-infarct, 401, 404–405
Cortisone, 277
vascular, 401, 404–405, 407
Cosyntropin test, 283
Democratic management style, 708
Co-trimoxazole, adverse reactions to, 100
Cowper’s glands, 311 Dendrites, 169
Cranial complications in neonate, 535 Denial, 384
Cranial nerves, 177 Denis Browne splint, 639
Craniotomy, 181 Deoxycorticosterone, 277
Creative studying, 16–17 Dependency, 384
Credé’s maneuver, 197i Dependent personality disorder, 410, 412–413
Crepitus, 233 Depersonalization disorder, 437, 438, 439, 443
Crisis intervention, 368 Depressants, 431
Crohn’s disease, 239, 254–255, 275 Dermis, 339, 683
dietary recommendations for, 353–354 Descending aortic aneurysm, 61
treatment for, 775 Descent of fetal presenting part, 501
Croup, 578, 584, 587–588 Designer drugs, 431
Croup tent, 581, 588 Detached retina, 175, 205–206
Cullen’s sign, 485 Developmental hip dysplasia, 630, 633–634, 639–640
Cultural considerations, 710 Developmental milestones
Cushing’s disease, depression as finding in, 355 for adolescent, 560, 563
Cushing’s syndrome, 278–279, 288–289 for infant, 559–560, 561
as asthma therapy complication, 301 for preschooler, 560, 562
nursing interventions for, 764 for school-age child, 560, 562
Cushing’s triad, 190 for toddler, 560, 561–562, 565
Cyclophosphamide, adverse effects of, 698 Dexamethasone suppression test, 283
Cystectomy, 318 Diabetes insipidus, 279, 289–290, 302
Cystic fibrosis, 579, 584–585, 589, 590 Diabetes mellitus, 279, 290–292, 763
appetite as indicator in, 698–699 in child, 662, 665–670, 702–703
characteristics of, 584 development of, 666
genetic transmission of, 585 diet for child with, 702–703
Cystitis, 306, 324–325 foot care for client with, 302
Cystometrogram, 313 patient and parent teaching for, 668–670

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Diabetes mellitus (continued) Down syndrome, 608, 615–616

as pregnancy complication, 472, 484–485 characteristics of, 615
types of, 290 Drag-and-drop question, 7
Diagnostic and Statistical Manual of Mental Disorders, Dressing, changing, 256
365 Duchenne’s muscular dystrophy, 630, 634–635, 641
Dialysis, types of, 324 early signs of, 700
Diaper rash, 684–685, 689–690, 694–695, 704 Duodenal ulcers, 243, 270–271
Diaphragmatic breathing, 111 Duodenum, 237
Diascopy, 686 Dyspareunia, 446, 448–449
DIC. See Disseminated intravascular coagulation. Dyssomnias, 373, 374–375, 378–381
Digestive process, 237, 643 Dystocia, 496–497, 506–507
organs and glands that facilitate, 647
Digital subtraction angiography, 33 E
Digoxin, administration guidelines for, in pediatric Ear canal in child, 607
patient, 574 Eardrops, instilling, in child, 785
Digoxin toxicity, signs of, 56, 135 Ear infection in child, 787
Dilated cardiomyopathy, 44–45 Ears, 177–178
Dilation, progress of labor and, 499
age-related changes in, 807t
Diltiazem, 66
neonatal assessment of, 536
Disaster management, 711–712
Eastern equine encephalitis, 192–194
recovery phase of, 712, 713
Eating Attitudes Test, 367
Discharge planning, patient teaching and, 709–711,
Eating disorders, 453–459
713–714, 739
characteristics of, 453
Dislocated hip. See Developmental hip dysplasia.
practice questions related to, 456–459
Disorganized schizophrenia, 418, 421–422, 427, 802
Eccrine sweat glands, 339
Disorganized thinking, 417, 419
body temperature regulation and, 350
Displacement, 420
in infant, 683
Dissecting aneurysm, 35, 60
Disseminated intravascular coagulation, 116, 137–138 Echocardiography, 32
as intrapartum complication, 496, 505–506 in child, 569, 574
Dissociation, 411 Echolalia, 420
Dissociative amnesia, 438, 439, 441, 444 Echopraxia, 420
Dissociative disorders, 437–444 Ecstasy as designer drug, 431
characteristics of, 437 Ectoderm, 478–479
practice questions related to, 440–444 Ectopic pregnancy, 472–473, 485–486
Dissociative fugue, 450 Effacement, 499
Dissociative identity disorder, 438, 439–440, 442 Effleurage, 503
Disulfiram therapy, 436, 464 Ego-dystonic behavior, 416
Diverticular disease, 239–240, 255, 257 Ego-syntonic behavior, 416
Diverticulitis, 239–240, 255, 257 Ejaculatory tract, 311
Diverticulosis, 239–240, 255, 257 Ejection fraction, 30
Documentation Elbow, passive range-of-motion exercises for, 209
of abuse, 730 Electrocardiography, 31, 32
data covered in, 727–728, 732 ambulatory, 31
functions of, 719 exercise, 32
importance of, 727 Electroconvulsive therapy, 461
of medication withheld, 734 adverse effects of, 461, 462
of restraint use, 740 indications for, 461
signing, 728 Electroencephalogram, 178, 213, 366
verbal and telephone orders and, 729 in child, 611
Documentation errors, 719, 727–729, 735 Electromyography, 179, 215, 219
Doll’s eye reflex, 536 in child, 611–612
Doppler ultrasound, 34 Elimination diet, 268
Dorsalis pedal pulse, locating, 750 Elimination patterns, postpartum, 523
Dorsal recumbent position, 811t Embolization, signs of, 47
Dosage calculation, 699, 752, 759, 768, 774, 784, 785, Emergency birth, 497, 510–513
789, 793, 794 Emphysema, 73, 93–94, 111

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Empyema, 74, 97–98 Extraocular eye muscle testing, 180

Encephalitis, 172–172, 192–194 Extraocular muscles, 177
transmission of, 192 Extremities
Endemic goiter, 279, 292–293 elevating, 811t
Endocarditis, 25, 46–47 neonatal assessment of, 536
Endocardium, 21 Extrinsic asthma, 86–87
Endocrine function study, 662–663 Exudate cultures, 686
Endocrine system, 277–302. See also Pediatric en- Eyes, 177
docrine system. age-related changes in, 807t
age-related changes in, 810t neonatal assessment of, 536
antepartum changes in, 475
components and functions of, 277, 281 F
diagnostic tests for, 282–285 Facial chloasma, 476
disorders for, 278–281, 285–299 Factor VIII deficiency, 116–117, 138–140
postpartum changes in, 519 Factor IX deficiency, 116–117, 138–140
practice questions related to, 299–302 Failure to thrive, 645, 653–654
Endoderm, 479 Fallopian tubes, 310
Endolymphatic hydrops, 173–174, 198–199 False aneurysm, 35
Endoscopic retrograde cholangiopancreatography, 247 False labor, 499t
in child, 647–648 Family therapy, 368
Endoscopy, 244 Fasting blood glucose test, 282
Enema administration, 757 Fear, irrational. See Phobias.
Engagement of fetal head, 501, 516
Febrile seizure, 622t
Enzyme-linked immunosorbent assay, 125, 365–366
Fecal fat test, 244–245, 273–274
Epicardium, 21
Fecal occult blood test, 126, 244, 245, 353
Epidermis, 339, 683
diet restrictions for, 756
Epididymides, 310
Female reproductive system, 309–310. See also Gen-
Epiglottis, 237
itourinary system.
Epiglottitis, 579, 585–586, 590
Epilepsy. See Seizure disorders.
postpartum changes in, 519
Epinephrine, 281
Femoral artery occlusion, 39–41
Episiotomy, 529, 780
Fern test, 550, 783
interventions for, 523
Epistaxis, interventions for, 166 Fertilization, 477, 776
Epstein’s pearls, 536 Fetal alcohol syndrome, 532, 537–538, 546–547
Erectile disorder, 446, 448–449, 451 Fetal biophysical profile, 481–482
Erotomanic delusion, 417 Fetal blood flow studies, 482
Erythema toxicum neonatorum, 537 Fetal blood sampling, 503, 549
Erythremia, 120, 153–155 Fetal circulation, 479
Erythrocyte fragility test, 127 Fetal development, 477–478
Erythrocytes, 123 Fetal distress, 497, 507, 549
life span of, 126 Fetal heart rate, monitoring, 500–501
Escharotomy, 344 Fetal lung maturity, promoting, 493
Esophageal atresia, 644–645, 652–653, 660 Fetal membranes, 478
with tracheoesophageal fistula, 701–702 Fetal movement count, 482
Esophageal cancer, 240, 257, 259 Fetal station, 499
Esophagogastroduodenoscopy in child, 646 Fetal structures, 478–479
Esophagus, 237 Fetishism, 446, 447–448
Estrogens, 277 Fetoscopy, 548
Excretory urography, 312 Fill-in-the-blank question, 5
in child, 674 Fingers and thumb, passive range-of-motion exer-
Exercise electrocardiography, 32 cises for, 209
Exhibit format question, 5 Flight of ideas, 464
Exhibitionism, 446, 447–448 Fluid and electrolyte balance, changes in, during la-
Existentialism, 442 bor, 500
External rotation of fetal head, 501 Fluid loss through skin in neonate, 671
Extracorporeal shock wave lithotripsy, 336–337 Fluorescent treponemal antibody-absorption test, 333

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Fluoxetine, 460 Gastrointestinal system (continued)

Focusing as communication technique, 363 changes in, during labor, 500
Follicle-stimulating hormone, 277 components and functions of, 237, 244
Fontanels, 536 diagnostic tests for, 244–247
Food poisoning, 240–241, 261–262 disorders of, 238–243, 247–273
Foot care for client with diabetes, 302, 764 neonatal adaptations and, 531
Forearm, passive range-of-motion exercises for, 209 postpartum changes in, 519
Foreign body in eye, 192 practice questions related to, 273–276
Fourchette, 309 Gastrointestinal tract, 643
Fowler’s position, 811t Gastrojejunostomy, 296
Fracture, 631, 635, 637 Gender identity disorder, 445–447, 451–452
of arm and leg, 216, 220–221 General anesthesia for labor pain, 503
clavicular, 629 Generalized anxiety disorder, 388, 391, 398, 796, 803
closed reduction of, 221 Generalized seizures, types of, 621–622t
common sites of, 635 General statements as communication technique, 363
femoral, 235–236, 766 Genital herpes, 307, 326–327
greenstick, 629 preventing spread of, 335
of hip, 217, 228–229 Genitalia, neonatal assessment of, 536
open reduction of, 221 Genitourinary system, 303–338. See also Pediatric
orthopedic treatments for, 636 genitourinary system
rehabilitation after, 235 age-related changes in, 808t
Frontal lobe of cerebrum, 169, 212 antepartum changes in, 476
changes in, during labor, 500
abscess in, 171, 185–187
components and functions of, 303, 309–311
tumor in, 171, 187–188
diagnostic tests for, 311–313
Frotteurism, 446, 447–448
disorders of, 304–309, 313–335
Fulminant hepatitis, 264. See also Hepatitis.
neonatal adaptations to, 531
Functional Dementia Scale, 367
postpartum changes in, 519, 528
Fundal assessment and massage, 521–522, 527–528,
530, 551, 776, 779
GERD, 241, 262–263
Fundoplication, 263
Gestational age, estimating, 477
Furosemide, adverse effects of, 773
Gestational diabetes, 472, 484–485, 492
Fusiform aneurysm, 35, 61
Gestational hypertension, 473–474, 488–490
Gestational trophoblastic disease, 473, 487
G Gigantism, 278, 285–287
Gag reflex, postprocedure assessment of, 274 Glasgow Coma Scale, 186t
Gallbladder, 237 Glaucoma, 173, 194–195
inflammation of, 238, 249–250 Global Deterioration Scale, 367
role of, in digestion, 647 Glomerulonephritis, 672–673, 676–678, 680, 681
Gametogenesis, 477 acute, 304, 313–314
Gas exchange, 69, 77 chronic, 306, 322
Gastric analysis, 126, 246 Glucagon, 281
Gastric cancer, 240, 259–260 Glucocorticoids, 277
Gastric decompression, 275 Glucose tolerance test, 282, 300
Gastric gavage, 258 Glue as inhalant, 431
Gastric tube feeding, delivering, 258 Gluten enteropathy, 644, 649–650, 659
Gastric ulcers, 243, 270–271 Gluten intolerance. See Celiac disease.
nonsteroidal anti-inflammatory–induced, 166 Glycosylated Hb test, 282–283
Gastritis, 240, 260–261 Goals, setting, 13–14
Gastroenteritis, 240–241, 261–262 Goiter, 279, 292–293
Gastroesophageal reflux disease, 241, 262–263 Gonorrhea, 306–307, 325–326
in neonate, 781 Goodell’s sign, 471
patient teaching for, 757 Gout, 217, 223–224
Gastrografin, 646 dietary restrictions for, 765
Gastrointestinal system, 237–276. See also Pediatric types of, 223
gastrointestinal system. Gouty arthritis, distinguishing, from rheumatoid
antepartum changes in, 475 arthritis, 358

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Gowers’ sign, 634 Hemoccult test, 245

Gram stains, 686 Hemodialysis, 324
Grandiose delusion, 417 Hemodynamic monitoring, 33
Grand mal seizure, 621t Hemolytic transfusion reaction, signs of, 359
Graves’ disease, 280, 293–294 Hemophilia, 116–117, 138–140
Gray matter, 177 in child, 592, 595–597, 605
Greenstick fractures, 629 inheritance pattern in, 138, 596
Group therapy, 368 types of, 138
Growth and development Hemothorax, 75, 101–103
major milestones for, 559–563 Hepatitis, 241, 263–265
practice questions related to, 563–566 fulminant, 264
Growth hormone, 277 phases of, 264
overproduction of, 285–287 types of, 263–264
Guaiac test for occult blood, 245 Hereditary chorea, 173, 197–198
Guillain-Barré syndrome, 173, 195–196 Herniated disk, 217, 227–228
complications of, 196 Herniated nucleus pulposus, 217, 227–228
pain associated with, 234
H Heroin, 431
Hair, 339 Herpes simplex, 307, 326–327
age-related changes in, 806t preventing spread of, 335
Hallucinations, 417, 425–426, 799 types of, 326
interventions for, 422 Herpes zoster, 340, 345–346
Hallucinogens, 431 skin lesions in, 351
Haloperiodol, adverse effects of, 800 Hiatal hernia, 241–242, 265–266
Hashimoto’s thyroiditis, 281, 298–299
diet recommendations for, 353
Head, neonatal assessment of, 535–536
reducing reflux associated with, 274
Head injury, acute, 170, 181–182
High blood pressure. See Hypertension.
classifying, 181
High Fowler’s position, 811t
Head lice, 685, 690, 695, 704
Hip, passive range-of-motion exercises for, 209
Hearing
Hip fracture, 217, 228–229
complications of, 235
development of, 607
repositioning patient in traction for, 235–236
Hearing-impaired client, teaching strategies for, 357
sites of, 228
Heart
Hip replacement
anatomy of, 21
blood circulation through, 21, 30–31 preventing dislocation after, 360
Heart attack. See Myocardial infarction. teaching plan for, 765
Heart disease as pregnancy complication, 473, 486–487 Hip-spica cast, 636, 639, 640
Heart failure, 26, 47–49 HIV infection. See Acquired immunodeficiency syn-
as cause of acute renal failure, 337 drome and Human immunodeficiency virus
as myocardial infarction complication, 54t infection.
pulmonary edema as complication of, 57–58 Hodgkin’s disease, 144–146
Heat therapy, applying, 226 stages of, 145
Hegar’s sign, 471 Holter monitoring, 31
HELLP syndrome, 489, 493 Hospice care, 755
Helper T cells, 124 Hospitalization, preparing preschooler for, 564, 789
Hemarthrosis, treating, 596–597 “Hot spot”question, 5
Hematologic study, 125 “Huffing,” 431
Hematologic system, 113–168. See also Pediatric Human chorionic gonadotropin, postpartum level
hematologic and immune systems. of, 551
components and functions of, 113, 123–124 Human immunodeficiency virus infection. See also
diagnostic tests for, 124–127 Acquired immunodeficiency syndrome.
disorders of, 114–123, 127–165 combination drug therapy for, 128
practice questions related to, 165–168 incubation period for, 594
Hematopoiesis, 113 in infants, 594–595
Hematopoietic system neonate and, 532, 538–539
changes in, during labor, 500 as pregnancy complication, 493
neonatal adaptations and, 534 Humoral immunity, 124

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Huntington’s chorea. See Huntington’s disease. Ileal conduit, complications of, 755
Huntington’s disease, 173, 197–198 Ileum, 237
genetic transmission of, 197 Illusions, 465
Hydatidiform molar pregnancy, 473, 487, 554 Immune response, 124
Hydrocephalus, 608–609, 616–617, 626, 627–628 Immune system, 113–168. See also Pediatric hema-
types of, 616 tologic and immune systems.
17–Hydroxycorticosteroids, 283 age-related changes in, 809t
Hyperbilirubinemia, 533, 534, 542–543, 545 components and functions of, 113
Hypercalcemia, 133–135 diagnostic tests for, 124–127
Hyperchloremia, 136–137 disorders of, 114–123, 127–165
Hypercortisolism, 278–279, 288–289 neonatal adaptations and, 531, 534
Hyperemesis gravidarum, 473, 488 practice questions related to, 165–168
Hyperglycemia Immunity, types of, 591, 593
interventions for, 666–667 Immunizations, 790
symptoms of, 354–355 Immunoglobulins, 124
Hypermagnesemia, 146–148 Immunologic studies, 125
Hypernatremia, 161–162 Immunosuppressive therapy, identifying cause of
Hyperosmolar coma, signs of, 291 fever in client receiving, 35
Hyperphosphatemia, 152–153 Impetigo, 685, 690–691
Hypersensitivity testing, technique for, 350 skin lesions in, 351
Hypersomnia, primary, 374, 378–379, 380, 381 Implantation of fertilized egg, 477
Hypertension, 26, 49–51 Impressions, sharing, as communication technique, 364
classifying, 49t Impulse control disorder, 800
DASH diet for, 50t Incentive spirometry, 88, 248
in pregnancy, 473–474, 488–490 Incident report, 732–733
risk factors for, 49–50, 775 medication error and, 725, 732–733, 737
types of, 49 patient accident and, 736
Hyperthyroidism, 280, 293–294, 300 Individual therapy, phases of, 368
Hypertrophic cardiomyopathy, 44–45 Indwelling urinary catheter, inserting, 317
Hypnosis, 369 Infant
Hypoactive sexual desire disorder, 446, 448–449, 451 developmental milestones for, 559–560, 561, 786
Hypocalcemia, 133–135 nutrition guidelines for, 561, 564, 792
after thyroidectomy, 301 Infantile eczema, 340, 342–343
Hypochloremia, 136–137 Infectious polyneuritis, 173, 195–196
Hypochondriasis, 374, 376–377, 384–385 Infective endocarditis, 25, 46–47
Hypodermis, 339 Informed consent, 718, 720–721, 733
Hypoglycemia elements of, 720, 731
interventions for, 354 emancipated minor and, 721
signs and symptoms of, 291, 668 mentally incompetent patient and, 721
Hypoglycemic reaction, interventions for, 668–669 negligent nondisclosure and, 721
Hypomagnesemia, 146–148 performing procedure without receiving, 733
Hyponatremia, 161–162 reasonable disclosure and, 720, 731
Hypophosphatemia, 152–153 witnessing, 720–721
Hypoplastic left-heart syndrome, 571–572 Inhalants, 431, 435
Hypospadias, 672, 676, 680, 681–682 Innominate artery occlusion, 39–41
Hypothalamus, 169, 277 Insomnia, primary, 374, 378, 379, 380, 381, 383–384
Hypothermia in neonate, 532, 539, 547, 553, 555 Insulin, 281
Hypothyroidism, 280, 294–295 Insulin-dependent diabetes mellitus, 279, 290–292
in child, 662, 663–665 Intake and output data to determine child’s hydra-
teaching plan for, 762 tion status, 674
warfarin therapy in client with, 300 Integumentary system, 339–352. See also Pediatric
Hypovolemic shock, 26–27, 51–52 integumentary system.
antepartum changes in, 476
I components and functions of, 339
I.M. injections, 748 diagnostic tests for, 339, 341–342
I.V. therapy, initiating, in school-age child, 791 disorders of, 340–341, 342–349
Ideas of reference, 423 practice questions related to, 350–352
Ig-mediated immunity, 124 Internal electronic fetal monitoring, 500–501

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Internalization, 373 Labia minora, 309

Internal rotation of fetal head, 501 Labor
Intestinal flu, 240–241, 261–262 admitting client in, 778
Intestinal obstruction, 242, 266–267 components of, 495, 499
in child, 645, 654–656, 659 difficult, 496–497, 506–507
forms of, 654 evaluating fetus during, 500–501
gastric decompression for, 275 evaluating mother during, 499–500
Intestine, role of, in digestion, 647 factors that affect, 495
Intracranial pressure, increased, 785 maternal responses to, 500, 553
Intracranial pressure monitoring in child, 611 nursing interventions during, 502
Intracranial surgery, aftercare for, 767 pain relief during, 502–503
Intrapartum period, 495–518. See also Labor. precipitate, 498, 509
complications of, 496–498, 504–514 preliminary signs of, 495, 499
diagnostic tests for, 503 preterm, 498, 513–514, 515, 518, 550
practice questions related to, 515–518 stages of, 501–502, 517, 551–552, 783
Intravesical chemotherapy, 318 true vs. false, 499t, 516–517
Intrinsic asthma, 86–87 Laboratory values
Intrinsic factor, deficiency of, 119, 151–152, 166–167 normal, 12
Iris, 177 as test pitfall, 12
Iron deficiency anemia, 117, 140–141, 168 Labyrinth, 178
in child, 592, 597–598, 602, 603–604, 605 dysfunction of, 173–174, 198–199
dietary modifications for, 697 Labyrinthectomy, 199
Iron supplementation
Laceration as delivery complication, 497, 508–509
administration guidelines for, 602
classifying, 508
adverse reactions to, 603–604
Lacrimal apparatuses, 177
Irritable bowel syndrome, 242, 267–268
in neonate, 536
Isometric exercises, 235
Laissez-faire management style, 707–708
Isotretinoin, patient teaching for, 687
Lamaze breathing, 503
Itching, interventions for, 352
Laminotomy, preoperative teaching for, 359
Landry-Guillain-Barré syndrome, 173, 195–196
J Lanugo, 537
Jealous delusion, 417
Large-bowel obstruction, signs and symptoms of,
Jejunum, 237
655. See also Intestinal obstruction.
Joint, 215
Large intestine, 237
Jones criteria for rheumatic fever, 572–573
Juvenile rheumatoid arthritis, 631, 637–638, 641 role of, in digestion, 647
forms of, 637 Laryngeal edema, early signs of, 130
Laryngoscopy, 79
K Larynx, 69
Kaposi’s sarcoma, 117, 141–142 Lasègue’s sign, 227
Kernig’s sign, 200 Lateral position, 811t
Ketoacidosis, signs of, 291 Left-sided heart failure, 47, 48, 775
17–Ketosteroids, 283 pulmonary edema as complication of, 57–58
Kidney cancer. See Nephroblastoma. Left-to-right shunt, congenital heart defects and,
Kidneys, 303 567, 568, 569–571
blood pressure regulation and, 303 Leg fracture, 216, 220–221
in child, 671 Legionnaire’s disease, 73–74, 94–95
role of, in acid-base balance, 303 Lens, 177
Kidney stones, 308, 331–332 Leopold’s maneuvers, 499, 776
Kidney-ureter-bladder X-ray, 312 Letting-go phase after delivery, 521
in child, 674 Leukemia, 177–118, 142–144, 167
Killer T cells, 124 alleviating anxiety in patient with, 144
Knee, passive range-of-motion exercises for, 209 in child, 592–593, 598–599, 605
Kveim-Siltzbach skin test, 107 protective isolation for patient with, 697
types of, 142
L Leukocytes, 123
La belle indifference, 376 Level of consciousness, assessing, 186t
Labia majora, 309 Levothyroxine, administration precautions for, 357

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Ligaments, 215 Male reproductive system (continued)

Lightening as preliminary sign of labor, 495 age-related changes in, 808t
Linea nigra, 476 Malignant lymphoma, 144–146
Lipase, 281 Malingering, 425
Listening as communication skill, 363 Mallory-Weiss tears, 459
Lithium, adverse effects of, 461, 798 Manic depression. See Bipolar disorder.
Lithotomy position, 812t Mantoux intradermal skin test, 79
Liver, 237 Maslow’s hierarchy, knowledge of, as test strategy, 10
palpating, 758 Mastitis, 520, 524, 779
role of, in digestion, 647 McDonald’s rule, 477
Liver biopsy, 246 Medication administration, 719, 724–725
Liver scan, 245–246 documenting, 725
Living wills, 718–719, 722–723, 731–732, 738 error in, 725
legal immunity and, 723 five rights formula and, 724–725
Patient Self-Determination Act and, 723, 741 legal expectations and, 725
provisions included in, 723 Medication order, questioning, 748
Local infiltration of anesthetic for labor pain, 503 Medulla oblongata, 177
Lochia, types of, 522, 530 Melanoma, 341, 349
Looseness of associations, 417, 419 Memory loss, 462. See also Amnesic disorder and
Loss of ego boundaries, 419 Dissociative amnesia.
Lou Gehrig’s disease, 170, 182–184 Ménière’s disease, 173–174, 198–199
Lower GI series, 244 Meningitis, 174, 200–201
in child, 609, 617–618, 625
in child, 646
respiratory isolation for infant with, 700
LSD as hallucinogen, 431
Meningocele, 623
Lumbar epidural anesthesia for labor pain, 503
Meperidine, 431
adverse reaction to, 517–518
Mescaline as hallucinogen, 431
Lumbar puncture, 178–179
Mesoderm, 479
aftercare for, 233
Metabolic acidosis, 119, 148–149
in child, 611
Metabolic alkalosis, 119, 149
Lund and Browder chart, 344
as pyloric stenosis complication, 701
Lung biopsy, 79–80
Metabolic system, antepartum changes in, 476
Lung cancer, 74, 96–97
Methadone, 431
types of, 96 Methylergonovine, 527–528
Lungs, 69, 77 Methylphenidate, adverse reactions to, 627
Lung scan, 79 Michigan Alcoholism Screening Test, 367
Luteinizing hormone, 277 Microscopic immunofluorescence, 686
Lymph, 113 Midbrain, 177
Lymphangiography, 125 Middle cerebral artery, clinical features of injury to,
Lymphatic vessels, 113 208. See also Stroke.
Lymph nodes, 113 Milieu therapy, 368
Lymphoma, 118, 144–146, 167 Milwaukee brace, 636
forms of, 144 patient teaching for, 701
Lysergic acid diethylamide as hallucinogen, 431 Mineralocorticoids, 277
Minimal cervical dysplasia, 305, 320–321
M Mini-Mental Status Examination, 367
Macular rash, 694 Minnesota Multiphasic Personality Inventory, 367
Magical thinking, 421, 465 Misoprostol, 166, 274
Magnesium adverse effects of, 354
functions of, 146 Mitral insufficiency, 29, 30, 63, 64
imbalance of, 118–119, 146–148 Mitral stenosis, 29, 30, 63, 64
Magnesium toxicity, 518 Mitral valve, 21
Magnetic resonance imaging, 178, 220 Mitral valve prolapse, 29, 30, 63, 64–65
in child, 610, 631–632, 641 Mitral valve prolapse syndrome, 63
Major depression, 388–389, 391–393, 797 Mixed cerebral palsy 613–615
Major motor seizure, 621t Molding of neonate’s head, 535
Male reproductive system, 310–311. See also Geni- Mongolian spot, 537
tourinary system. Monoamine oxidase inhibitors, diet restrictions for, 460

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Mons pubis, 309 NCLEX (continued)

Mood disorders, 387, 388–389, 390, 391–393 client needs categories in, 3, 4t
concepts of, 387 computer testing and, 4–5
practice questions related to, 396–398 preparing for, 13–18
Moro’s reflex, 537 questions on, 5, 6–7i, 7–9
Morphine, 431 strategies for, 9–11
Mother-infant attachment, 779 structure of, 3–4
Mouth Neck
functions of, 69, 237 neonatal assessment of, 536
neonatal assessment of, 536 passive range-of-motion exercises for, 209
Multifetal pregnancy, 474, 490–491 Negligence, 719, 725–727, 737
Multi-infarct dementia, 401, 404–405 criteria for claim of, 726
Multiple gestation, 474, 490–491 Neologisms, 419, 464
Multiple myeloma, 119, 149–151 Neonatal care, parent teaching for, 540
Multiple personality disorder, 438, 439–440, 442 Neonatal drug dependency, 532–533, 539–541, 545,
Multiple-response question, 5 547, 553, 555
Multiple sclerosis, 174, 201–202, 767 Neonatal infections, 533, 541–542, 546
plasmapheresis as treatment for, 213 Neonatal jaundice, 533, 534, 542–543, 545
Musculoskeletal system, 215–236. See also Pediatric Neonate, 531–556
musculoskeletal system. adaptations of, to extrauterine life, 531, 534
age-related changes in, 810t Apgar scoring system and, 535t
components and functions of, 215 complications and disorders of, 532–533, 537–544
diagnostic tests for, 215, 219–220 data collection for, 534–535
disorders of, 216–218, 220–232 developmental milestones for, 559, 560
practice questions related to, 233–236 fluid loss through skin in, 671
Mushrooms as hallucinogens, 431 physical examination of, 535–537
Myasthenia gravis, 175, 202–203 practice questions related to, 545–548, 549, 553,
Myasthenic crisis, monitoring body systems in, 360 554, 555–556
Myelin sheath, 169 Nephrectomy, aftercare for, 678–679, 703–704
degeneration of, 174, 201–202 Nephritis, 672–673, 676–678, 680, 681
Myelography, 179, 219 Nephroblastoma, 673, 678–679, 681, 682
in child, 632 stages of, 678
Myelomeningocele, 623 Nephron, 303, 671
Myelosuppression therapy, 756 Nerve cell, 169
interventions for, 155 Nerve entrapment syndrome, 216, 222–223
Myocardial infarction, 27, 52–55 Nerve impulse transmission, disturbance in, 202–203
monitoring for complications of, 54t Neurogenic bladder, 307, 327–328
Myocarditis, 27, 55–56 Neuroleptic malignant syndrome, 800
Myocardium, 21 Neurologic bladder, 307, 327–328
Myoclonic seizure, 621t, 625 Neuromuscular dysfunction of the lower urinary
tract, 307, 327–328
N Neuron, 169
Nägele’s rule for estimating delivery date, 477, 494 Neuropathic bladder, 307, 327–328
Nail polish remover as inhalant, 431 Neurosensory system, 169–214. See also Pediatric
Nails, 339 neurosensory system.
NANDA-I Taxonomy II, 818–821 age-related changes in, 809t
Narcolepsy, 374–375, 379, 380, 381 components and functions of, 169, 177–178
Nares, 69 diagnostic tests for, 178–181
Nasal cannula, pediatric patient and, 581 disorders of, 170–176, 181–212
Nasogastric intubation in child, 648, 658–659 neonatal adaptations and, 534
Nasogastric tube care, 250 practice questions related to, 212–214
Nasopharyngeal suctioning, 771 Neurotransmitters, 169
Natural immunity, 591 Nevus flammeus, 537
Naturally acquired active immunity, 591 Nevus vasculosus, 537
Naturally acquired passive immunity, 591 Nicotine, 431
NCLEX Nightmare disorder, 375, 381–382
avoiding pitfalls in, 11–12 Nipple stimulation stress test, 481

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Nitroglycerin, 66–67 Opisthotonos, 200

Nonatopic asthma, 86–87 Opium, 431
Noncommunicating hydrocephalus, 616–617 Optic nerve, 177
Non-Hodgkin’s lymphoma, 144–146 Oralgastric intubation in child, 648, 658–659
Non-insulin-dependent diabetes mellitus, 279, 290–292 Orchiectomy, 334
Non-rapid-eye-movement sleep, 373, 375 perioperative care for, 335
Nonsteroidal anti-inflammatory therapy, adverse ef- Orgasmic disorder, 446, 448–449
fects of, 166, 234 Oronasopharyngeal suctioning, 84
Nonstress test, 481 Oropharynx, 237
Nontoxic goiter, 279, 292–293 Orthopedic treatments, 636
Norepinephrine, 281 Orthotolidine test for occult blood, 245
Norwood procedure, 572 Ortolani’s click, 633
Nose Osteoarthritis, 217–218, 229–230, 233–234
functions of, 69 distinguishing, from rheumatoid arthritis, 358
neonatal assessment of, 536 lifestyle changes and, 234
Nosebleed, interventions for, 166 types of, 229
Nostrils, 69 Osteomyelitis, 218, 230–231
Nuclear cardiology, 32–33 common sites of, 230
Nurse-client relationship, phases of, 795 Osteoporosis, 218, 231–232
Nurse-manager Otitis media, 609–610, 618–620, 626–627
delegation and, 709, 714 types of, 618–619
management styles and, 707–708 Otosclerosis, 175, 203–204
role of, 707–709, 712, 714, 715–716 Otoscopic examination, 180
Nurse practice acts, 717, 718, 719–720 in child, 612
conflicts of duty and, 720 Ovarian cancer, 307, 328–330
interpreting, 717, 719 Ovaries, 310
licensure requirements and, 717, 735 Ovum, 477
revision of, 720 Oxygenation failure, 82
scope of, 717, 720, 730–731 Oxygen tent, pediatric patient and, 581
state or provisional board of nursing and, 717 Oxyhemoglobin, 123
violation of, 717 Oxytocin, 277
Nursing leader, 709, 712–713 adverse reactions to, 777
Nursing process, applying, as test strategy, 9–10 Oxytocin administration, monitoring, 551
Nutritional needs Oxytocin challenge test, 481
during pregnancy, 476–477, 492 P
Pacemaker, teaching plan for, 753
O Pain disorder, 374, 377–378, 386, 804
Obliterative cardiomyopathy, 44–45 Painful crisis in sickle cell anemia, 159–160
Obsessive-compulsive disorder, 389, 393, 795, 796 Pain relief during labor and delivery, 502–503
Obsessive thoughts, 393 Paint thinners as inhalants, 431
Obstructive cardiomyopathy, 44–45 Pancarditis, 59
Obstructive sleep apnea syndrome, 374, 378, 380, 381 Pancreas, 244, 281
Occiptal lobe of cerebrum, 169, 212 endocrine function of, 281
tumor in, 171, 187–188 exocrine function of, 281
Occult blood, testing for, 244, 245 inflammation of, 242, 268–270
Oculogyric crisis, 461 role of, in digestion, 647
Olfactory hallucinations, 426 Pancreatic cancer, 280–281, 295–297
Open-angle glaucoma, 173, 194–195 Pancreatitis, 242, 268–270
Open pneumothorax, 101–103 Pancreatoduodenectomy, 296
Ophthalmia neonatorum Pancytopenia, 115, 132–133
administering preparation to prevent, 556 Panic attack, interventions for, 394, 396, 465–466
chlamydia as cause of, 675 Panic disorder, 389, 393–394, 396–397, 466
Ophthalmodynamometry, 40 Papillary muscle rupture as myocardial infarction
Ophthalmoscopic examination in child, 612 complication, 54t
Opiates, 431, 435 Papular rash, 691, 694

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Paracervical block for labor pain, 503 Pediatric integumentary system (continued)
Paranasal sinuses, 69 disorders of, 684–685, 686–692
Paranoia, 465. See also Paranoid schizophrenia. practice questions related to, 693–695
Paranoid disorder, 417, 419, 423–424 Pediatric musculoskeletal system, 629–642
Paranoid personality disorder, 410–411, 413–414 diagnostic tests for, 629, 631–632
Paranoid schizophrenia, 418–419, 422–423 disorders of, 630–631, 632–638
Paraphilias, 446, 447–448, 450, 452 function of, 629
Parasomnias, 373, 381–382 practice questions related to, 639–642
Parasympathetic nervous system, 177 Pediatric neurosensory system, 607–628
Parathormone. See Parathyroid hormone. diagnostic tests for, 607, 610–612, 780
Parathyroid gland, 277 disorders of, 608–610, 612–624
Parathyroid hormone, 277 function of, 607
deficiency of, 299, 763 practice questions related to, 625–628
Paraurethral glands, 310 Pediatric respiratory system, 577–590
Parietal lobe of cerebrum, 169, 212 compared with adult respiratory system, 577
tumor in, 171, 187–188 components and functions of, 577
Parkinson’s disease, 175, 204–205 disorders of, 578, 580–587
eating problems associated with, 213 practice questions related to, 587–589
Partial seizures, types of, 621t Pediculosis capitis, 685, 690, 695, 704
Participative management style, 708, 713 Pedophilia, 446, 447–448
Passage as labor component, 495 Pemberton’s sign, 292
Passenger, fetus as, during labor, 495 Penis, 310
Passive-aggressive behavior, 460 Pentamidine
Passive behavior, 460 adverse reactions to, 100
Passive range-of-motion exercises, 209 assessing effectiveness of, 167
Patch tests, 686 Peptic ulcer disease, 243, 270–271, 756
Patent ductus arteriosus, 567, 568, 569–571, 576 nonsteroidal anti-inflammatory–induced, 166
Patient history, 364 peritonitis in, 276
Pauciarticular juvenile rheumatoid arthritis, 637–638 Percutaneous thyroid biopsy, closed, 284
Pavlik harness, 639 Percutaneous transhepatic cholangiography, 247
Pediatric cardiovascular system, 567–576 Percutaneous umbilical blood sampling, 482
diagnostic tests for, 567, 569 Pericardial sac, 21
disorders of, 567, 568, 569–573 Pericardiocentesis, interventions for, 42
practice questions related to, 573–576 Pericarditis, 27–28, 56–57
Pediatric endocrine system, 661–670 as myocardial infarction complication, 54t
diagnostic tests for, 662–663 Perineal body, 310
disorders of, 662, 663–667 Peripheral nervous system, 177
function of, 661 Peripheral paresthesia, 105
practice questions related to, 667–670 Peritoneal cavity, inflammation of, 243, 271–272
Pediatric gastrointestinal system, 643–660 Peritoneal dialysis, 324
characteristics of, 643 Peritonitis, 243, 271–272
diagnostic tests for, 643, 646–648 parenteral nutrition for, 354
disorders of, 644–645, 648–658 in peptic ulcer disease, 276
functions of, 643 Pernicious anemia, 119, 151–152, 166–167
practice questions related to, 658–660 Persecutory delusion, 417
Pediatric genitourinary system, 671–682 Perseveration, 419
characteristics of, 671 Personality disorders, 409–414
diagnostic tests for, 671, 673–675 diagnostic criteria for, 409
disorders of, 672–673, 675–679 factors that contribute to development of, 409
practice questions related to, 680–682 practice questions related to, 414–416
Pediatric hematologic and immune systems, 591–606 Personality traits, 409
disorders of, 592–593, 594–602 Petechiae, 694
functions of, 591, 593 Petit mal seizure, 621t, 625
practice questions related to, 602–606 Petroleum products as inhalants, 431
Pediatric integumentary system, 683–695 pH, significance of, 104
characteristics of, 683, 685 Phagocytosis, 123
diagnostic tests for, 685–686 Phalen’s wrist-flexion test, 222

9201Index.qxd 8/7/08 4:02 PM Page 839
Index 839
Pharynx, 69 Posttraumatic stress disorder, 389, 395–396, 398,

Phenazopyridine, urine color change and, 336 466–467, 795
Phencyclidine, 431 Potassium supplement, administration guidelines
Phenytoin, administration guidelines for, 773 for, 275
Phlebitis as I.V. therapy complication, 747 Pouching a wound, 256
Phobias, 389, 394–395, 397–398 Power as labor component, 495
Phosphorus Practice questions as study strategy, 18
functions of, 152 Precipitate labor, 498, 509
imbalance of, 119–120, 152–153 Preeclampsia, 473–474, 488–490, 782
Phototherapy, goal of, 556 Pregnancy
Physical examination, 364–365 adolescent, 472, 483–484
neonatal, 535–537, 545, 546 cardiovascular system changes in, 471, 474–475
Physiologic shunting, 82 discomforts of, 478
Pituitary gland, 277 ectopic, 472–473, 485–486
Placenta, 479 endocrine system changes in, 475
formation of, 477–478 gastrointestinal system changes in, 475, 777
functions of, 479 genitourinary system changes in, 476
premature separation of, 496, 504 hypertension in, 473–474, 488–490
Placental separation after delivery, 778 integumentary system changes in, 476
Placenta previa, 474, 491, 528 metabolic system changes in, 476
Plasma, 123 multifetal, 474, 490–491
Plasmapheresis as multiple sclerosis treatment, 213 nutritional needs during, 476–477, 492
Platelets, 123 positive signs of, 471
Pleura, 77 presumptive signs of, 471
Pleural effusion, 74, 97–98 probable signs of, 471
Pleurisy, 74, 98–99 psychological changes after, 519, 521
Pleuritis, 74, 98–99 respiratory system changes in, 475
Pneumocystis carinii pneumonia, 75, 99–100, 110, 167 weight gain in, 476
Pneumonia, 75, 100–101, 769 Premature ejaculation, 446, 448–449
chlamydia in child with, 675 Premature labor, 498, 513–514, 515, 518, 550
interventions for, 789 Premature rupture of membranes, 498, 509–510,
Pneumothorax, 75, 101–103, 112 550, 783
types of, 101–102 Preschooler, developmental milestones for, 560, 562
Polyarticular juvenile rheumatoid arthritis, 637–638 Pressure-sensitive catheter for determining con-
Polycythemia rubra vera, 153–155 traction intensity, 501
Polycythemia vera, 120, 153–155 Pressure ulcers, 341, 346–347
Polysomnography, 375 preventing, 347, 758
Pons, 177 risk factors for developing, 749
Pontiac fever, 95 staging, 346–347
Popliteal artery occlusion, 39–41 Preterm labor, 498, 513–514, 515, 518, 550
Port-wine stain, 537 Primary polycythemia, 153–155
Positron emission tomography, 179, 366–367 Prinzmetal’s angina, 36
Posterior cerebral arteries, clinical features of in- Proctosigmoidoscopy, 245
jury to, 208. See also Stroke. in child, 646
Posterior chamber of the eye, 177 Progesterone, 277
Posterior tibial pulse, palpating, 754 Progressive systemic sclerosis, 121, 156–158
Postmenopausal osteoporosis, 218, 231–232 Prone position, 812t
Postpartum depression, 519, 520, 521, 525–526 Prostate cancer, 308, 330–331
Postpartum hemorrhage, 520, 524–525, 528, 529 Prostate gland, 303, 311
Postpartum maladaptation, 519, 520, 521, 525–526 enlargement of, 304, 316
Postpartum period, 519–530 Prostate-specific antigen as screening test, 356
complications of, 520, 523–527, 552 Pseudohypertrophic dystrophy, 630, 634–635, 641
data collection for, 521–523, 552, 778 Pseudoparkinsonism, 461
physiologic changes after, 519 Psoas sign, 248
practice questions related to, 527–530 Psoralens plus ultraviolet A therapy, precautions
psychological changes in, 519, 520, 521, 529 for, 348
Postpartum psychosis, 526 Psoriasis, 341, 348

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840 Index
Psychiatric nursing, 363–372 Raynaud’s disease, 28, 58–59

data collection and, 364–365 Raynaud’s phenomenon, 58–59
physiologic testing and, 365–367 Reality therapy, 368
practice questions related to, 369–372 Real world vs. NCLEX, 11–12
psychological testing and, 367 Rectal cancer. See Colorectal cancer.
therapeutic communication techniques and, 363–364 Red blood cells, 123
treatment options and, 367–369 Reflexes, neonatal assessment of, 537, 781
Psychological maladaptation, 520, 525–526 Regional enteritis. See Crohn’s disease.
Psychological tests, 367 Regression, 465
Psychosis, 417 Renal angiography, 312
Psychosomatic, definition of, 373 Renal biopsy, 312–313
Pudendal block for labor pain, 503 Renal calculi, 308, 331–332
Puerperal infection, 520, 526–527 recommended daily fluid consumption for, 337
Pulmonary angiography, 78 Renal failure
Pulmonary artery catheterization, purpose of, 41 acute, 304, 314–316
Pulmonary artery stenosis, 569–571 chronic, 306, 323–324
Pulmonary blood flow in pediatric patient Renal scan, 312
decreased, mixed defects related to, 568, 571–572, Renal system
575, 576 age-related changes in, 808t
increased, defects and obstructions related to, changes in, during labor, 500
568, 569–571 neonatal adaptations and, 531
Pulmonary edema, 28, 57–58 Rephrasing as communication technique, 363
Pulmonary embolism, 75–76, 103–104, 784 Reproductive system. See also Genitourinary system.
Pulmonary function tests, 79 female, 309–310
in child, 580 male, 310–311
Pulmonic valve, 21 Respiratory acidosis, 76, 104–105
auscultating, 754 Respiratory alkalosis, 76, 105–106
Pulse oximetry, 34 Respiratory assessment in child, urgency of, 699
in child, 579–580 Respiratory assistance for children, 581
Pulse pressure, 753 Respiratory distress in child, signs of, 698
Pump failure, 24–25, 42–44 Respiratory distress syndrome, 533, 543–544, 546, 556
Punch biopsy, 341–342 Respiratory failure in child, signs of, 698
Pupil, 177 Respiratory system, 69–112. See also Pediatric res-
Pustular rash, 691 piratory system.
PUVA therapy, precautions for client receiving, 348 age-related changes in, 807t
Pyelonephritis, 672–673, 676–678, 680, 681 antepartum changes in, 475
Pyloric stenosis, 645, 656–657, 658, 660 changes in, during labor, 500
components and functions of, 69, 77
Q diagnostic tests for, 78–80
Quality management, 711, 715 disorders of, 70–77, 80–109
Quickening, 471, 477, 492 gas exchange and, 69, 77
neonatal adaptations and, 531
R practice questions related to, 110–112
Radiant heat loss in neonate, sources of, 548 Restrictive cardiomyopathy, 44–45
Radiation therapy Retina, 177
adverse effects of, 755 Retinal cones, 177
skin care and, 338 Retinal detachment, 175, 205–206
Radioactive iodine uptake, 284 Retinal rods, 177
interpreting results of, 300 Retroperitoneal lymph node dissection, 334
RAIU. See Radioactive iodine uptake. Reverse Trendelenburg’s position, 812t
Range-of-motion exercises, passive, performing, 209 Reye’s syndrome, 593, 599–600, 602
Rapid reagin test, 333 stages of, 599–600
Rapid adrenocorticotropic hormone stimulation Rheumatic fever, 28, 59–60, 568, 572–573, 575, 790
test, 283 Rheumatic heart disease, 28, 59–60
Rapid-eye-movement sleep, 373, 375 Rheumatoid arthritis, 120–121, 155–156
Rashes, 685, 691, 694, 749 distinguishing, from osteoarthritis and gouty
types of, 691 arthritis, 35

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Index 841
Rh factor, 124 Seizure disorders, 610, 620–622, 625–626

Riedel’s thyroiditis, 281, 298–299 classifying, 621–622t
Right-sided heart failure, 47, 48 Seizure precautions, implementing, 183
Rights to safe drug administration, 748 Self-destructive behavior, assessing potential for, 365
Right to privacy, 719, 723–724, 734 Semi-Fowler’s position, 812t
criminal cases and, 724 Semilunar valves, 21
disclosure of confidential information and, 724 Seminal vesicles, 311
elder abuse and, 724 Senile osteoporosis, 218, 231–232
ethical responsibility and, 724 Septic shock, 121–122, 158–159
government requests and, 724 Sertraline, adverse effects of, 797
legal recognition of, 723–724 Severe acute respiratory syndrome, 77, 108
professional responsibility and, 724 Sex hormones, 277
suspected child abuse and, 724 Sexual arousal disorders, 446, 448–449
Right to refuse treatment, 718, 721–722, 731, 734 Sexual aversion disorder, 446, 448–449
advance directives and, 722 Sexual desire disorders, 446, 448–449
end-of-life issues and, 721 Sexual disorders, 445–452, 804
nurse’s responsibility to follow, 722 characteristics of, 445
patient incompetency and, 722 practice questions related to, 449–452
religious beliefs and, 722, 732 Sexual dysfunctions, 446, 448–449
Rigid cerebral palsy, 613–615 Sexually transmitted diseases. See Chlamydia, Gon-
Romberg test, 126–127 orrhea, and Syphilis.
Rovsing’s sign, 248 Sexual masochism, 446, 447–448
Sexual pain disorders, 446, 448–449
Rubella, skin lesions in, 351
Sexual sadism, 446, 447–448
Rule of Nines, 343
Shingles, 340, 345–346
Ruptured disk, 217, 227–228
Shock
Russell’s sign, 456
cardiogenic, 24–25, 42–44
hypovolemic, 26–27, 51–52
S septic, 121–122, 158–159
Saccular aneurysm, 35, 60, 189
Shoulders, passive range-of-motion exercises for, 209
Salicylate poisoning, 645, 657–658
Sickle cell anemia, 122, 159–160
Salivary glands, role of, in digestion, 647
in child, 593, 601–603, 604
Sarcoidosis, 76–77, 106–107
genetic inheritance in, 159
SARS. See Severe acute respiratory syndrome. Sickle cell crisis
Scabies, 685, 692, 695 forms of, 159–160
Schilling test, 126 interventions for, 697
Schizophrenia, 802 triggers for, 601, 604
characteristics of, 417, 419 Sickle cell trait, 159
negative symptoms of, 417 Sidelighting as diagnostic aid, 686
positive symptoms of, 417 Side-lying position, 811t
Schizophrenic disorders, 417–428 Silence as communication technique, 363–364
negative symptoms of, 417, 425 Simple goiter, 279, 292–293
positive symptoms of, 417, 425 Sims’ position, 812t
practice questions related to, 425–428 Sinoatrial node, 30
School-age child Skeletal muscles, 215
accidents as cause of disability in, 565 Skeleton, 215
cognitive abilities of, 791 Skeleton traction, 636
developmental milestones for, 560, 562 Skene’s glands, 310
initiating I.V. therapy in, 791 Skin, 339
Scleroderma, 121, 156–158 age-related changes in, 806t
Scoliosis, 631, 638, 642 in child, 683, 685
nonstructural vs. structural, 638 functions of, 683
Scrotum, 310 layers of, 683
Sebaceous glands, 339 maintaining healthy status of, 351
in adolescent, 683 neonatal assessment of, 537
Segmental bladder resection, 318 Skin biopsy, 341–342
Seizure, nursing interventions for, 766 in child, 686

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842 Index
Skin cancer, 341, 349 Staphylorrhaphy, 650, 651, 659, 660

types of, 349 State boards of nursing, 813–817
Skin graft donor site care, 352 Station during labor, 499
Skin scraping, 342 Status epilepticus, 622t
Skin study, 342 Stem cells, 113, 123
Skin testing, 342 Stimulants, 431
evaluating results of, 356 Stomach, 237
Skin traction, 636 role of, in digestion, 647
Skull X-rays, 179 Stomach cancer, 240, 259–260
Sleep, drugs that affect, 379 Stool specimen, proper handling of, 646
Sleep disorders, 373, 374–375, 378–385 Strawberry hemangioma, 537
concepts related to, 373 Streptococcal infection, signs of, 60
practice questions related to, 383–384, 385 Stress test, 32
Sleep terror disorder, 375, 382 Stretch marks, 476
Sleepwalking disorder, 375, 382 Striae gravidarum, 476
Small-bowel obstruction, signs and symptoms of, Stroke, 176, 207–210
655. See also Intestinal obstruction. arteries affected by, 208
Small intestine, 237 Stroke volume, 30
role of, in digestion, 647 Study partners, 16–17
Snellen chart, 180 Stump care, 41
Sodium Subacute granulomatous thyroiditis, 281, 298–299
functions of, 161
Subarachnoid hemorrhage, guidelines for caring
imbalance of, 122, 161–162
for patient at risk for, 18
Sodium-potassium pump, 161
Subclavian artery occlusion 39–41
Somatic delusion, 417
Subclavian steel syndrome, 39
Somatization, 373, 385
Subcutaneous fat in infants, 683
Somatoform disorders, 373, 374, 376–378, 384–386
Subcutaneous tissue, 683
concepts related to, 373
Subdued lighting as diagnostic aid, 686
Subinvolution, 529
Somatostatin, 281
Submandibular lymph nodes, palpating, 750
Spastic cerebral palsy, 613–615
Substance abuse, 429
Spastic colitis, 242, 266–267
Substance abuse disorders, 430, 433–434
Spastic colon, 242, 266–267
Spermatozoon, 477 Substance dependence, 429
Spina bifida, 610, 623–624, 626 Substance-induced sexual dysfunction, 446, 448–449
forms of, 623 Substance intoxication, 429
Spinal anesthesia for labor pain, 503 Substance-related disorders, 429–436
Spinal cord, 177 concepts related to, 429
Spinal cord injury, 175–176, 206–207 practice questions related to, 434–436
bed-to-wheelchair transfer technique for, 214 Sudden infant death syndrome, 579, 586–587,
Spinal nerves, 177 589–590
Spinal wedge osteotomy, 131 Sulkowitch’s test, 284–285
Spine Sunset sign, 616
curvature of, 638 Superficial vein thrombophlebitis, 62–63
neonatal assessment of, 536–537 Supine position, 811t
Spleen, 113 Suppressor T cells, 124
palpating, 761 Surfactant, 69
Splenomegalic polycythemia, 153–155 Surgical wounds, caring for, 256
Spontaneous pneumothorax, 101–103 Sweat glands, 339
Sporadic goiter, 279, 292–293 Sympathetic nervous system, 177
Sprue, 644, 649–650, 659 Syndrome of inappropriate antidiuretic hormone,
Sputum study, 78 signs and symptoms of, 188, 214
in child, 579 evaluating effectiveness of treatment in, 762
Squamous cell carcioma, 341, 349 Synovium, 215
Stable angina, 36 Syphilis, 308, 332–333
Stalking behavior, 423 skin lesions in, 351
Standard precautions, 265, 760 stages of, 332–333

9201Index.qxd 8/7/08 4:02 PM Page 843
Index 843
Systemic disease with polyarthritis, 637–638 Thyroiditis, 281, 298–299

Systemic lupus erythematosus, 122–123, 162–164 forms of, 298
butterfly rash as characteristic sign of, 359 Thyroid scan, 284
teaching plan for, 761 patient preparation for, 762
Thyroid-stimulating hormone, 277
T Thyroid storm, signs of, 293
T3, 277 Thyroid uptake, 284
T4, 277 Thyrotoxicosis, 280, 293–294
Takayasu’s arteritis, 123, 164–165 Thyroxine, 277
Taking-hold phase after delivery, 521 Tic douloureux, 176, 210–211
Taking-in phase after delivery, 521 Tinel’s sign, 222
Talipes. See Clubfoot. Tissue perfusion, decreased, signs of, 138
Tardive dyskinesia, 461 T lymphocytes, 124
T cells, 124 Tocotransducer, monitoring uterine contractions with,
Telangiectasia, 537 500
Temporal arteritis, 123, 164–165 Toddler
Temporal lobe of cerebrum, 169, 212 developmental milestones for, 560, 561–562, 565, 788
abscess in, 171, 185–187 fontanel closure in, 563
tumor in, 171, 187–188 Toes, passive range-of-motion exercises for, 209
Tendons, 215 Tolerance, 429, 435
Tensilon test, 203 Tonic-clonic seizure, 621t
Tension pneumothorax, 101–103 Tonic seizure, 621t
Testes, 310 Tonometry, 180
Tonsils, 113
Testicles, 310
Toxicology screening, 366
Testicular cancer, 308–309, 333–335
Trachea, 69
Tetanic contractions, 500
Tracheoesophageal fistula, 533, 544, 548, 644–645,
Tetracycline, patient teaching for, 687
652–653, 658, 660
Tetrahydrocannabinol, 429, 431
Traction
Tetralogy of Fallot, 571–572, 575, 696
Bryant’s, 636
Thalamus, 169
care related to, 636
Therapeutic communication
repositioning client in, 235–236
implementing, 355–356
types of, 636
psychiatric nursing and, 363, 369–372
Transfusion reaction, 359
reviewing principles of, as test strategy, 11 Transient ischemic attacks, signs of, 39
Thermogenesis, neonatal, changes in, 531 Transposition of the great vessels, 571–572
Thoracentesis, 78–79 Transurethral resetion, 318
interventions for, 98 Transverse aneurysm, 61
Thoracic aortic aneurysm, 28–29, 60–62 Transvestic fetishism, 446, 447–448
aftercare for repair of, 62 Traumatic pneumothorax, 101–103
Thoracotomy, interventions for, 42 Traveler’s diarrhea, 240–241, 261–262
Thrombocytes, 123 Trendelenburg’s position, 812t
Thrombophlebitis, 29, 62–63 Trendelenburg’s test, 633
Thyrocalcitonin, 277 Tricuspid valve, 21
Thyroid biopsy, closed percutaneous, 284 Tricuspid valve insufficiency, 30, 63–64, 65
Thyroid cancer, 281, 297–298 Trigeminal neuralgia, 176, 210–211
Thyroidectomy, aftercare for, 299 minimizing pain episodes in, 767
discharge instructions for, 763 Triiodothyronine, 277
hypocalcemia as complication of, 764 True labor, 499t, 516–517
Thyroid gland, 277 Truncus arteriosus, 571–572
enlargement of, 279, 292–293 Trypsin, 281
hormones secreted by, 664 Tuberculosis, 77, 108–109
inflammation of, 281, 298–299 precautions for caring for client with, 770
Thyroid hormone Twenty-four-hour urine test, 283
deficiency of, 280, 294–295 specimen collection for, 311, 357
increased synthesis of, 280, 293–294 Two-hour postprandial glucose test, 282
Thyroid hormone replacement overdose, signs of, 670 Tympanum, 178

9201Index.qxd 8/7/08 4:02 PM Page 844
844 Index
U Venogram, 34
Ulcerative colitis, 243, 272–273 Ventilation, 577
Ultrasonography, 246 Ventilation-perfusion mismatching, 82
in child, 611 Ventilatory failure, 82
Umbilical cord, 479 Ventricular fibrillation, 22, 23, 37, 38
care of, 782 Ventricular septal defect, 569–571, 574, 786
emergency birth and, 512–513 Ventricular tachycardia, 22, 23, 37–38
prolapsed, 498, 510–511 Ventriculoperitoneal shunt, aftercare for, 699–700
Universal donor, 124 Ventriculostomy, 181
Universal recipient, 124 Venules, 31
Unstable angina, 36 Vernix caseosa, 537
Upper GI series, 244 Vertebral artery occlusion, 39–41
in child, 646 Vertebrobasilar artery, clinical features of injury to,
Ureter, 303 208. See also Stroke.
Urethra, 303, 311
Vesicular rash, 691, 694
Urethral meatus, 310
Vibroacoustic stimulation test, 481
Urethritis, 305–306, 321–322
Viral enteritis, 240–241, 261–262
Urinalysis, 311
Vision, age-related changes in, 807t
in child, 674
Visual acuity test, 180
Urinary catheter, indwelling, inserting, 317
Urinary tract infection, 771 Visual field examination, 180
in child, 673, 679, 680, 681, 703, 792 Visual function, development of, 607
Urine, 303 Vitreous humor, 177
concentration of, in child, 671 Voice box, 69
Urine culture and sensitivity test, 311 Voiding cystourethrography, 327
collecting specimen for, 336 in child, 675
Urine output, calculating, 772 Voyeurism, 446, 447–448, 450, 452
Urine specimen collection
for culture and sensitivity, 772 W
from infant, 674, 681 Warfarin, evaluating effectiveness of, 68
twenty-four-hour, 772 Water turnover rate in child, 671
Urine vanillymandelic acid test, 283 Weber’s test, 751
Urocosuric drugs, adverse effects of, 224 Wegener’s granulomatosis, 123, 164–165
Urodynamic studies, 327 Weight gain in pregnancy, 476
Urolithiasis, 308, 331–332 Wernicke’s encephalopathy, 464
Uterine atony, 528, 529 Western blot test, 125, 366
Uterine contractions, phases of, 500, 550, 553 West Nile encephalitis, 176, 211–212
Uterine rupture, 498, 511 Whipple’s procedure, 296
emergency birth and, 512–513 White blood cells, 123
Uterus, 310
Whitehead, 687
inverted, 497, 507–508
White matter, 177
Wilms’ tumor. See Nephroblastoma.
V Withdrawal, 429
Vagina, 310
signs of, 432, 463
Vaginal vestibule, 309
Vaginismus, 446, 448–449 Wood’s light test, 342
Valvular heart disease, 29–30, 63–65 Word salad, 420, 464
Vaquez-Osler disease, 153–155 Wound care, 256
Varicella, skin lesions in, 351 Wrist, passive range-of-motion exercises for, 209
Vascular dementia, 401, 404–405, 407
Vasculitis, 123, 164–165 XY
Vas deferens, 310 X-ray, 219
Vaso-occlusive crisis in sickle cell anemia, 159–160 in child, 632
Vasopressin, 277
VDRL slide test, 333 Z
Veins, 31 Zidovudine therapy during pregnancy, 493
Venereal Disease Research Laboratory slide test, 333 Zygote, 477

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9201FM.

qxd 8/7/08 4:03 PM Page i

Staff The clinical treatments described and recommended in this publica-

Digital Composition Services

Editorial Assistants Library of Congress Cataloging-in-Publication Data

Part I Getting ready

Part II Care of the adult

Part III Psychiatric care

Part IV Maternal-neonatal care

Part V Care of the child

Part VI Coordinating care

Appendices and index

Contributors and consultants

Not another boring foreword

I’VE EARNED ADVENTURE

BY PASSING THE NCLEX,

Joy’s NCLEX adventure

LOOK. LET’S SO WHAT’S THE SECRET TO

Joy’s NCLEX adventure

MOST NCLEX CANDIDATES

Joy’s NCLEX adventure

FILL OUT THE

Joy’s NCLEX adventure

REVIEW BASIC BECOME LEARN HOW

I NEED TO OH, LOOK. MY

A FEW WEEKS LATER…

Joy’s NCLEX adventure

I’LL NEED THIS MY

WELL, TOMORROW IS THE

Joy’s NCLEX adventure

NOW IT’S WELCOME. PLEASE SIGN

NEXT, YOUR PLEASE ALLOW

Joy’s NCLEX adventure

YOU’LL HAVE UP TO FIVE EVEN AFTER THE

ABOUT THREE HOURS LATER… WHEW!

Joy’s NCLEX adventure

RESULTS ARE MAILED TO THE

Part I Getting ready

2 Strategies for success 13

What’s the point? The whole kit and caboodle

4 Preparing for the examination

Client needs categories

Category Subcategories Percentage of questions

Safe, effective care environment Coordinated care 12% to 18%

Safety and infection control 8% to 14%

Health promotion and maintenance — 7% to 13%

Psychosocial integrity — 8% to 14%

Physiological integrity Basic care and comfort 11% to 17%

Pharmacological therapies 9% to 15%

Reduction of risk potential 10% to 16%

Physiological adaptation 11% to 17%

6 Preparing for the examination

Sample NCLEX questions

Four-option, multiple-choice question

Fill-in-the-blank calculation question

Sample NCLEX questions (continued)

2. Assess responsiveness. 1. Activate the emergency response system.

3. Call for a defibrillator. 3. Call for a defibrillator.

4. Provide two slow breaths. 6. Assess breathing. Focusing on

8 Preparing for the examination

Understanding the question telemetry unit? Probably not; his reaction to

DETERMINE WHAT FACTS ABOUT THE

Can I use a lifeline? First things first

Advice from the experts